An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Ask the client to describe how they are feeling.

Administer a PRN dose of a prescribed analgesic.

Document that the client denies pain in the nurse's notes.

Confront the client about inconsistent behavior and response.

Answer and Explanation

The Correct Answer is A

A.   Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B.   Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C.   While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D.   Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

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Correct Answer is C

Explanation

A. While hydration is important, it's not the most immediate concern when the client is experiencing severe pain and nausea. Addressing the pain should be the priority.
B. Antiemetics can be helpful for managing nausea and vomiting, but they may not be as effective in addressing the severe pain.
C. The client's self-reported pain level of 9 on a 0 to 10 scale indicates severe pain, which requires immediate management. IV narcotics are effective for managing severe pain and can be administered quickly to provide immediate relief. Addressing the client's pain can also help to alleviate nausea and vomiting, as pain can exacerbate these symptoms.
D. This is not relevant to the client's current symptoms of severe pain and nausea.

A. Working together can decrease the risk of back injury to the nurses. B. The technique is intended to maintain straight spinal alignment. C. Turning Instead of pulling reduces the likelihood of skin damage. D. Using two or three people increases client safety.

Correct Answer is B

Explanation

A. While it is true that using proper techniques can reduce the risk of back injuries for healthcare providers, this is not the primary purpose of the log rolling technique. The main goal of log rolling is to protect the client’s spinal alignment rather than focusing on the safety of the staff.
B. This is the best explanation for the purpose of using the log rolling technique. Log rolling is designed to keep the client’s spine in a straight, aligned position while turning. This technique is particularly important for clients with spinal injuries or conditions where maintaining spinal alignment is crucial to prevent further injury or complications.
C. While it is true that turning a client is generally better for skin integrity than pulling, this explanation does not specifically address the purpose of log rolling. Log rolling is more focused on maintaining spinal alignment rather than solely on reducing skin damage.
D. Using two or three people can indeed increase safety during the turning process and help in managing the client more effectively, but this explanation does not capture the primary purpose of the log rolling technique itself.

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An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

Correct Answer is B

Explanation

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

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