Exhibits

The nurse is evaluating the effectiveness of pain interventions for Mrs. Thompson who is unconscious and at the end of life. Which of the following methods is the most appropriate for assessing pain management effectiveness in this client?

Requesting feedback from the patient's family about the patient's comfort.

Monitoring changes in vital signs such as blood pressure and heart rate.

Assessing the patient's responsiveness to verbal stimuli.

Observing for non-verbal cues such as facial expressions and body movements.

Answer and Explanation

The Correct Answer is D

A. Requesting feedback from the patient's family about the patient's comfort. While family members can provide insight, they cannot reliably assess pain in an unconscious client. Pain assessment should be based on objective clinical observations rather than second-hand reports.
B. Monitoring changes in vital signs such as blood pressure and heart rate. While pain can cause changes in vital signs, this method is not the most reliable in end-of-life care. Vital signs may fluctuate due to the body’s natural decline rather than pain alone.
C. Assessing the patient's responsiveness to verbal stimuli. Responsiveness to verbal stimuli helps assess consciousness, but it does not directly determine pain levels. An unconscious client may still experience discomfort, requiring alternative assessment methods.
D. Observing for non-verbal cues such as facial expressions and body movements. In unconscious or non-verbal clients, pain is best assessed through behavioral cues like grimacing, restlessness, moaning, muscle tension, or changes in breathing patterns. These signs help determine whether pain interventions are effective or need adjustment.

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Correct Answer is D

Explanation

A. Aggravating and alleviating factors. The patient has not provided information about what makes the pain worse or better. Aggravating factors could include movement or temperature changes, while alleviating factors might involve rest or medication use.
B. Exacerbation, with associated signs and symptoms. The patient describes pain but does not mention any worsening trends or additional symptoms such as swelling, numbness, or redness. Exacerbation refers to how the pain has progressed or worsened over time, which is not addressed in this report.
C. Intensity, temporal characteristics, and functional impact. The patient has not provided a pain rating (e.g., on a 0-10 scale) to describe intensity. Temporal characteristics refer to patterns such as intermittent or continuous pain, which were not specified. Functional impact, such as difficulty walking or standing, was also not mentioned.
D. Location, quality, and duration. The patient describes location ("left foot" and "moves up along the calf"), quality ("feels like it is on fire"), and duration ("started yesterday"). These are key components of a pain assessment that help guide further evaluation and treatment.

A. Patient-centered care B. Quality improvement C. Teamwork and collaboration D. Evidence-based practice

Correct Answer is A

Explanation

A. Patient-centered care. Nursing education strongly emphasizes patient-centered care by teaching students to prioritize the needs, preferences, and values of patients in all aspects of care. Students gain hands-on experience through clinical rotations, simulations, and coursework that focus on individualized care and effective communication with patients and families.
B. Quality improvement. While nursing students learn about quality improvement concepts, they typically have limited direct involvement in large-scale healthcare quality initiatives. This competency is more commonly developed through workplace experience and participation in hospital-based improvement programs.
C. Teamwork and collaboration. Nursing programs introduce students to interprofessional collaboration, but their experience working in healthcare teams is often limited during training. Full integration into teamwork and decision-making processes typically occurs after entering the workforce.
D. Evidence-based practice. Nursing curricula emphasize evidence-based practice, but applying it in real-world settings requires experience. Newly licensed nurses may need additional guidance to interpret and implement the latest research findings effectively in clinical decision-making.

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Exhibits The nurse is evaluating the effectiveness of pain interventions for Mrs. Thompson who is unconscious and at the end of life. Which of the following methods is the most appropriate for assessing pain management effectiveness in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 49-year-old patient who reports pain in the foot that moves up along the calf says, "My left foot feels like it is on fire." The patient reports that the pain started yesterday, and they have no prior history of injury or falls. Which components of pain assessment has the patient reported?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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Exhibits

The nurse is evaluating the effectiveness of pain interventions for Mrs. Thompson who is unconscious and at the end of life. Which of the following methods is the most appropriate for assessing pain management effectiveness in this client?