The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

Provide a numeric pain scale.

Observe body language and movement.

Ask the client to describe the pain.

Identify effective pain relief measures.

Answer and Explanation

The Correct Answer is C

A. Provide a numeric pain scale:

While a numeric pain scale can help quantify the intensity of pain, it does not directly assess the quality or characteristics of the pain, which is important for identifying potential causes and selecting appropriate interventions.

B. Observe body language and movement:

Observing body language and movement can provide valuable information about the client's pain experience, but it primarily assesses the behavior associated with pain rather than the quality or characteristics of the pain itself.

C. Ask the client to describe the pain:

This approach allows the client to provide subjective information about the pain, including its quality, location, intensity, duration, and aggravating or alleviating factors. Asking the client to describe the pain helps the nurse gain insight into its characteristics, which can aid in identifying the underlying cause and determining appropriate interventions.

D. Identify effective pain relief measures:

Identifying effective pain relief measures is important for managing the client's pain, but it does not directly assess the quality or characteristics of the pain. Before implementing pain relief measures, it's essential to understand the nature of the pain through client self-report or other assessment methods.

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Correct Answer is C

Explanation

A. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care:

This option might be tempting but is not appropriate because the UAP should be properly equipped with the correct protective gear before any contact with the client. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

B. Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client:

This action is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N95, which is used for airborne precautions. This option indicates a misunderstanding of the type of precautions needed for bacterial meningitis.

C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client:

This is the correct course of action. Bacterial meningitis requires droplet precautions, which only require a standard face mask. The UAP can safely provide care using a standard mask.

D. Before changing assignments, determine which staff members have fitted particulate filter masks:

While it is prudent to know which staff members are fitted for particulate filter masks, this is not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

A. Auscultate the bowel sounds in all four quadrants. B. Palpate the client's pedal pulse volume bilaterally. C. Determine the elasticity of the client's skin turgor. D. Observe the client's skin and mucous membranes.

Correct Answer is D

Explanation

A. Auscultate the bowel sounds in all four quadrants:

Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.

B. Palpate the client's pedal pulse volume bilaterally:

Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.

C. Determine the elasticity of the client's skin turgor:

Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.

D. Observe the client's skin and mucous membranes:

This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.

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The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is D

Explanation

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