The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Review the client's medical history and admission assessment.

Compare the client's current vital signs to the admission baseline.

Note how frequently doses of analgesics have been administered.

Ask the client to describe the intensity of the pain being experienced.

Answer and Explanation

The Correct Answer is D

Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.

Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.

Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.

Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.

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Correct Answer is C

Explanation

Choice A reason: Offering positive reinforcement is a good practice in teaching, but it does not directly facilitate the learning of problem-solving strategies.

Choice B reason: Physical demonstrations are more suited to teaching psychomotor skills rather than problem-solving strategies.

Choice C reason: Simulation activities allow individuals to practice problem-solving in a controlled environment, which can enhance learning and retention of these strategies.

Choice D reason: Verbal analogies can aid in understanding concepts, but they are less interactive and engaging than simulation activities when it comes to learning problem-solving strategies.

A. Offer to contact the family's spiritual counselor to meet with the client and spouse. B. Discuss comfort measures with the client and family that will be available during withdrawal. C. Inform the healthcare provider of the client's desire to have life support withdrawn. D. Explain the actions that the healthcare team will follow for the removal of life support.

Correct Answer is C

Explanation

Choice A reason: Offering to contact the family's spiritual counselor can provide emotional and spiritual support, but it is not the immediate priority in a situation where the client has expressed a desire to have life support withdrawn.

Choice B reason: Discussing comfort measures is important for the client and family to understand what to expect during the withdrawal process. However, this step comes after the healthcare provider has been informed and a plan of care is being developed.

Choice C reason: Informing the healthcare provider is the priority nursing intervention. The nurse acts as an advocate for the client's wishes and ensures that the appropriate steps are taken to respect the client's autonomy and decisions regarding their care.

Choice D reason: Explaining the actions that the healthcare team will follow is an essential part of the process, but it is not the first step. The healthcare provider must first be informed so that the proper orders and arrangements can be made.

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The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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