The nurse is caring for a client who has been admitted with recurring migraine headaches.
To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?
Observe body language and movement.
Identify effective pain relief measures.
Provide a numeric pain scale.
Ask the client to describe the pain.
The Correct Answer is D
Choice A rationale:
Observing body language and movement is a valuable method for assessing pain, but it may not provide a comprehensive understanding of the client's pain experience. Clients may have different ways of expressing pain, and verbal communication should also be considered.
Choice B rationale:
Identifying effective pain relief measures is relevant but does not assess the quality of the pain itself. It focuses on pain management rather than pain assessment.
Choice C rationale:
Providing a numeric pain scale is a useful tool for quantifying pain intensity, but it does not assess the quality of pain, which is essential for understanding the nature of migraine headaches.
Choice D rationale:
Asking the client to describe the pain is the most appropriate approach for assessing the quality of pain. It allows the client to express the characteristics of the pain, such as its location, intensity, duration, and any associated symptoms, which can aid in diagnosis and treatment planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
The educational materials should contain a list with definitions of unfamiliar terms because older clients may not be familiar with medical terminology. Providing definitions can enhance their understanding of the new antihypertensive medications and promote medication adherence.
Choice B rationale:
Writing materials at a twelfth-grade reading level may not be appropriate for older clients. Many older individuals may have lower literacy levels, and using complex language can lead to confusion and hinder comprehension. Simple and clear language is more effective in educating this population.
Choice C rationale:
Using common words with few syllables is important for ensuring that older clients can easily understand the educational materials. Complex language and lengthy words can make it difficult for them to grasp important information about their antihypertensive medications.
Choice D rationale:
Using pictures to help illustrate complex ideas is essential when educating older clients. Visual aids can enhance comprehension and retention of information, especially for individuals who may have cognitive impairments or difficulty with written text.
Choice E rationale:
Printing materials using a 12-point type font is important for ensuring that the text is easy to read for older clients. Smaller fonts can be challenging for individuals with visual impairments, and readability is crucial for effective education.
Correct Answer is B
Explanation
Choice A rationale:
Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.
Choice B rationale:
Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.
Choice C rationale:
Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.
Choice D rationale:
Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.
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