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?

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.

Choice A rationale:

Correcting electrolytes that are out of normal range is a crucial goal of therapy for this client. In diabetic ketoacidosis (DKA), the body’s cells are unable to use glucose for energy due to a lack of insulin. This leads to the breakdown of fat for energy, producing ketones as a by-product. Ketones are acidic and can cause the blood’s pH to decrease, leading to metabolic acidosis. This process also leads to an increased production and excretion of electrolytes such as potassium and sodium. Therefore, correcting these electrolyte imbalances is a key goal of therapy.

Choice B rationale:

While promoting oxygenation to tissues is generally important in critical care, it is not a specific goal in the management of DKA. The primary issues in DKA are metabolic in nature, including hyperglycemia, ketosis, and acidosis.

Choice C rationale:

Preventing hyperventilation is not a specific goal in the management of DKA. Hyperventilation in DKA is a compensatory mechanism for metabolic acidosis (Kussmaul breathing). The body tries to expel more carbon dioxide to reduce the acidity of the blood.

Choice D rationale:

Reversing dehydration is another important goal of therapy for this client. In DKA, high blood glucose levels lead to osmotic diuresis, where water is drawn into the urine from the blood, leading to dehydration. This can cause hypotension and reduced tissue perfusion. Therefore, reversing dehydration through fluid replacement is a key part of treatment.

Choice E rationale:

Replacing insulin is a fundamental goal of therapy for this client. Insulin deficiency is the primary cause of DKA. Insulin allows glucose to enter cells where it can be used for energy, preventing the breakdown of fat for energy and the subsequent production of ketones.

Choice F rationale:

Providing respiratory support may be necessary in severe cases of DKA where the patient’s compensatory respiratory efforts are insufficient to maintain adequate gas exchange. However, it is not one of the primary goals of therapy in DKA management.