The nurse is caring for a patient from another culture who recently had surgery on their right arm. The patient grimaces every time the nurse tries to assess the right arm, however when asked about their pain level the patient reports, "The pain is not so bad, I can take it. Which of the following should the nurse do next?

Assess the patient for physiological indicators of pain.

Observe the patient for behavior that is indicative of pain.

Involve the patient in the pain assessment by asking more direct questions.

Compare the patient's facial expression to a FACES pain scale.

Answer and Explanation

The Correct Answer is C

A. Assess the patient for physiological indicators of pain. While assessing physiological indicators (such as increased heart rate, blood pressure, or sweating) can provide clues about pain, these signs are not always reliable and can be influenced by other factors. This option does not directly address the patient’s verbal and non-verbal communication about their pain.

B. Observe the patient for behavior that is indicative of pain. Observing the patient’s behavior can be helpful, but it is not sufficient on its own. The patient’s cultural background may influence how they express pain, and relying solely on observation might lead to underestimating their pain.

C. Involve the patient in the pain assessment by asking more direct questions. This is the best option because it respects the patient’s cultural background and encourages a more accurate and detailed assessment of their pain. By asking direct questions, the nurse can gain a better understanding of the patient’s pain experience and provide appropriate care.

D. Compare the patient's facial expression to a FACES pain scale. Using a FACES pain scale can be useful, especially for patients who have difficulty verbalizing their pain. However, this option does not involve the patient in a more detailed discussion about their pain, which is crucial given the cultural context and the patient’s reluctance to openly admit to pain.

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Correct Answer is A

Explanation

A. Assess the patient's decision to ensure this is an informed and voluntary choice. This option ensures that the patient’s choice is informed and voluntary, which is crucial for respecting patient autonomy and making sure that the decision aligns with their wishes and understanding.

B. Tell the patient that this decision is a form of suicide and is not permitted in the hospital. This response dismisses the patient’s feelings and fails to address the underlying issues. It also does not respect patient autonomy or provide compassionate care.

C. Immediately support the patient's wishes by removing food and water from the room. This action might not be appropriate without first ensuring that the decision is informed and voluntary. The patient’s needs and feelings should be fully explored first.

D. Explain to the patient that their feelings are part of the grieving process. This response might minimize the patient’s current experience and needs. While feelings of distress may be part of the process, addressing the patient’s wishes and ensuring informed consent is more crucial.

A. DNR prevents resuscitation while AND allows for feeding tubes only. B. Both orders require healthcare professionals do everything possible to save the patient. C. Both orders prevent resuscitation, however, AND is more perceived to be more helpful. D. DNR allows mechanical ventilation while AND prevents all resuscitation efforts.

Correct Answer is C

Explanation

A. "DNR prevents resuscitation while AND allows for feeding tubes only." This is incorrect as the Allow Natural Death (AND) order does not specifically address feeding tubes; it focuses on allowing natural death without aggressive life-sustaining interventions.

B. "Both orders require healthcare professionals do everything possible to save the patient." This is incorrect because both DNR and AND orders are intended to prevent certain resuscitation efforts. The goal of both is to limit or avoid aggressive interventions, though AND is more focused on allowing natural death with comfort care.

C. "Both orders prevent resuscitation; however, AND is more perceived to be more helpful." Both DNR and AND orders prevent resuscitation efforts, but AND is often perceived as a more comprehensive approach to end-of-life care, focusing on comfort and allowing a natural death.

D. "DNR allows mechanical ventilation while AND prevents all resuscitation efforts." This is incorrect because a DNR order specifically addresses not performing CPR, but it does not necessarily prevent other forms of life support such as mechanical ventilation. AND is a broader term that generally aims to limit all forms of aggressive treatment, including mechanical ventilation.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a seriously ill patient with a terminal disease who states, "I do not want to eat anymore, I cannot prolong this agony." Which of the following interventions should the nurse do first?

Correct Answer is A

Explanation

The nurse is discussing the difference between a Do Not Resuscitate (DNR) order and a Allow Natural Death (AND) order to a patient with a terminal illness. Which of the following correctly explains the difference of these two orders?

Correct Answer is C

Explanation

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