The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.
Use a standard pain assessment tool
Increase features of the scale, such as font size
Repeat instructions and questions more than once D. Ask about present level of pain rather than pain history
Ask about present level of pain rather than pain history
Allow ample time for the patient to respond (Source: https://quizlet.com/129952120/pain-assessment-hesi-flash-cards/).
Correct Answer : A,B,C,E
The correct answer is choice A, B, C and E. These actions by the nurse help facilitate the pain assessment by using a consistent and clear method to measure the patient’s pain level, enhancing the visibility and understanding of the scale, repeating the information for clarity and accuracy, and giving the patient enough time to respond without rushing or interrupting.
Choice D is wrong because asking about the present level of pain rather than the pain history is more relevant for pain management, not the pain assessment. The pain history provides valuable information about the onset, duration, frequency, quality, intensity, location, and aggravating or relieving factors of the pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Intensity.Intensity is one of the key components of pain assessmentand it is measured by asking a client to rate his or her current level of discomfort on a scale of 0-10.
This helps to quantify the severity of pain and monitor its changes over time.
Choice B. Quality is wrong because quality refers to the nature or characteristics of pain, such as burning, stabbing, throbbing, etc.It is usually assessed by asking the client to describe the pain in his or her own words.
Choice C.Onset is wrong because onset refers to the time when the pain started or what triggered it.It is usually assessed by asking the client about the mechanism of injury or etiology of pain, if identifiable.
Choice D.Duration is wrong because duration refers to how long the pain lasts or how often it occurs.It is usually assessed by asking the client about the course or temporal pattern of pain, such as constant, intermittent, or episodic.
Correct Answer is A
Explanation
The correct answer is choice A. Avoid driving while taking this medication.The nurse should instruct the client to avoid driving or operating heavy machinery while taking acetaminophen and hydrocodone (Vicodin) because these medications can cause drowsiness, dizziness, and impaired mental function.The nurse should also warn the client about the risk of addiction, overdose, and death from misuse of this medication.
Choice B is wrong because taking this medication on an empty stomach can increase the risk of nausea and vomiting.The nurse should advise the client to take this medication with food or milk to prevent stomach upset.
Choice C is wrong because increasing the intake of foods rich in vitamin K is not relevant to taking acetaminophen and hydrocodone (Vicodin).Vitamin K is involved in blood clotting and may interact with some anticoagulant medications, but not with this medication.
Choice D is wrong because limiting fluid intake to prevent fluid retention is not necessary for a client taking acetaminophen and hydrocodone (Vicodin).This medication does not cause fluid retention or edema.The nurse should encourage the client to drink plenty of fluids to prevent constipation, which is a common side effect of opioid medications.
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