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","B","C","E"]
Explanation
The correct answer is choice A, B, C, and E. The nurse should use the following strategies to assess this client’s pain:
• Ask yes or no questions: This can help the client to communicate their pain level and location with minimal language difficulty.
• Use a visual analog scale (VAS): This is a self-report pain scale that uses a line with endpoints labeled as “no pain” and “worst pain imaginable”.The client can point to a position on the line that corresponds to their pain intensity.VAS has been shown to be feasible, valid, and reliable for stroke patients with mild-to-moderate aphasia.
• Observe for nonverbal cues: This can include facial expressions, body movements, vocalizations, and changes in vital signs that may indicate pain.Nonverbal cues are especially important for clients with severe aphasia who cannot use self-report scales.
• Involve family members or caregivers: They can provide information about the client’s pain history, preferences, and behaviors that may indicate pain.They can also help the nurse to communicate with the client and interpret their responses.
Choice D is wrong because open-ended questions require more complex language skills and may frustrate the client with aphasia.The nurse should use simple and direct questions that can be answered with yes or no, gestures, or pointing.
Correct Answer is ["A","C","E"]
Explanation
The correct answer is choice A, C and E. These statements indicate that the client understands the teaching about nonpharmacological pain management techniques.
• Choice A is correct becausemeditationcan help the client relax and cope with pain by reducing stress and anxiety.
• Choice C is correct becausedistractioncan help the client divert attention from pain by engaging in enjoyable or stimulating activities.
• Choice E is correct becauseheatcan help the client soothe the painful area by increasing blood flow and relaxing muscles.
• Choice B is wrong becausecold packsshould not be applied to the painful area for more than15 minutesat a time, as they can cause tissue damage or frostbite.
• Choice D is wrong becausemassageshould not be done with firm pressure, as it can aggravate the pain or cause injury.Gentle massage may be beneficial for some clients.
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