To assess the quality of an adult client's pain, which approach should the nurse use?
Identify effective pain relief measures.
Provide a numeric pain scale.
Ask the client to describe the pain.
Observe body language and movement.
The Correct Answer is C
C. Asking the client to describe their pain allows the nurse to gather subjective information directly from the client, which can provide valuable insight into the quality, intensity, location, and duration of the pain.
A. This option focuses on pain management rather than pain assessment. While identifying effective pain relief measures is important, it does not directly address the need to assess the quality of the client's pain.
B. While numeric pain scales can be useful for quantifying pain intensity, they do not capture the quality or characteristics of the pain.
D. Observing body language and movement can provide valuable information about the client's pain experience, such as grimacing, guarding, or difficulty moving. However, this approach primarily assesses pain behaviors rather than the quality of the pain itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This ensures that the tracheostomy tube remains stable and reduces the risk of the tube becoming dislodged during the process.
A. Tying knots close to the tracheostomy tube can increase the risk of pressure ulceration and irritation to the skin around the stoma.
C. A disposable, soft foam collar with self-adhesive fastening may be used for additional support and comfort, but it does not replace the need for securing the tracheostomy ties.
D. Placing knots laterally may not provide adequate support and can increase the risk of accidental displacement of the tracheostomy tube.
Correct Answer is C
Explanation
C. Type I hypersensitivity reactions, also known as immediate hypersensitivity reactions, involve the production of IgE antibodies in response to an allergen. In this case, the bee sting likely triggered an IgE-mediated immune response, leading to the release of inflammatory mediators such as histamine. The client's symptoms of body rash, shortness of breath, tachycardia, and hypotension are characteristic of anaphylaxis, which is a severe and potentially life-threatening manifestation of Type I hypersensitivity reactions.
A.. Type II hypersensitivity reactions occur when the immune system targets antigens on the body's own cells, leading to cell destruction or dysfunction.
B. Autoimmune responses involve the immune system mistakenly attacking the body's own tissues and organs, leading to inflammation and tissue damage.
D. Cell-mediated hypersensitivity reactions involve the activation of T cells and the release of cytokines, resulting in inflammation and tissue damage. Examples include delayed-type hypersensitivity reactions such as contact dermatitis or tuberculin skin testing reactions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today