To assess the quality of an adult client’s pain, which approach should the nurse use?

Observe body language and movement

Ask the client to describe the pain

Identify effective pain relief measures

Provide a numeric pain scale

Answer and Explanation

The Correct Answer is B

Choice A reason: Observing body language and movement provides clues to pain but is subjective and incomplete. Clients may mask pain, and movements vary. Verbal description captures quality, like burning or stabbing, guiding specific interventions, making this approach less comprehensive for pain assessment.

Choice B reason: Asking the client to describe the pain is best, as it captures quality, location, and characteristics (e.g., sharp, dull), essential for diagnosing etiology and tailoring treatment. Subjective verbal input provides detailed data, aligning with pain management guidelines, making this the most effective approach.

Choice C reason: Identifying pain relief measures is part of management, not assessment. Understanding pain quality via description informs which measures are effective, and this step follows assessment, making it premature and less focused on capturing the pain’s nature.

Choice D reason: A numeric pain scale quantifies intensity but not quality, missing details like burning or throbbing, which guide diagnosis. Descriptive verbal input provides a fuller picture, making the scale useful but secondary to asking for a detailed pain description.

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Correct Answer is A

Explanation

Choice A reason: Escorting the client with Huntington’s disease is best, as chorea and cognitive decline impair navigation and memory. Physical guidance ensures safety, preventing falls or disorientation in unfamiliar hospital settings, directly addressing the disease’s motor and cognitive deficits for effective cafeteria access.

Choice B reason: Orienting to a color-coding system is impractical, as Huntington’s cognitive impairments, like executive dysfunction, hinder processing complex visual cues. This approach overwhelms the client, increasing confusion, and is less effective than physical escorting to ensure safe and direct cafeteria navigation.

Choice C reason: Using a hospital map relies on spatial reasoning, which is impaired in Huntington’s due to basal ganglia degeneration. The client’s cognitive and motor deficits make map-based navigation challenging, increasing disorientation risk, making this less effective than escorting for cafeteria access.

Choice D reason: Step-by-step verbal directions require intact memory and processing, compromised in Huntington’s due to cortical and striatal atrophy. Verbal instructions may confuse the client, leading to navigation errors, making physical escorting a more reliable method to ensure safe cafeteria arrival.

A. Remind the client that it is also important to switch to decaffeinated coffee and tea B. Suggest that the client also plan to eat frequent small meals to reduce discomfort C. Review with the client the need to avoid foods that are rich in milk and cream D. Reinforce the teaching by asking the client to make a list of snack foods high in dairy content

Correct Answer is C

Explanation

Choice A reason: Switching to decaffeinated coffee and tea reduces acid stimulation, but it does not address the misconception about dairy coating ulcers. Dairy increases acid production, worsening ulcers, making this action less critical than correcting the client’s harmful dietary plan.

Choice B reason: Frequent small meals reduce acid load, aiding ulcer management, but the client’s dairy plan increases acid secretion, negating benefits. Correcting the dairy misconception is more urgent, as it directly worsens the ulcer, making this suggestion secondary.

Choice C reason: Reviewing the need to avoid milk and cream is best, as dairy stimulates gastric acid via gastrin release, worsening duodenal ulcers. The client’s plan to use dairy for coating is incorrect, and correcting this prevents exacerbation, aligning with evidence-based ulcer management.

Choice D reason: Reinforcing dairy use by listing snacks is harmful, as milk and cream increase acid production, aggravating ulcers. This action perpetuates the client’s misconception, worsening the condition, making it incorrect compared to correcting the dietary error.

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To assess the quality of an adult client’s pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which approach is best for the nurse to use when directing a client with Huntington’s disease to the hospital cafeteria?

Correct Answer is A

Explanation

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?

Correct Answer is C

Explanation

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The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?

To assess the quality of an adult client’s pain, which approach should the nurse use?

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