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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Pancreatitis is indicated by elevated amylase and lipase, abdominal pain radiating to the back, vomiting, and fever. Cholecystectomy can trigger pancreatic inflammation due to bile duct manipulation or gallstone migration, causing enzyme leakage, making this the condition to observe for based on the findings.

Choice B reason: Peritonitis causes diffuse abdominal pain and fever but not typically elevated pancreatic enzymes. Post-cholecystectomy, localized pain and specific amylase/lipase elevation point to pancreatitis, not peritoneal infection, making this condition less likely based on the client’s presentation.

Choice C reason: Cholangitis involves bile duct infection, causing jaundice and right-upper-quadrant pain, but not elevated amylase/lipase. The client’s pancreatic enzyme elevation and back-radiating pain align with pancreatitis, not bile duct inflammation, making this condition incorrect for the observed findings.

Choice D reason: Ileus causes vomiting and abdominal distension but not elevated pancreatic enzymes or back-radiating pain. Pancreatitis better explains the client’s enzyme levels, pain pattern, and fever post-cholecystectomy, as ileus lacks specific pancreatic involvement, making this condition unlikely.

A. Test for Helicobacter pylori B. Give intravenous fluids C. Insert a rectal tube D. Monitor hemoglobin

Correct Answer is B

Explanation

Choice A reason: Testing for Helicobacter pylori is irrelevant, as vomiting and anorexia 8 days post-laparotomy suggest postoperative complications like ileus or obstruction, not peptic ulcer disease. H. pylori causes gastritis, not acute surgical issues, making this action inappropriate for the client’s current presentation.

Choice B reason: Giving intravenous fluids is critical, as vomiting and refusal to eat post-laparotomy risk dehydration and electrolyte imbalances. Fluids restore volume, stabilize hemodynamics, and support recovery from potential ileus or obstruction, addressing the client’s acute symptoms and preventing further deterioration.

Choice C reason: Inserting a rectal tube is inappropriate, as vomiting indicates upper gastrointestinal issues, not lower bowel obstruction. Post-laparotomy vomiting suggests ileus or adhesion, and rectal tubes do not address gastric or small bowel complications, making this action ineffective.

Choice D reason: Monitoring hemoglobin assesses blood loss, relevant post-laparotomy, but vomiting and anorexia prioritize fluid replacement to prevent dehydration. Hemoglobin checks are secondary, as fluid loss is the immediate threat, making IV fluids the more urgent intervention for stabilization.

View Question and Answer

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit (ICU), the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to “speak up” so that she can hear the questions. Which action is best for the nurse to take?

While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider (HCP), the nurse should note which of the client’s laboratory values?

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?