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: Explaining the five positions for postural drainage is correct, as COPD clients benefit from varied postures to drain mucus from different lung segments. Positioning enhances gravity-assisted clearance, improving airway patency and gas exchange, ensuring the client understands the procedure for effective participation.

Choice B reason: Performing drainage after meals is incorrect, as it risks aspiration and discomfort due to gastric pressure in COPD clients with hyperinflated lungs. Timing drainage between meals ensures safety and efficacy, making this approach inappropriate for mucus clearance.

Choice C reason: Obtaining an ABG before drainage is unnecessary unless respiratory distress is evident. Postural drainage is routine in COPD to clear mucus, and ABGs monitor acid-base status, not procedure efficacy, making this choice irrelevant for standard drainage preparation.

Choice D reason: Instructing shallow, fast breathing is incorrect, as it reduces tidal volume, worsening mucus clearance in COPD. Deep, slow breathing enhances drainage by mobilizing secretions, making this approach counterproductive to the goal of improving airway clearance during the procedure.

A. Escort the client to the cafeteria B. Orient the client to the color-coding system used for locating hospital services C. Use the hospital map to show the client where the cafeteria is located D. Provide step-by-step verbal directions

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.

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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

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

Correct Answer is A

Explanation

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

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