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 C

Explanation

Choice A reason: Cell-mediated hypersensitivity (Type IV) involves T-cells, causing delayed reactions like contact dermatitis, not acute symptoms like rash, hypotension, and dyspnea. Bee sting reactions are rapid, driven by IgE-mediated histamine release, making this immune mechanism incorrect for the client’s presentation.

Choice B reason: Autoimmune responses target self-antigens, as in lupus, not external allergens like bee venom. The client’s acute rash, hypotension, and respiratory distress indicate an allergic reaction, not autoimmunity, making this mechanism irrelevant to the anaphylactic response observed.

Choice C reason: IgE response hypersensitivity (Type I) causes anaphylaxis, as bee venom triggers IgE-mediated mast cell degranulation, releasing histamine. This leads to rash, hypotension, and bronchoconstriction, matching the client’s symptoms, making this the correct immune reaction for the acute, life-threatening presentation.

Choice D reason: Type II hypersensitivity involves antibody-mediated cytotoxicity, as in hemolytic anemia, not allergic reactions. Bee sting anaphylaxis results from IgE-driven histamine release, not cell destruction, making this mechanism incorrect for the client’s rapid-onset allergic symptoms.

A. I should use this medication in its handihaler every day B. If I have sudden shortness of breath, I will use this inhaler C. I will use my other inhaler in between uses D. When I cough up sputum, the secretions should be less thick

Correct Answer is A

Explanation

Choice A reason: Daily use of tiotropium via its handihaler is correct, as this long-acting anticholinergic bronchodilator is administered once daily for COPD maintenance. It relaxes airway smooth muscles, improving airflow, and consistent use prevents exacerbations, indicating proper understanding of the medication’s administration schedule.

Choice B reason: Using tiotropium for sudden shortness of breath is incorrect, as it is not a rescue inhaler. Tiotropium provides sustained bronchodilation over 24 hours, not rapid relief. Short-acting beta-agonists like albuterol are used for acute symptoms, indicating a need for further teaching.

Choice C reason: Using another inhaler between tiotropium doses suggests misunderstanding, as tiotropium is a once-daily maintenance therapy. Additional inhalers may be prescribed, but this statement implies incorrect timing or overuse, which could lead to improper COPD management, requiring clarification.

Choice D reason: Expecting thinner sputum is incorrect, as tiotropium does not affect mucus viscosity. It dilates airways, not liquefying secretions, which is the role of mucolytics. This misunderstanding indicates a need for teaching about tiotropium’s bronchodilatory, not mucolytic, effects in COPD.

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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

Correct Answer is C

Explanation

A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

Correct Answer is A

Explanation

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