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. Heart rate 120 beats/minute B. Respiratory rate 28 breaths/minute C. Oxygen saturation 90% D. Peak expiratory flow 60% of predicted

Correct Answer is A

Explanation

Choice A reason: A heart rate of 120 beats/minute requires immediate intervention, as albuterol, a beta-agonist, stimulates cardiac beta-1 receptors, causing tachycardia. In emphysema, repeated dosing increases cardiovascular stress, risking arrhythmias or ischemia, necessitating evaluation to adjust therapy or address potential overdose effects.

Choice B reason: Respiratory rate of 28 breaths/minute is elevated but expected in emphysema with dyspnea. Albuterol aims to reduce bronchospasm, and this rate does not indicate immediate danger compared to tachycardia, which poses a cardiovascular risk, making it less urgent.

Choice C reason: Oxygen saturation of 90% is low but common in emphysema exacerbations. Albuterol improves airflow, and supplemental oxygen may address hypoxia. While concerning, this is less immediately life-threatening than tachycardia, which indicates potential albuterol toxicity, requiring urgent intervention.

Choice D reason: Peak expiratory flow at 60% reflects airflow limitation in emphysema, improved by albuterol. While low, it is not as urgent as tachycardia, which signals cardiovascular strain from repeated albuterol doses, posing a greater immediate risk to the client’s stability.

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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

A client with emphysema is reporting a difficulty in breathing and exhibiting an audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

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