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: 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. Monitor daily urine output volume B. Use salt tablets after strenuous exercise C. Review food labels for sodium content D. Drink plenty of water whenever thirsty

Correct Answer is C

Explanation

Choice A reason: Monitoring urine output assesses fluid status but does not directly prevent hypernatremia, which results from excess sodium or water loss. Reducing dietary sodium intake is more proactive, as urine output is a secondary indicator, making this instruction less effective for management.

Choice B reason: Using salt tablets after exercise is dangerous, as they increase sodium intake, worsening hypernatremia. This condition requires sodium reduction and water replacement, making this instruction harmful, as it exacerbates elevated serum sodium levels, risking neurological complications.

Choice C reason: Reviewing food labels for sodium content is critical, as hypernatremia results from high sodium intake or water loss. Limiting dietary sodium prevents further elevation of serum sodium, protecting against cerebral edema or seizures, making this the most effective discharge instruction.

Choice D reason: Drinking water when thirsty helps hydration but is reactive and insufficient for hypernatremia, which requires proactive sodium reduction. Thirst may be impaired in some patients, and dietary sodium control is more direct, making this instruction less comprehensive than label review.

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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 A

Explanation

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

Correct Answer is C

Explanation

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