Which component of pain assessment is addressed by asking a client to rate his or her current level of discomfort on a scale of 0-10?

Intensity

Quality

Onset

Duration (Source: https://quizlet.com/303867498/pain-management-nclex-practice-quiz-25-questions-flash-cards/).

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Intensity. Intensity is one of the key components of pain assessment and it is measured by asking a client to rate his or her current level of discomfort on a scale of 0-10.

This helps to quantify the severity of pain and monitor its changes over time.

Choice B. Quality is wrong because quality refers to the nature or characteristics of pain, such as burning, stabbing, throbbing, etc. It is usually assessed by asking the client to describe the pain in his or her own words.

Choice C. Onset is wrong because onset refers to the time when the pain started or what triggered it. It is usually assessed by asking the client about the mechanism of injury or etiology of pain, if identifiable.

Choice D. Duration is wrong because duration refers to how long the pain lasts or how often it occurs. It is usually assessed by asking the client about the course or temporal pattern of pain, such as constant, intermittent, or episodic.

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Correct Answer is D

Explanation

The correct answer is choice D. Serum bilirubin.The nurse should monitor the client’s serum bilirubin level closely because acetaminophen, a non-opioid analgesic, can cause hepatotoxicity and acute liver failure in cases of overdose.

Serum bilirubin is a marker of liver function and damage.

A high level of serum bilirubin indicates jaundice, a sign of liver injury.

Choice A is wrong because serum creatinine is a marker of kidney function and damage.Acetaminophen has limited nephrotoxicity compared to NSAIDs.

Choice B is wrong because serum potassium is not directly affected by acetaminophen.

Serum potassium is an electrolyte that reflects fluid and acid-base balance in the body.

Choice C is wrong because serum albumin is a protein that is synthesized by the liver.

Although serum albumin may be low in chronic liver disease, it is not a sensitive indicator of acute liver injury caused by acetaminophen overdose.

Normal ranges for serum bilirubin are 0.3 to 1.2 mg/dL for adults and 1 to 12 mg/dL for newborns.

Normal ranges for serum creatinine are 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women.

Normal ranges for serum potassium are 3.5 to 5 mEq/L for adults and children.

Normal ranges for serum albumin are 3.4 to 5.4 g/dL for adults and children.

A. Hepatic necrosis B. Pulmonary fibrosis C. Pancreatitis D. Cardiac dysrhythmias.

Correct Answer is A

Explanation

The correct answer is choice A. Hepatic necrosis.Acetaminophen (APAP) is a common cause of drug-induced liver injury and can lead to hepatic necrosis, especially in patients who have chronic hepatitis C.APAP is metabolized by the liver and produces a toxic intermediate called N-acetyl-p-benzoquinone imine (NAPQI), which can deplete glutathione and damage hepatocytes.Patients who have chronic hepatitis C may have reduced glutathione levels and increased oxidative stress, making them more susceptible to APAP toxicity.

Choice B. Pulmonary fibrosis is wrong because APAP does not cause pulmonary fibrosis.

Pulmonary fibrosis is a chronic lung disease that involves scarring of the lung tissue and impaired gas exchange.Some drugs that can cause pulmonary fibrosis are amiodarone, bleomycin, methotrexate and nitrofurantoin.

Choice C. Pancreatitis is wrong because APAP does not cause pancreatitis.

Pancreatitis is an inflammation of the pancreas that can result from gallstones, alcohol abuse, hypertriglyceridemia, hypercalcemia, infections, trauma or certain medications.

Some drugs that can cause pancreatitis are azathioprine, valproic acid, didanosine and pentamidine.

Choice D. Cardiac dysrhythmias is wrong because APAP does not cause cardiac dysrhythmias.

Cardiac dysrhythmias are abnormal heart rhythms that can result from electrolyte imbalances, ischemia, myocardial infarction, heart failure, congenital defects or certain medications.

Some drugs that can cause cardiac dysrhythmias are digoxin, quinidine, sotalol and erythromycin.

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Which component of pain assessment is addressed by asking a client to rate his or her current level of discomfort on a scale of 0-10?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been prescribed acetaminophen, a non-opioid analgesic, for mild pain. Which laboratory test result should the nurse monitor closely in this client?

Correct Answer is D

Explanation

A nurse is caring for a client who has chronic hepatitis C and reports taking acetaminophen daily for headaches.The nurse should monitor the client for which of the following adverse effects?

Correct Answer is A

Explanation

A nurse is reviewing laboratory results for a client who takes acetaminophen for osteoarthritis pain management.Which of the following findings should alert the nurse to possible hepatotoxicity? (Select all that apply.).

A nurse is caring for a patient who is receiving epidural analgesia with buprenorphine (Buprenex). Which assessment finding would indicate that an adverse effect may be occurring?

A patient who has chronic low back pain is prescribed oxycodone (OxyContin) for long-term use. Which of the following interventions should the nurse implement to prevent complications from this medication? (Select all that apply.)

A nurse is educating a client about ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), that has been prescribed for moderate pain and inflammation. Which of the following instructions should the nurse include? (Select all that apply.).

A nurse is teaching a client who has cancer pain about the use of oral oxycodone with acetaminophen (Percocet). Which statement by the client indicates a need for further teaching?

A nurse is administering naloxone to a patient who has overdosed on heroin. What is the expected outcome of this intervention?

The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.