Which nursing intervention is most effective in determining the severity of a client’s pain?

Compare the client’s current vital signs to the admission baseline.

Review the client’s medical history and admission assessment.

Note how frequently doses of analgesics have been administered.

Ask the client to describe the intensity of the pain being experienced.

Answer and Explanation

The Correct Answer is D

Choice A reason: Comparing vital signs to baseline may show tachycardia from pain-induced sympathetic activation, but this is non-specific, as fever or anxiety can mimic these. Pain is subjective, involving nociceptor signaling, and the client’s direct intensity description provides the most accurate severity measure, guiding targeted treatment.

Choice B reason: Reviewing medical history provides pain context but not current severity. Pain perception involves spinal and cortical nociceptive pathways, and only the client’s description quantifies intensity. Historical data informs diagnosis, but direct assessment is more precise for evaluating present pain, ensuring appropriate analgesic intervention.

Choice C reason: Noting analgesic frequency suggests pain control needs but not current severity. Frequent dosing may indicate tolerance or inadequate relief, not intensity. Pain’s subjective nature, mediated by neural pathways, requires the client’s report to assess severity accurately, guiding dosing over indirect medication usage patterns.

Choice D reason: Asking the client to describe pain intensity directly captures their subjective experience, mediated by nociceptors and cortical perception. Using a 0–10 scale quantifies severity, guiding precise analgesia. This is most effective, as pain is personal, ensuring accurate assessment and tailored treatment to alleviate discomfort effectively.

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Correct Answer is C

Explanation

Choice A reason: Feeling emptiness reflects depression but is less urgent than access to firearms in suicidal ideation. Firearms indicate immediate risk, requiring safety planning. Emptiness needs therapy but not priority documentation, per suicide risk assessment and mental health nursing protocols.

Choice B reason: Monthly panic attacks are relevant but not the highest priority in suicidal ideation. Firearm access poses an immediate lethal risk, requiring urgent documentation. Panic attacks are secondary, per suicide risk assessment and psychiatric nursing care standards.

Choice C reason: Documenting firearm access is critical, as it indicates a means for suicide in a client with suicidal ideation. This prompts immediate safety interventions, like removing access, to prevent harm, per suicide risk assessment and patient safety protocols in psychiatric nursing.

Choice D reason: The daughter as a reason to live is protective but less urgent than firearm access, which poses immediate risk. Firearms require priority documentation to ensure safety. This is secondary, per suicide prevention and mental health assessment standards in nursing.

A. Place the chair by the bed. B. Support the client when rising. C. Determine how the client feels. D. Offer a pair of non-skid socks.

Correct Answer is C

Explanation

Choice A reason: Placing the chair by the bed is preparatory but not immediate after sitting up. Prolonged bedrest risks orthostatic hypotension from reduced plasma volume and baroreceptor sensitivity. Assessing the client’s response ensures stability before transfer, preventing falls, making this less urgent than evaluating for dizziness or hypotension.

Choice B reason: Supporting the client when rising is premature before assessing their response to sitting. Bedrest causes deconditioning, increasing orthostatic hypotension risk, leading to dizziness or syncope. Determining how the client feels confirms cardiovascular stability, preventing falls during transfer due to blood pressure drops.

Choice C reason: Determining how the client feels assesses for orthostatic hypotension, common post-bedrest due to reduced venous return and baroreceptor dysfunction. Dizziness or lightheadedness signals syncope risk during transfer. This ensures cardiovascular stability, prioritizing safety before physical support, addressing physiological changes from prolonged immobility.

Choice D reason: Offering non-skid socks prevents falls during ambulation but is secondary to assessing sitting response. Bedrest heightens hypotension risk, and ensuring the client is not dizzy takes precedence to avoid syncope. Socks are a later safety measure, making this less immediate than evaluating physiological stability.

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Which nursing intervention is most effective in determining the severity of a client’s pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

Correct Answer is C

Explanation

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

Correct Answer is C

Explanation

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