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 D

Explanation

Choice A reason: Evaluating urinary output hourly monitors renal function post-ureterolithotomy, as obstruction or complications may reduce output. However, urine leakage around the catheter suggests dislodgement or ureteral injury, risking peritonitis or infection. Reporting leakage is more urgent, as it indicates a critical catheter malfunction requiring immediate medical attention.

Choice B reason: Clamping the ureteral catheter risks obstructing urine flow, increasing pressure and causing ureteral damage or reflux, potentially leading to hydronephrosis or infection. Leakage around the catheter is a more pressing issue, indicating possible perforation or displacement, necessitating urgent reporting to prevent severe complications.

Choice C reason: Securing the catheter prevents dislodgement but is routine. Urine leakage suggests a critical issue like catheter malfunction or ureteral injury, which could cause peritonitis or fistula. Reporting leakage takes precedence, as it addresses a potentially life-threatening complication, ensuring timely intervention over standard catheter care.

Choice D reason: Reporting urine leakage is critical, as it may indicate catheter displacement or ureteral perforation, risking peritonitis or infection. Leakage suggests the catheter fails to drain urine properly, a serious post-surgical issue requiring immediate assessment, potentially via imaging or surgical correction, to prevent renal or systemic complications.

A. Reports difficulties with short-term memory since a traumatic brain injury. B. Describes self as a social drinker who drinks alcoholic beverages daily. C. Client’s medication history includes the frequent use of antidepressants. D. Medical history includes that the client was recently sexually assaulted.

Correct Answer is B

Explanation

Choice A reason: Memory issues from TBI traumatic brain injury warrant cognitive assessment, not CAGE, which screens for alcoholism. Daily drinking suggests potential misuse, requiring CAGE. Memory affects recall, not alcohol screening priority, per substance abuse and neurological assessment standards in nursing admission interviews.

Choice B reason: Daily social drinking raises suspicion for alcohol misuse, warranting the CAGE questionnaire to screen for dependence. CAGE assesses alcohol-related behaviors, critical for identifying alcoholism in clients with regular intake, per substance abuse screening and admission assessment protocols in nursing practice.

Choice C reason: Antidepressant medication use suggests depression, requiring mental health assessment, not CAGE, which is for alcohol misuse. Daily drinking indicates screening need. Antidepressants are unrelated to alcohol patterns, per psychiatric and substance abuse assessment standards in nursing care during admission.

Choice D reason: Sexual assault history trauma requires trauma-informed care, not CAGE, which screens for alcoholism. Daily drinking triggers alcohol misuse screening. Assault history addresses psychological needs, per trauma assessment and substance abuse screening protocols, but CAGE is specific to alcohol in nursing.

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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

Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

Correct Answer is D

Explanation

Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Correct Answer is B

Explanation

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

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Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

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