A client with a hip fracture is requesting pain medication prior to being repositioned in the bed. To assess the quality of the client's pain, which approach should the nurse use?

Observe body language and movement.

Provide a numeric pain scale.

Identify effective pain relief measures.

Ask the client to describe the pain.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Observe body language and movement: Nonverbal cues such as guarding, grimacing, or limited movement can suggest the presence of pain, but they do not describe its quality. Observation alone cannot determine characteristics such as sharp, dull, throbbing, or burning. These cues are supportive but incomplete for pain assessment.

B. Provide a numeric pain scale: A numeric scale measures pain intensity but does not assess quality. Knowing how severe the pain is does not explain its nature or character. Quality assessment requires descriptive information beyond numerical rating.

C. Identify effective pain relief measures: Determining what relieves pain helps evaluate prior interventions but does not define the pain’s characteristics. This approach is more useful after quality and intensity have already been established. It does not directly assess the nature of the pain.

D. Ask the client to describe the pain: Pain quality is best assessed through the client’s subjective description using terms such as sharp, aching, stabbing, or burning. This information guides appropriate pain management and anticipates responses to movement or repositioning. Client self-report is the most reliable method for pain assessment.

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Correct Answer is A

Explanation

Rationale:
A. Imbalanced Nutrition: less than body requirements: Malnutrition is the most immediate threat to life in adolescents with anorexia nervosa. Addressing inadequate nutrition is critical to prevent complications such as electrolyte imbalances, cardiac arrhythmias, and organ failure, making it the highest priority.

B. Interrupted Family Processes: Family dysfunction can contribute to the disorder, but it is not an immediate threat to the client’s physical health. It is a secondary concern to nutritional stabilization.

C. Noncompliance with treatment regimen: Noncompliance affects long-term outcomes, but the immediate risk from malnutrition takes precedence. Interventions for compliance follow stabilization.

D. Disturbed Body Image: Body image concerns are central to anorexia nervosa but primarily affect psychosocial health. While important for therapy, they are not the most urgent nursing problem compared with physiological risk.

A. Gram-negative and gram-positive bacteria on blood cultures. B. Third spacing of fluid into the vascular space. C. Jugular venous distention (JVD). D. Decrease in systolic blood pressure during inspiration. E. Hyperactive deep tendon reflexes (DTR).

Correct Answer is ["C","D"]

Explanation

Rationale:
A. Gram-negative and gram-positive bacteria on blood cultures: The presence of bacteria indicates sepsis, which is associated with distributive shock, not obstructive shock. This finding does not reflect mechanical or obstructive circulatory compromise.

B. Third spacing of fluid into the vascular space: Third spacing (fluid shift into interstitial or nonfunctional spaces) occurs in hypovolemic or distributive shock but is not characteristic of obstructive shock, which involves a physical barrier to blood flow.

C. Jugular venous distention (JVD): JVD is a classic sign of obstructive shock caused by impaired venous return to the heart, such as in cardiac tamponade, tension pneumothorax, or massive pulmonary embolism. Elevated central venous pressure reflects backflow from the obstruction.

D. Decrease in systolic blood pressure during inspiration: Pulsus paradoxus, a drop in systolic blood pressure >10 mmHg during inspiration, is indicative of obstructive shock, often seen in cardiac tamponade or severe tension pneumothorax. This reflects impaired ventricular filling.

E. Hyperactive deep tendon reflexes (DTR): Hyperactive DTRs are associated with neurologic conditions or electrolyte imbalances, not obstructive shock. They do not provide information about circulatory obstruction or hemodynamic compromise.

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A client with a hip fracture is requesting pain medication prior to being repositioned in the bed. To assess the quality of the client's pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is A

Explanation

The nurse is caring for a client in the intensive care unit (ICU) that has multisystem alterations following abdominal surgery. Which finding(s) indicate that the client is experiencing obstructive shock? Select all that apply.

Correct Answer is ["C","D"]

Explanation

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A client with a hip fracture is requesting pain medication prior to being repositioned in the bed. To assess the quality of the client's pain, which approach should the nurse use?

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