A nurse is assessing a client for acute postoperative pain. Which of the following actions should the nurse take first?
Provide an analgesic for pain.
Obtain a self-report from the client.
Observe the client's behaviors.
Develop a behavioral pain score.
The Correct Answer is B
A. Provide an analgesic for pain. Administering medication is important but should be done after assessing the pain.
B. Obtain a self-report from the client. The client's self-report is the most reliable indicator of pain and should be obtained first.
C. Observe the client's behaviors. Observing behaviors is helpful but should follow the self-report to validate the client's experience.
D. Develop a behavioral pain score. This can be useful for non-verbal clients, but the self-report is the primary method of assessment for verbal clients.
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Related Questions
Correct Answer is D
Explanation
A. Airborne precautions are used for diseases that spread through airborne particles, such as tuberculosis and varicella, not bacterial meningitis.
B. Protective environment precautions are used for clients with severely compromised immune systems, not for preventing the spread of bacterial meningitis.
C. Contact: Contact precautions are used for infections spread by direct contact with the patient or their environment, such as MRSA or C. difficile, not bacterial meningitis.
D. Droplet: This is correct. Droplet precautions are required for bacterial meningitis as it spreads through large respiratory droplets.
Correct Answer is C
Explanation
A. "Self-examinations should be completed every 3 months." Self-examinations should be performed monthly, not every 3 months.
B. "I should squeeze the testicles firmly to determine the presence of lumps." Squeezing firmly can cause pain and is not necessary. The testicles should be examined gently.
C. "I should perform a self-examination after a warm shower." The warmth of the shower relaxes the scrotal skin, making it easier to feel any abnormalities.
D. "I should examine both of my testicles at the same time." Each testicle should be examined separately to ensure a thorough examination.
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