A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?

Pulse and blood pressure findings

Scheduled treatments and client illness

A self-report pain rating scale

Behavioral indicators and aﬀect

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be inﬂuenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.

Choice B Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reﬂect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.

Choice C Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reﬂects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.

Choice D Reason: This is incorrect. Behavioral indicators and aﬀect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be inﬂuenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.

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Correct Answer is A

Explanation

The correct answer is: A. Elective cardioversion

Choice A reason:

Elective cardioversion is a medical procedure that is used to restore a normal heart rhythm in patients experiencing certain types of arrhythmias, including ventricular tachycardia (VT), when they are stable. It involves the delivery of a controlled electric shock to the heart, which is synchronized with the heart's electrical activity to convert the abnormal rhythm back to a normal sinus rhythm. This procedure is typically performed when VT is not causing hemodynamic instability and the patient is not in immediate danger.

Choice B reason:

Defibrillation is an emergency treatment for life-threatening cardiac arrhythmias, particularly ventricular fibrillation (VF) or pulseless ventricular tachycardia. It involves delivering a high-energy electric shock to the heart unsynchronized to the heart's electrical cycle, aiming to reset the heart's electrical state and allow it to reestablish an effective rhythm. In the scenario provided, where the patient is experiencing VT but not VF, defibrillation would not be the first line of action unless the VT deteriorates into VF or the patient becomes pulseless.

Choice C reason:

CPR, or cardiopulmonary resuscitation, is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. In the case of VT, if the patient is conscious and has a pulse, CPR is not indicated. CPR would only be necessary if the patient's heart stops beating (cardiac arrest) as a result of the VT.

Choice D reason:

Radiofrequency catheter ablation is a procedure used to treat some types of arrhythmias, including VT, by destroying the area of heart tissue that is causing the abnormal heart rhythm. This treatment is generally considered when medication is ineffective or not tolerated, or in recurrent VT. It is not typically the first line of treatment in an acute setting where the patient is stable and experiencing VT.

A. Cold and numb sensation distal to the fistula site B. A raised red rash around the fistula site C. Pain in the right arm proximal to the fistula site D. Foul-smelling drainage from the fistula site

Correct Answer is A

Explanation

Choice A: Cold and numb sensation distal to the fistula site is a possible indication of venous insufficiency. Venous insufficiency is a condition in which the veins have difficulty returning blood from the limbs to the heart, resulting in blood pooling and reduced perfusion. A new arteriovenous fistula can cause increased blood ﬂow through the artery and decreased blood ﬂow through the vein, leading to venous insufficiency. This can manifest as coldness, numbness, tingling, or cyanosis in the fingers or hand below the fistula site.

Choice B: A raised red rash around the fistula site is not a possible indication of venous insufficiency. A raised red rash around the fistula site can indicate an allergic reaction, an infection, or an inﬂammation of the skin or subcutaneous tissue. The nurse should assess the rash for size, shape, color, texture, temperature, and drainage, and report any signs of infection or inﬂammation, such as fever, pus, or swelling.

Choice C: Pain in the right arm proximal to the fistula site is not a possible indication of venous insufficiency. Pain in the right arm proximal to the fistula site can indicate arterial insufficiency, which is a condition in which the arteries have difficulty delivering oxygen-rich blood to the tissues, resulting in ischemia and necrosis. Arterial insufficiency can be caused by atherosclerosis, thrombosis, embolism, or vasospasm. The nurse should assess the pain for location, intensity, duration, frequency, and quality, and report any signs of ischemia or necrosis, such as pallor, coolness, weak pulses, or ulceration.

Choice D: Foul-smelling drainage from the fistula site is not a possible indication of venous insufficiency. Foul-smelling drainage from the fistula site can indicate an infection of the fistula or surrounding tissue. The nurse should assess the drainage for color, odor, amount, and consistency, and report any signs of infection or sepsis, such as fever, chills, malaise, or hypotension.

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A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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