A nurse is caring for a who speaks a different language than the nurse and is 6 hr postoperative. Which of the following actions should the worse take to determine the client's level of pain?
Use the FACES pain scale to gauge the client's level of pain.
Use a communication board to interact with the client.
Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level.
Ask an assistive personnel who speaks the same language as the client to interpret.
The Correct Answer is C
Choice A Reason:
Using the FACES pain scale to gauge the client's level of pain is appropriate. This scale relies on the client's ability to understand and communicate using a specific language, which might not be possible if there is a language barrier.
Choice B Reason:
Using a communication board to interact with the client is inappropriate. While communication boards can be helpful, they might not effectively gauge the client's level of pain, especially if the client's primary language isn't available on the board.
Choice C Reason:
Using the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level is appropriate. The FLACC scale is a pain assessment tool that evaluates pain in nonverbal patients or those who can't communicate effectively. It assesses facial expressions, leg movement, activity level, crying, and consolability to determine the level of pain the patient is experiencing.
Choice D Reason:
Asking an assistive personnel who speaks the same language as the client to interpret is inappropriate. Relying on an interpreter, even if they speak the same language as the client, might not be the best approach for pain assessment, as nuances related to pain expression and interpretation might be better captured through a standardized pain assessment tool like the FLACC scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Discontinuing supplements containing vitamin C 24 hr before the test is appropriate. This is not necessary for fecal occult blood testing. However, vitamin C supplements should be avoided before certain stool tests that use a chemical reaction involving guaiac.
Choice B Reason:
Placing a thick layer of stool on the specimen card is inappropriate. The client should apply a small amount of stool to the designated area on the specimen card. A thick layer is not required, and excess stool may interfere with the test.
Choice C Reason:
Urinating prior to collecting the stool specimen is appropriate. This instruction is important because it helps prevent contamination of the stool specimen with urine, which could potentially interfere with the accuracy of the test results.
Choice D Reason:
Refraining from consuming pork 7 days before the test is inappropriate. There is no need for the client to avoid consuming pork specifically for fecal occult blood testing. The instructions usually focus on dietary restrictions that could affect the presence of blood in the stool, such as avoiding red meat or certain medications.
Correct Answer is C
Explanation
Choice A Reason:
"Your doctor has an excellent reputation for being honest with clients." This response is incorrect. While intending to provide reassurance, this statement may come across as dismissive of the client's feelings and might not address their immediate concern.
Choice B Reason:
"Why do you think the doctor is lying?" This response is incorrect. This response might come off as confrontational or defensive. It could potentially escalate the client's emotions and not effectively address their feelings of being misled.
Choice C Reason:
"You feel as if the doctor hasn't been honest with you?" This response acknowledges the client's emotions and concerns without making assumptions about the doctor's actions. It demonstrates empathy and allows the client to express their feelings and concerns further.
Choice D Reason:
"I am certain the doctor would not lie to you." This response might be perceived as dismissive or invalidating of the client's feelings and beliefs, as it asserts the nurse's certainty without fully understanding the client's perspective.
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