A nurse is conducting a pain assessment for a client who reports discomfort. Which of the following actions is the most appropriate for the nurse to take to obtain a comprehensive understanding of the client's pain?
Observe the patient's facial expressions and body language for signs of discomfort.
Measure the patient's vital signs and note any changes.
Review the patient's medical history for past pain management interventions and their outcomes.
Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity.
The Correct Answer is D
A. Observe the patient's facial expressions and body language for signs of discomfort: While observation is important, it doesn't provide a complete picture of the client's pain experience and may not capture all aspects, such as intensity or location.
B. Measure the patient's vital signs and note any changes: Vital signs are important but can be nonspecific indicators of pain and are not as reliable for assessing pain intensity or quality.
C. Review the patient's medical history for past pain management interventions and their outcomes: While this is useful, it does not directly address the client's current pain experience.
D. Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity. A comprehensive pain assessment requires the client's self-report to fully understand the pain's characteristics. A pain scale (e.g., 0-10) helps quantify the intensity, and asking about its location, duration, and type allows for a thorough understanding of the pain's impact.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determine the location of the pain. The nurse should first assess the client's pain, including its location, intensity, quality, and factors that alleviate or exacerbate it. This assessment is critical to determining the most appropriate intervention and evaluating the effectiveness of the treatment.
B. Reposition the client: Repositioning is a valid nursing intervention for managing pain caused by discomfort or poor positioning. However, it should not be the first action, as the nurse must first assess the pain to determine if repositioning alone is sufficient or if medication is necessary.
C. Review the effects of the pain medication: While reviewing the effects of the prescribed medication is important to ensure its appropriateness and safety, this step is part of preparation for medication administration. It is not the first action; assessment of the client's pain takes priority.
D. Administer the medication: Administering pain medication without assessing the client's pain is not appropriate. Pain management should be individualized, and assessment ensures that the prescribed medication is suitable for the client's current pain and condition.
Correct Answer is ["B","C","D"]
Explanation
A. "You should avoid using the PCA system if you feel that the pain is manageable without medication." This is misleading as the PCA system is intended for effective pain control; clients are encouraged to use it before pain becomes severe.
B. "The PCA system is designed with safety features to prevent you from receiving too much medication." This reassures clients about the system's safety features, such as lockout mechanisms that prevent overdose.
C. "The PCA system is programmed to deliver a specific dose of medication each time you press the button." This explains how the device is pre-programmed by healthcare providers to deliver a safe, therapeutic dose.
D. "You will be able to administer pain medication to yourself by pressing the PCA button whenever you need it." This empowers the client to take control of their pain management within the limits set by the PCA system.
E. "Family members should press the PCA button for you if you are unable to do so yourself." This is unsafe. Only the client should press the PCA button to avoid overmedication or dosing errors.
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