A priority goal of the nursing pain assessment is to:

Demonstrate a caring attitude to the patient and family.

Ensure complete documentation in the EHR.

Gather subjective and objective data in order to plan and implement appropriate pain management techniques.

Develop a therapeutic relationship with the patient.

Answer and Explanation

The Correct Answer is C

Choice A: Demonstrate a caring attitude to the patient and family
While demonstrating a caring attitude is an essential aspect of nursing, it is not the primary goal of pain assessment. A caring attitude helps build trust and rapport with patients and their families, which is crucial for effective communication and overall patient care. However, the main objective of pain assessment is to gather data that will inform pain management strategies.
Choice B: Ensure complete documentation in the EHR
Ensuring complete documentation in the Electronic Health Record (EHR) is important for maintaining accurate patient records and facilitating communication among healthcare providers. However, this is a secondary goal that supports the primary objective of pain assessment. The main focus of pain assessment is to collect data that will guide pain management interventions.
Choice C: Gather subjective and objective data in order to plan and implement appropriate pain management techniques
This is the correct answer. The primary goal of a nursing pain assessment is to gather both subjective data (patient’s self-reported pain levels, descriptions, and experiences) and objective data (observations, vital signs, and physical assessments). This comprehensive data collection allows nurses to develop and implement effective pain management plans tailored to the individual needs of the patient. Accurate pain assessment is crucial for identifying the type, intensity, and cause of pain, which in turn informs the selection of appropriate pain relief measures.
Choice D: Develop a therapeutic relationship with the patient
Developing a therapeutic relationship with the patient is an important aspect of nursing care, as it fosters trust and open communication. However, it is not the primary goal of pain assessment. The main objective of pain assessment is to gather data that will inform pain management strategies. A therapeutic relationship can enhance the effectiveness of pain assessment and management, but it is a means to an end rather than the end itself.

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Correct Answer is True

Explanation

Choice A: True

The essential core of nursing practice indeed revolves around delivering holistic, patient-centered care. This approach integrates the art and science of nursing to ensure comprehensive care that addresses the physical, emotional, social, and spiritual needs of patients. Holistic care involves thorough assessment and evaluation to understand the patient’s overall health status and needs. Nurses provide a variety of interventions, from administering medications to performing procedures, to support patient health and recovery. Additionally, patient and caregiver teaching is crucial for empowering individuals to manage their health effectively. Nurses also play a vital role as members of the interprofessional healthcare team, collaborating with other healthcare professionals to ensure coordinated and effective care.

Choice B: False

The statement that the essential core of nursing practice is not to deliver holistic, patient-centered care is incorrect. Holistic, patient-centered care is a fundamental principle of nursing practice. It emphasizes the importance of treating the whole person rather than just the symptoms of a disease. This approach ensures that care is tailored to the individual needs of each patient, promoting better health outcomes and patient satisfaction. By focusing on holistic care, nurses can address the diverse aspects of a patient’s well-being, including their physical, emotional, social, and spiritual needs.

A. Potassium (K+) level of 5.6 mEq/L. B. BP 109/70. C. No nausea and vomiting. D. Watery diarrhea for 3 days. E. Lightheaded when standing up. F. Blood Urea Nitrogen (BUN) level of 30 mg/dL. G. HR 102. H. Lung sounds are clear.

Correct Answer is ["A","D","E","F","G"]

Explanation

Choice A reason:

Potassium (K+) level of 5.6 mEq/L is a critical finding that requires immediate follow-up. Hyperkalemia, defined as a potassium level greater than 5.0 mEq/L, can lead to severe cardiac complications, including arrhythmias and cardiac arrest. The patient’s ECG changes, such as alterations in the T wave and PR interval, indicate that the elevated potassium level is already affecting cardiac function. Immediate intervention is necessary to lower the potassium level and prevent life-threatening complications. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice B reason:

BP 109/70 is slightly lower than the normal range but not critically low. While it is important to monitor blood pressure, this finding does not require immediate follow-up compared to the other more critical issues. The patient’s blood pressure should be monitored regularly to ensure it does not drop further, but it is not the most urgent concern at this moment. Normal blood pressure is typically around 120/80 mmHg.

Choice C reason:

No nausea and vomiting is a positive finding indicating that the patient is not losing additional fluids and electrolytes through emesis. While it is important to note, it does not require follow-up as it does not pose an immediate risk to the patient’s health. The absence of nausea and vomiting is beneficial but does not address the primary concerns related to fluid and electrolyte imbalances.

Choice D reason:

Watery diarrhea for 3 days is a significant finding that requires follow-up due to the risk of dehydration and electrolyte imbalances. Diarrhea leads to the loss of fluids and essential electrolytes, which can result in complications such as hypovolemia and electrolyte disturbances. The patient’s ongoing diarrhea needs to be managed to prevent further fluid loss and stabilize their condition. This symptom is directly contributing to the patient’s current state of weakness and electrolyte imbalance.

Choice E reason:

Lightheaded when standing up suggests orthostatic hypotension, which can be a result of dehydration or electrolyte imbalances. This symptom indicates that the patient is experiencing hemodynamic instability, likely due to fluid loss from diarrhea. It is important to address this issue to prevent falls and further complications. Managing the underlying cause, such as rehydration and correcting electrolyte imbalances, will help stabilize the patient’s condition.

Choice F reason:

Blood Urea Nitrogen (BUN) level of 30 mg/dL is elevated, indicating impaired kidney function or dehydration. Normal BUN levels range from 6 to 24 mg/dL. An elevated BUN level suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions. Addressing the elevated BUN is essential for improving renal function and overall patient health.

Choice G reason:

HR 102 is slightly elevated, indicating tachycardia. Normal heart rate ranges from 60 to 100 beats per minute. Tachycardia can be a sign of dehydration, pain, anxiety, or other underlying conditions. In this case, the elevated heart rate is likely related to the patient’s dehydration and electrolyte imbalances. Monitoring and managing the heart rate is important to ensure the patient’s cardiovascular stability. Interventions to correct fluid and electrolyte imbalances will help normalize the heart rate.

Choice H reason:

Lung sounds are clear is an important assessment finding but does not require follow-up in the context of fluid and electrolyte imbalances. Clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection. While this is a positive finding, it does not address the immediate concerns related to the patient’s fluid and electrolyte status.

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A priority goal of the nursing pain assessment is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The essential core of nursing practice is to deliver holistic, patient-centered care. This includes assessment and evaluation, providing a variety of interventions, patient and caregiver teaching, and being a member of the interprofessional healthcare team.

Correct Answer is True

Explanation

Instructions: Use this scenario for the next 4 questions. Exhibits Indicate 5 findings in the assessment and laboratory results which require follow-up by the nurse.

Correct Answer is ["A","D","E","F","G"]

Explanation

The nurse is assigned to care for a newly admitted patient. Place the steps for using the nursing process in the correct order, starting with the first step.

The nurse is assigned to care for a newly admitted patient. Place the steps for using the nursing process in the correct order, starting with the first step.

Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

A 49-year-old female patient receives 3% NaCl solution for the correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

The following 4 questions pertain to this case study: Exhibits Which task is appropriate for the nurse to delegate to experienced certified nurse assistant (CNA)?

All patient teaching occurs in a formalized teaching session.

The following 4 questions pertain to this case study: Exhibits The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.

Neutropenia increases the patient’s risk for life-threatening infection and sepsis.