The nurse is assessing a client who is having pain in the right upper abdominal area. To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Identify effective pain relief measures.

Ask the client to describe the pain.

Provide a numeric pain scale.

Observe body language and movement.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Identifying effective pain relief measures is important, but it does not directly assess the quality of the pain. This approach focuses on management rather than understanding the pain’s characteristics.

Choice B rationale

Asking the client to describe the pain is the most direct way to assess its quality. This allows the nurse to gather detailed information about the pain’s nature, intensity, and characteristics, which is crucial for accurate diagnosis and treatment.

Choice C rationale

Providing a numeric pain scale helps quantify the pain’s intensity but does not provide qualitative details about the pain’s nature. It is useful for monitoring pain levels over time but not for initial assessment.

Choice D rationale

Observing body language and movement can give clues about pain but is subjective and less reliable than directly asking the client. It should be used as a supplementary method rather than the primary approach.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale

Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.

Choice B rationale

Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.

Choice C rationale

Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep.

Choice D rationale

Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.

Choice E rationale

Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.

A. Provide a back rub at bedtime. B. Apply wrist restraints to prevent wandering. C. Administer a PRN sedative prescription. D. Leave the door to the client’s room open slightly.

Correct Answer is D

Explanation

Choice A rationale

Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.

Choice B rationale

Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.

Choice C rationale

Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.

Choice D rationale

Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.

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The nurse is assessing a client who is having pain in the right upper abdominal area. To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","E"]

Explanation

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Correct Answer is D

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