The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?
Provide a numeric pain scale.
Observe body language and movement.
Ask the client to describe the pain.
Identify effective pain relief measures.
The Correct Answer is C
A. Provide a numeric pain scale:
While a numeric pain scale can help quantify the intensity of pain, it does not directly assess the quality or characteristics of the pain, which is important for identifying potential causes and selecting appropriate interventions.
B. Observe body language and movement:
Observing body language and movement can provide valuable information about the client's pain experience, but it primarily assesses the behavior associated with pain rather than the quality or characteristics of the pain itself.
C. Ask the client to describe the pain:
This approach allows the client to provide subjective information about the pain, including its quality, location, intensity, duration, and aggravating or alleviating factors. Asking the client to describe the pain helps the nurse gain insight into its characteristics, which can aid in identifying the underlying cause and determining appropriate interventions.
D. Identify effective pain relief measures:
Identifying effective pain relief measures is important for managing the client's pain, but it does not directly assess the quality or characteristics of the pain. Before implementing pain relief measures, it's essential to understand the nature of the pain through client self-report or other assessment methods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Provide a numeric pain scale:
While a numeric pain scale can help quantify the intensity of pain, it does not directly assess the quality or characteristics of the pain, which is important for identifying potential causes and selecting appropriate interventions.
B. Observe body language and movement:
Observing body language and movement can provide valuable information about the client's pain experience, but it primarily assesses the behavior associated with pain rather than the quality or characteristics of the pain itself.
C. Ask the client to describe the pain:
This approach allows the client to provide subjective information about the pain, including its quality, location, intensity, duration, and aggravating or alleviating factors. Asking the client to describe the pain helps the nurse gain insight into its characteristics, which can aid in identifying the underlying cause and determining appropriate interventions.
D. Identify effective pain relief measures:
Identifying effective pain relief measures is important for managing the client's pain, but it does not directly assess the quality or characteristics of the pain. Before implementing pain relief measures, it's essential to understand the nature of the pain through client self-report or other assessment methods.
Correct Answer is D
Explanation
A. Places food on the unaffected side of the mouth:
This is correct practice for clients at risk for aspiration. Placing food on the unaffected side helps ensure safer swallowing.
B. Raises the head of the bed to 60 degrees:
This is appropriate as it helps reduce the risk of aspiration by promoting proper positioning during feeding.
C. Positions the head with the chin tilted slightly downward:
Positioning the head with the chin tilted slightly downward (chin tuck) helps close off the airway during swallowing, further reducing the risk of aspiration. This is another appropriate technique to minimize the risk of aspiration during feeding.
D. Allows 30 minutes of rest before feeding:
This is incorrect because it’s generally important to avoid long periods of rest before feeding. The client should be well-rested, but allowing 30 minutes specifically as a rest period before feeding is not a standard practice and may not align with the client's needs or feeding protocols.
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