The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
Review the client's medical history and admission assessment.
Compare the client's current vital signs to the admission baseline.
Note how frequently doses of analgesics have been administered.
Ask the client to describe the intensity of the pain being experienced.
The Correct Answer is D
Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.
Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.
Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.
Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Offering positive reinforcement is a good practice in teaching, but it does not directly facilitate the learning of problem-solving strategies.
Choice B reason: Physical demonstrations are more suited to teaching psychomotor skills rather than problem-solving strategies.
Choice C reason: Simulation activities allow individuals to practice problem-solving in a controlled environment, which can enhance learning and retention of these strategies.
Choice D reason: Verbal analogies can aid in understanding concepts, but they are less interactive and engaging than simulation activities when it comes to learning problem-solving strategies.
Correct Answer is D
Explanation
Choice A reason: Offering fruit juice is part of good nutrition and hydration but does not directly assist with the client's breathing difficulty.
Choice B reason: Encouraging the client to eat all meals is important for nutritional support, but it is not the most critical action related to the client's immediate respiratory comfort.
Choice C reason: Lowering the bed may be a safety measure but does not address the client's need for respiratory support.
Choice D reason: Having the client hold a pillow over the abdomen can help splint the chest while coughing, reducing discomfort and facilitating deep breathing, which is essential for a client with emphysema experiencing difficulty breathing.
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