The nurse is caring for a client who has been admitted with recurring migraine headaches.
To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?
Observe body language and movement.
Identify effective pain relief measures.
Provide a numeric pain scale.
Ask the client to describe the pain.
The Correct Answer is D
Choice A rationale:
Observing body language and movement is a valuable method for assessing pain, but it may not provide a comprehensive understanding of the client's pain experience. Clients may have different ways of expressing pain, and verbal communication should also be considered.
Choice B rationale:
Identifying effective pain relief measures is relevant but does not assess the quality of the pain itself. It focuses on pain management rather than pain assessment.
Choice C rationale:
Providing a numeric pain scale is a useful tool for quantifying pain intensity, but it does not assess the quality of pain, which is essential for understanding the nature of migraine headaches.
Choice D rationale:
Asking the client to describe the pain is the most appropriate approach for assessing the quality of pain. It allows the client to express the characteristics of the pain, such as its location, intensity, duration, and any associated symptoms, which can aid in diagnosis and treatment planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"Tell me about your coping strategies and support system." This is an appropriate statement during the assessment of a client with panic disorder. Understanding the client's coping mechanisms and support system can help the nurse tailor the care plan to the client's specific needs and strengths.
Choice B rationale:
"How often do you experience panic attacks and what triggers them?" While this question may be relevant, it focuses primarily on the frequency and triggers of panic attacks. While this information is important, it doesn't address coping strategies or support systems, which are equally important aspects of the assessment.
Choice C rationale:
"What medications are you currently taking for your panic disorder?" This question is essential for medication management but does not directly address coping strategies or support systems, which are more pertinent to the assessment in this context.
Choice D rationale:
"Have you ever had any laboratory tests done for your panic disorder?" This question is not relevant to the assessment of panic disorder. Panic disorder is primarily diagnosed based on clinical criteria and does not require specific laboratory tests.
Correct Answer is B
Explanation
Choice A rationale:
Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.
Choice B rationale:
Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.
Choice C rationale:
Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.
Choice D rationale:
Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.
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