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","B"]
Explanation
Choice A rationale:
Fresh or frozen vegetables without sauce. Rationale: Fresh or frozen vegetables without sauce are excellent choices for a client with hypertension. These foods are low in sodium and can help manage blood pressure effectively. The absence of added sauces ensures that there is no hidden sodium content.
Choice B rationale:
Fruits without sauce. Rationale: Fruits without sauce are also suitable for clients with hypertension. They are naturally low in sodium and provide essential nutrients that can support blood pressure control. The absence of sauce ensures that no additional sodium is added.
Choice C rationale:
Pickled olives. Rationale: Pickled olives are high in sodium due to the pickling process. Therefore, they are not recommended for clients with hypertension as they can lead to an increase in blood pressure.
Choice D rationale:
Canned soup. Rationale: Canned soup often contains high levels of sodium, which is not suitable for clients with hypertension. Excessive sodium intake can contribute to elevated blood pressure and should be avoided.
Choice E rationale:
Cottage cheese. Rationale: Cottage cheese is generally considered acceptable for clients with hypertension, especially if it is the low-sodium or reduced-sodium variety. However, it is not as strongly recommended as fresh or frozen vegetables and fruits without sauce.
Correct Answer is A
Explanation
- A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suffering and improving the quality of life for the client and their family.
- An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admited to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care.
- A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation.
- Health care proxy documentation is an important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reflects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because the name of the funeral home to contact is not relevant or necessary for the admission assessment of a terminally ill client, as it does not affect their health status or care plan.
Option C is incorrect because the client's wishes regarding organ donation may be included in their health care proxy documentation, but they are not required or essential for the admission assessment of a terminally ill client.
Option D is incorrect because the contact information for the client's next of kin may be useful for communication and support purposes, but it is not as important as the health care proxy documentation for the admission assessment of a terminally ill client.
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