The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.
Use a standard pain assessment tool
Increase features of the scale, such as font size
Repeat instructions and questions more than once D. Ask about present level of pain rather than pain history
Ask about present level of pain rather than pain history
Allow ample time for the patient to respond (Source: https://quizlet.com/129952120/pain-assessment-hesi-flash-cards/).
Correct Answer : A,B,C,E
The correct answer is choice A, B, C and E. These actions by the nurse help facilitate the pain assessment by using a consistent and clear method to measure the patient’s pain level, enhancing the visibility and understanding of the scale, repeating the information for clarity and accuracy, and giving the patient enough time to respond without rushing or interrupting.
Choice D is wrong because asking about the present level of pain rather than the pain history is more relevant for pain management, not the pain assessment. The pain history provides valuable information about the onset, duration, frequency, quality, intensity, location, and aggravating or relieving factors of the pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
The correct answer is choice A, C and E. These statements indicate that the client understands the teaching about nonpharmacological pain management techniques.
• Choice A is correct becausemeditationcan help the client relax and cope with pain by reducing stress and anxiety.
• Choice C is correct becausedistractioncan help the client divert attention from pain by engaging in enjoyable or stimulating activities.
• Choice E is correct becauseheatcan help the client soothe the painful area by increasing blood flow and relaxing muscles.
• Choice B is wrong becausecold packsshould not be applied to the painful area for more than15 minutesat a time, as they can cause tissue damage or frostbite.
• Choice D is wrong becausemassageshould not be done with firm pressure, as it can aggravate the pain or cause injury.Gentle massage may be beneficial for some clients.
Correct Answer is D
Explanation
The correct answer is choice D. Serum bilirubin.The nurse should monitor the client’s serum bilirubin level closely because acetaminophen, a non-opioid analgesic, can cause hepatotoxicity and acute liver failure in cases of overdose.
Serum bilirubin is a marker of liver function and damage.
A high level of serum bilirubin indicates jaundice, a sign of liver injury.
Choice A is wrong because serum creatinine is a marker of kidney function and damage.Acetaminophen has limited nephrotoxicity compared to NSAIDs.
Choice B is wrong because serum potassium is not directly affected by acetaminophen.
Serum potassium is an electrolyte that reflects fluid and acid-base balance in the body.
Choice C is wrong because serum albumin is a protein that is synthesized by the liver.
Although serum albumin may be low in chronic liver disease, it is not a sensitive indicator of acute liver injury caused by acetaminophen overdose.
Normal ranges for serum bilirubin are 0.3 to 1.2 mg/dL for adults and 1 to 12 mg/dL for newborns.
Normal ranges for serum creatinine are 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women.
Normal ranges for serum potassium are 3.5 to 5 mEq/L for adults and children.
Normal ranges for serum albumin are 3.4 to 5.4 g/dL for adults and children.
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