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
Explanation
The correct answer is choice A.Blurred vision is a common side effect of gabapentin and should be reported to the doctor.
Blurred vision can affect the patient’s ability to perform daily activities and may indicate a serious problem with the eyes or the brain.
Choice B is wrong because constipation is not a common side effect of gabapentin.
Constipation can be caused by other factors such as diet, dehydration, or lack of physical activity.
Choice C is wrong because dry mouth is a common side effect of gabapentin and does not usually require medical attention.
Dry mouth can be relieved by drinking water, chewing sugar-free gum, or using saliva substitutes.
Choice D is wrong because tinnitus is not a common side effect of gabapentin.
Tinnitus is a ringing or buzzing sound in the ears that can be caused by many conditions such as ear infections, hearing loss, or exposure to loud noises.
Correct Answer is A
Explanation
The correct answer is choice A) Respiratory rate: 10 breaths/min.This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.
Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.
The normal respiratory rate for adults is 12 to 20 breaths/min.
Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg.Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.
Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min.Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.
Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans.Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.
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