To assess the quality of an adult client's pain, which approach should the nurse use?

Identify effective pain relief measures.

Provide a numeric pain scale.

Ask the client to describe the pain.

Observe body language and movement.

Answer and Explanation

The Correct Answer is C

C. Asking the client to describe their pain allows the nurse to gather subjective information directly from the client, which can provide valuable insight into the quality, intensity, location, and duration of the pain.

A. This option focuses on pain management rather than pain assessment. While identifying effective pain relief measures is important, it does not directly address the need to assess the quality of the client's pain.

B. While numeric pain scales can be useful for quantifying pain intensity, they do not capture the quality or characteristics of the pain.

D. Observing body language and movement can provide valuable information about the client's pain experience, such as grimacing, guarding, or difficulty moving. However, this approach primarily assesses pain behaviors rather than the quality of the pain itself.

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Correct Answer is A

Explanation

A Hematemesis refers to vomiting blood, which can occur when esophageal varices rupture and bleed into the gastrointestinal tract. It is a hallmark sign of upper gastrointestinal bleeding and requires immediate medical attention. Monitoring for hematemesis allows for early detection of variceal bleeding and prompt intervention to prevent further complications.

B Brown, foamy urine may indicate the presence of blood or protein in the urine, which can occur in various kidney and urinary tract disorders.

C Clay-colored stool may indicate a lack of bile in the stool, which can occur in conditions affecting the liver or bile ducts, such as obstructive jaundice.

D Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, including cirrhosis. However, while anorexia may impact nutritional status and overall health, it is not directly related to the complications of esophageal varices.

A. Primes the inhaler with 7 pumps. B. Rinses the mouth after each use. C. Stores the medication at room temperature. D. Attaches spacer device to the Inhaler.

Correct Answer is A

Explanation

A. According to the usage guidelines for ipratropium inhalers, priming the inhaler typically requires only two sprays into the air, away from the face, before the first use to ensure proper medication dosage.

B. Rinsing the mouth after each use is a recommended practice to prevent irritation and infection.

C. Storing the medication at room temperature is correct, as extreme temperatures can affect the medication's efficacy.

D. Attaching a spacer device to the inhaler is also a recommended practice to improve medication delivery and reduce the risk of side effects.

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To assess the quality of an adult client's pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Correct Answer is A

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

Correct Answer is A

Explanation

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

The nurse is preparing a teaching plan for a group of clients who were found to be HIV positive within the last year. Members of the group express an interest in learning about the pathology of AIDS. The nurse should explain that HIV acts in which way to suppress the immune system?

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