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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Obstruction of bile flow leads to accumulation of bilirubin, a pigment produced by the breakdown of red blood cells, in the bloodstream and causes jaundice (yellowing of the sclera). Yellow sclera is a concerning sign that should be reported promptly to the healthcare provider as it indicates potential bile duct obstruction and impaired liver function
A. Amber urine refers to urine that is dark yellow, often indicating concentrated urine due to dehydration or certain medications. While amber urine may be noted in various conditions, it is not specifically indicative of a complication related to cholelithiasis.
C. While flatulence may be uncomfortable for the client, it is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
D. belching may be uncomfortable for the client but is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
Correct Answer is D
Explanation
D. Vancomycin is primarily excreted by the kidneys, and monitoring serum creatinine levels helps assess renal function. Impaired renal function can affect vancomycin clearance and increase the risk of toxicity.
A. Measuring oxygen saturation is not directly related to the administration of vancomycin for Clostridium difficile infection.
B. Assessing body temperature may not be the most pertinent action before administering vancomycin for Clostridium difficile infection.
C. Auscultating bowel sounds is also not directly related to the administration of vancomycin for Clostridium difficile infection.
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