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

Observe body language and movement

Ask the client to describe the pain

Identify effective pain relief measures

Provide a numeric pain scale

Answer and Explanation

The Correct Answer is B

Choice A reason: Observing body language and movement provides clues to pain but is subjective and incomplete. Clients may mask pain, and movements vary. Verbal description captures quality, like burning or stabbing, guiding specific interventions, making this approach less comprehensive for pain assessment.

Choice B reason: Asking the client to describe the pain is best, as it captures quality, location, and characteristics (e.g., sharp, dull), essential for diagnosing etiology and tailoring treatment. Subjective verbal input provides detailed data, aligning with pain management guidelines, making this the most effective approach.

Choice C reason: Identifying pain relief measures is part of management, not assessment. Understanding pain quality via description informs which measures are effective, and this step follows assessment, making it premature and less focused on capturing the pain’s nature.

Choice D reason: A numeric pain scale quantifies intensity but not quality, missing details like burning or throbbing, which guide diagnosis. Descriptive verbal input provides a fuller picture, making the scale useful but secondary to asking for a detailed pain description.

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Correct Answer is A

Explanation

Choice A reason: Culture and sensitivity identify the causative organism and antibiotic susceptibility of purulent drainage, indicating a wound infection. This guides targeted antimicrobial therapy, as postoperative infections may involve resistant bacteria like MRSA, ensuring effective treatment and preventing complications like sepsis or delayed healing.

Choice B reason: C-reactive protein indicates systemic inflammation but is non-specific for wound infections. Purulent drainage requires pathogen identification via culture to guide therapy. While elevated CRP may support infection suspicion, it does not direct antibiotic choice, making it less critical than culture results.

Choice C reason: Serum blood glucose is relevant for wound healing, as hyperglycemia impairs immune response, but it does not identify the infection’s cause. Purulent drainage requires microbiological data from culture to select antibiotics, making glucose levels secondary for immediate infection management.

Choice D reason: Blood pH level assesses acid-base balance, irrelevant to localized wound infection. Purulent drainage indicates bacterial infection, requiring culture to identify pathogens. pH may be altered in systemic sepsis, but culture is the priority for guiding therapy in postoperative wound infections.

A. Remind the client that it is also important to switch to decaffeinated coffee and tea B. Suggest that the client also plan to eat frequent small meals to reduce discomfort C. Review with the client the need to avoid foods that are rich in milk and cream D. Reinforce the teaching by asking the client to make a list of snack foods high in dairy content

Correct Answer is C

Explanation

Choice A reason: Switching to decaffeinated coffee and tea reduces acid stimulation, but it does not address the misconception about dairy coating ulcers. Dairy increases acid production, worsening ulcers, making this action less critical than correcting the client’s harmful dietary plan.

Choice B reason: Frequent small meals reduce acid load, aiding ulcer management, but the client’s dairy plan increases acid secretion, negating benefits. Correcting the dairy misconception is more urgent, as it directly worsens the ulcer, making this suggestion secondary.

Choice C reason: Reviewing the need to avoid milk and cream is best, as dairy stimulates gastric acid via gastrin release, worsening duodenal ulcers. The client’s plan to use dairy for coating is incorrect, and correcting this prevents exacerbation, aligning with evidence-based ulcer management.

Choice D reason: Reinforcing dairy use by listing snacks is harmful, as milk and cream increase acid production, aggravating ulcers. This action perpetuates the client’s misconception, worsening the condition, making it incorrect compared to correcting the dietary error.

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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

While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider (HCP), the nurse should note which of the client’s laboratory values?

Correct Answer is A

Explanation

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?

Correct Answer is C

Explanation

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

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?

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