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 C

Explanation

Choice A reason: Hyperventilation rapidly eliminates carbon dioxide, causing respiratory alkalosis, not acidosis. In respiratory acidosis, hypoventilation retains CO2, increasing blood carbonic acid, lowering pH. This contradicts the client’s condition, as rapid CO2 loss would raise, not lower, blood pH.

Choice B reason: Blood oxygen levels stimulating respiration may occur in hypoxia but do not directly cause respiratory acidosis. Low oxygen can coexist with CO2 retention, but acidosis results from high CO2, not oxygen-driven respiratory changes, making this choice irrelevant to the pathophysiology.

Choice C reason: High blood carbon dioxide levels cause respiratory acidosis, as hypoventilation in respiratory distress retains CO2, forming carbonic acid, lowering blood pH. This aligns with the client’s condition, where impaired gas exchange increases CO2, driving acid-base imbalance, making this the correct pathophysiological process.

Choice D reason: Carbon dioxide conversion in kidneys occurs during bicarbonate buffering, a compensatory mechanism, not the primary cause of respiratory acidosis. Acidosis results from pulmonary CO2 retention, not renal processes, which are secondary and slower, making this choice incorrect for the acute condition.

A. Teach a family member to administer eye drops B. Obtain vital signs every 2 hours during hospitalization C. Provide an eye shield to be worn while sleeping D. Encourage deep breathing and coughing exercises

Correct Answer is C

Explanation

Choice A reason: Teaching a family member to administer eye drops is important for post-discharge care but not immediate post-procedure. Eye protection is critical initially to prevent injury, as drops are typically nurse-administered in-hospital, making this intervention secondary.

Choice B reason: Obtaining vital signs every 2 hours monitors systemic stability but is not specific to eye surgery. Local protection of the surgical site with an eye shield prevents immediate complications like trauma, making vital signs monitoring less urgent post-procedure.

Choice C reason: Providing an eye shield for sleeping is critical immediately post-procedure, as the right eye is vulnerable to accidental trauma during sleep. The shield protects the surgical site, preventing complications like infection or displacement, making this the priority intervention for recovery.

Choice D reason: Deep breathing and coughing exercises prevent pulmonary complications in major surgeries, not minor eye procedures. These actions may increase intraocular pressure, risking surgical site damage, making this intervention inappropriate and potentially harmful post-eye surgery.

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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 who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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