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: Chronic constipation and gastrin levels are irrelevant to pancreatitis. Gastrin relates to gastric acid production, not pancreatic inflammation. Pancreatitis is confirmed by amylase/lipase elevation, and constipation does not reflect its severity, making this information less valuable for reporting.

Choice B reason: Bowel sounds and abdominal pain degree provide general data but are non-specific. Pancreatitis requires amylase/lipase levels for diagnosis, and nausea/vomiting severity better indicates clinical status, making this information secondary to laboratory confirmation and symptom severity.

Choice C reason: Severity of nausea and vomiting and serum amylase results are critical, as elevated amylase confirms pancreatitis, and nausea/vomiting severity reflects disease impact. These directly inform the provider about pancreatic inflammation and clinical status, making this the most valuable information to report.

Choice D reason: H. pylori antibodies and urine output are unrelated to pancreatitis. H. pylori causes gastritis, and urine output monitors hydration, but amylase and nausea/vomiting directly address pancreatitis’s diagnosis and severity, making this information less relevant for immediate reporting.

A. Heart rate 120 beats/minute B. Respiratory rate 28 breaths/minute C. Oxygen saturation 90% D. Peak expiratory flow 60% of predicted

Correct Answer is A

Explanation

Choice A reason: A heart rate of 120 beats/minute requires immediate intervention, as albuterol, a beta-agonist, stimulates cardiac beta-1 receptors, causing tachycardia. In emphysema, repeated dosing increases cardiovascular stress, risking arrhythmias or ischemia, necessitating evaluation to adjust therapy or address potential overdose effects.

Choice B reason: Respiratory rate of 28 breaths/minute is elevated but expected in emphysema with dyspnea. Albuterol aims to reduce bronchospasm, and this rate does not indicate immediate danger compared to tachycardia, which poses a cardiovascular risk, making it less urgent.

Choice C reason: Oxygen saturation of 90% is low but common in emphysema exacerbations. Albuterol improves airflow, and supplemental oxygen may address hypoxia. While concerning, this is less immediately life-threatening than tachycardia, which indicates potential albuterol toxicity, requiring urgent intervention.

Choice D reason: Peak expiratory flow at 60% reflects airflow limitation in emphysema, improved by albuterol. While low, it is not as urgent as tachycardia, which signals cardiovascular strain from repeated albuterol doses, posing a greater immediate risk to the client’s stability.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with emphysema is reporting a difficulty in breathing and exhibiting an audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

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