When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

Ask the client to describe the pain experienced.

Provide the client with a visual analog scale.

Instruct the client in use of a numeric pain scale.

Gently palpate the area and observe the response.

Answer and Explanation

The Correct Answer is A

A.   Asking the client to describe the pain is the most direct way to gather information about the quality of the pain. This approach allows the client to express characteristics such as whether the pain is sharp, dull, burning, aching, throbbing, or stabbing.
B.   A visual analog scale (VAS) is useful for assessing the intensity of pain, not the quality. The VAS typically involves a line with endpoints representing no pain and worst possible pain, where the client marks their pain level.
C.   The numeric pain scale is designed to measure the intensity of pain on a scale from 0 to 10, where 0 indicates no pain and 10 represents the worst pain imaginable. Like the VAS, this scale assesses pain intensity rather than quality.
D.   Palpation and observing the client's response can help assess the location and intensity of pain, particularly if there are physical findings associated with the pain. However, this method does not provide information about the pain’s quality, such as its character or nature.

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Correct Answer is ["A","B","C"]

Explanation

A. Escorting the client back to their room is a direct and immediate intervention that ensures the client is safely returned to a controlled environment. This action helps prevent further wandering and reduces the risk of falls or accidents.
B. Securing a bed alarm is a preventive measure that helps alert staff if the client attempts to get out of bed. This can be particularly useful for clients who are confused or at risk of wandering. The alarm provides an early warning to intervene before the client leaves the bed, thereby enhancing their safety and reducing the risk of falls.
C. Orienting the client helps them become more aware of their environment and can reduce confusion. Providing verbal cues and reassuring the client about their location and time can be beneficial in calming them and helping them to recognize where they are.
D. Raising all four side rails can be considered a form of restraint and is generally not recommended unless absolutely necessary and with appropriate justification. It can lead to increased risk of injury if the client tries to climb over the rails or if there is an emergency.
E. Closing the client’s room door can be a safety measure to prevent them from wandering out into other areas of the facility. However, it is crucial to ensure that the client is not left feeling isolated or trapped.

A. Explain the respiratory problems that can occur with morphine use. B. Recommend asking the healthcare professional for a patient-controlled analgesia (PCA) pump. C. Provide client with a schedule of around-the-clock prescribed analgesic use. D. Teach family how to evaluate the effectiveness of analgesics.

Correct Answer is C

Explanation

A. Morphine is a potent opioid used for pain relief, but it can have side effects, including respiratory depression. While it is important to be aware of and discuss potential side effects, focusing on
respiratory problems might increase the client’s anxiety about using the medication.
B. A PCA pump allows patients to self-administer pain medication within prescribed limits, providing more control over pain management. However, PCA pumps are typically used in hospital settings and may not be practical or appropriate for home hospice care.
C. Providing a schedule for around-the-clock analgesic use is a practical and effective approach to pain management. It ensures that the client receives consistent pain relief and helps prevent the pain from becoming unmanageable.
D. Teaching the family to evaluate the effectiveness of analgesics is important for ongoing pain management. This includes recognizing signs of pain relief and potential side effects. However, this action might be more relevant once pain management is underway and requires follow-up, rather than addressing the immediate concern of managing pain effectively from the start.

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When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

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