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

Explanation

A. Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B. Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C. While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D. Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

A. Visible subcutaneous tissue with sloughing. B. An area of erythema that is painful to touch. C. Shallow open ulcer with a red pink wound bed. D. A deep pocket of infection and necrotic tissues.

Correct Answer is C

Explanation

A. This description is more characteristic of a Stage 3 or Stage 4 pressure injury. Stage 3 pressure injuries involve full-thickness skin loss and may expose subcutaneous tissue, and Stage 4 involves extensive damage with possible exposure of muscle, bone, or tendon. Sloughing (a type of necrotic tissue) is not typical of Stage 2 pressure injuries.
B. This description is more indicative of a Stage 1 pressure injury. Stage 1 injuries are characterized by non-blanchable erythema of intact skin, and pain or discomfort in the affected area is common. Stage 1 does not involve the loss of skin integrity, so it would not be the appearance of a Stage 2 injury.
C. This description accurately matches the appearance of a Stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness loss of skin, which may present as a shallow open ulcer with a red or pink wound bed. It does not extend through the entire thickness of the skin.
D. This description aligns with Stage 3 or Stage 4 pressure injuries, which involve full-thickness skin loss with possible necrotic tissue and deep pockets of infection. These stages involve significant tissue damage beyond what is seen in Stage 2 injuries.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Correct Answer is A

Explanation

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Correct Answer is C

Explanation

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