Which nursing intervention is most effective in determining the severity of a client’s pain?

Compare the client’s current vital signs to the admission baseline.

Review the client’s medical history and admission assessment.

Note how frequently doses of analgesics have been administered.

Ask the client to describe the intensity of the pain being experienced.

Answer and Explanation

The Correct Answer is D

Choice A reason: Comparing vital signs to baseline may show tachycardia from pain-induced sympathetic activation, but this is non-specific, as fever or anxiety can mimic these. Pain is subjective, involving nociceptor signaling, and the client’s direct intensity description provides the most accurate severity measure, guiding targeted treatment.

Choice B reason: Reviewing medical history provides pain context but not current severity. Pain perception involves spinal and cortical nociceptive pathways, and only the client’s description quantifies intensity. Historical data informs diagnosis, but direct assessment is more precise for evaluating present pain, ensuring appropriate analgesic intervention.

Choice C reason: Noting analgesic frequency suggests pain control needs but not current severity. Frequent dosing may indicate tolerance or inadequate relief, not intensity. Pain’s subjective nature, mediated by neural pathways, requires the client’s report to assess severity accurately, guiding dosing over indirect medication usage patterns.

Choice D reason: Asking the client to describe pain intensity directly captures their subjective experience, mediated by nociceptors and cortical perception. Using a 0–10 scale quantifies severity, guiding precise analgesia. This is most effective, as pain is personal, ensuring accurate assessment and tailored treatment to alleviate discomfort effectively.

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Correct Answer is D

Explanation

Choice A reason: Keeping pressure on the abdomen and coughing is incorrect for diaphragmatic breathing, which enhances lung expansion, not airway clearance. Coughing is for post-drainage. The client’s incorrect technique (abdominal expansion on exhalation) requires correction, as this reverses mechanics, reducing ventilation efficiency in conditions like COPD.

Choice B reason: The client’s technique is incorrect, expanding the abdomen on exhalation, not inhalation, reducing diaphragmatic efficacy. Confirming it as correct is wrong, as it impairs lung expansion. Demonstrating proper technique corrects the error, ensuring effective breathing to improve oxygenation, addressing the physiological need for ventilation.

Choice C reason: Documenting success is inaccurate, as the client’s technique is reversed, expanding the abdomen on exhalation. Diaphragmatic breathing requires inhalation expansion to lower the diaphragm, increasing lung capacity. Correcting the technique via demonstration ensures proper mechanics, not documenting an ineffective method that hinders ventilation.

Choice D reason: Demonstrating proper diaphragmatic breathing corrects the client’s error of exhalation expansion. Inhaling expands the abdomen via diaphragmatic descent, increasing tidal volume; exhaling relaxes it. This optimizes ventilation, addressing the need for effective breathing in conditions requiring enhanced lung function, ensuring the client learns the correct technique.

A. Blood pressure is 142/88 mm Hg. B. 2+ edema of fingers and hands. C. Radial pulse volume is 3+. D. Capillary refill time is 2 seconds.

Correct Answer is B

Explanation

Choice A reason: Blood pressure of 142/88 mm Hg indicates mild hypertension but does not directly affect pulse oximetry, which measures arterial oxygen saturation via hemoglobin light absorption. Hypertension does not typically cause hypoxemia (91% SpO₂). Edema is more likely, as it disrupts sensor accuracy, leading to false low readings.

Choice B reason: 2+ edema in fingers and hands impairs pulse oximeter accuracy, as fluid in tissues scatters light, reducing the sensor’s ability to detect arterial hemoglobin saturation. This causes falsely low SpO₂ readings (91%), common in edema from heart failure, making it the primary contributor to the inaccurate measurement.

Choice C reason: A radial pulse volume of 3+ indicates strong arterial flow, supporting accurate pulse oximetry by ensuring perfusion. This does not explain a low SpO₂ of 91%, as strong pulses enhance sensor reliability. Edema’s interference with light transmission is more likely to cause the reduced reading.

Choice D reason: Capillary refill of 2 seconds is normal, indicating adequate perfusion. This does not contribute to a low SpO₂ (91%), as pulse oximetry measures arterial flow, not capillary dynamics. Edema disrupts light transmission, causing inaccurate readings, making it the most likely cause of the observed saturation.

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Which nursing intervention is most effective in determining the severity of a client’s pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?

Correct Answer is D

Explanation

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

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Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

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While completing an admission assessment, the nurse is unable to palpate the client’s left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

The nurse is teaching a client with newly diagnosed glaucoma about the condition. Which statement by the client indicates a need for further teaching?