Which of the following is most appropriate when the nurse assesses the intensity of the client's pain?

Use open-ended questions to find out about the sensation.

Offer the client a pain scale to quantify the current level of pain

Question the client about the location of the pain.

Ask about what precipitates the pain.

Answer and Explanation

The Correct Answer is B

A. Use open-ended questions to find out about the sensation: While open-ended questions can help the nurse gather information about the nature and quality of the pain, they may not provide a precise measure of pain intensity. Open-ended questions are valuable for understanding the client's subjective experience of pain, but they may not be as effective as using a pain scale for quantifying pain intensity.

B. Offer the client a pain scale to quantify the current level of pain: This is the most appropriate action for assessing pain intensity. Pain scales, such as the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), allow clients to indicate their pain intensity on a scale from 0 to 10 or by marking a point along a continuum. Pain scales provide a standardized method for quantifying pain intensity, which helps healthcare providers monitor changes in pain over time and assess the effectiveness of pain management interventions.

C. Question the client about the location of the pain: While identifying the location of pain is important for understanding its source and potential underlying causes, it does not directly assess pain intensity. Location is one aspect of pain assessment but does not provide a complete picture of pain intensity on its own.

D. Ask about what precipitates the pain: Understanding what precipitates or exacerbates pain is important for comprehensive pain assessment, but it focuses more on pain triggers rather than pain intensity. While this information can be valuable for developing a holistic pain management plan, it does not directly assess the current level of pain intensity.

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Correct Answer is C

Explanation

A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.

B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.

C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.

D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.

A. A document that the client signs indicating they wish to be an organ donor B. A medical order that outlines the client's wishes if cardiac or respiratory arrest occurs C. A witnessed legal document that describes the client's wishes regarding medical care if unable to speak D. A legal document that lists who gets the client's property & belongings before if they cannot communicate

Correct Answer is C

Explanation

A. A document that the client signs indicating they wish to be an organ donor: This describes an organ donor card or organ donation consent form, not a living will. An organ donor card is a document indicating the individual's wish to donate organs after death to benefit others in need of organ transplants.

B. A medical order that outlines the client's wishes if cardiac or respiratory arrest occurs: This describes a do-not-resuscitate (DNR) order, which is a medical order indicating that the individual does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It is specific to resuscitation preferences and is different from a living will.

C. A witnessed legal document that describes the client's wishes regarding medical care if unable to speak: This is the correct description of a living will. A living will is a legal document that outlines a person's preferences regarding medical treatment and interventions in the event they become incapacitated and unable to communicate their wishes. It typically addresses preferences for life-sustaining treatments, such as mechanical ventilation, artificial nutrition and hydration, and other medical interventions.

D. A legal document that lists who gets the client's property & belongings before if they cannot communicate: This describes a last will and testament, which is a legal document that outlines how a person's property and assets should be distributed after their death. It does not address medical care preferences or interventions during the person's lifetime.

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Which of the following is most appropriate when the nurse assesses the intensity of the client's pain?

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