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NurseDive Free Nursing Practice Question
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?
A. Pulse and blood pressure findings
Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be influenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.
B. Scheduled treatments and client illness
Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reflect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.
C. A self-report pain rating scale
Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reflects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.
D. Behavioral indicators and affect
Reason: This is incorrect. Behavioral indicators and affect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be influenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg 2 Proctored Exam. Take the full exam now
Full Explanation
Choice A Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be influenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.
Choice B Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reflect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.
Choice C Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reflects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.
Choice D Reason: This is incorrect. Behavioral indicators and affect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be influenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.
Similar Questions
A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?
A. Administer opioids.
Reason: This is incorrect. Opioids are not indicated for a client who is emerging from a coma, as they can cause respiratory depression, sedation, and confusion. They may also mask the signs of increased intracranial pressure or neurological deterioration.
B. Darken the room.
Reason: This is incorrect. Darkening the room may not be helpful for a client who is emerging from a coma, as it may increase their disorientation and agitation. The nurse should provide adequate lighting and orient the client to time, place, and person frequently.
C. Apply restraints.
Reason: This is incorrect. Applying restraints may worsen the restlessness and agitation of a client who is emerging from a coma, as they may perceive them as a threat or a restriction. Restraints may also increase the risk of injury, infection, or skin breakdown. The nurse should use restraints only as a last resort and with a physician's order.
D. Reduce stimuli.
Reason: This is correct. Reducing stimuli is an appropriate intervention for a client who is emerging from a coma, as it can help calm them and prevent sensory overload. The nurse should limit noise, visitors, and unnecessary procedures, and provide a quiet and comfortable environment.
Full Explanation
Choice A Reason: This is incorrect. Opioids are not indicated for a client who is emerging from a coma, as they can cause respiratory depression, sedation, and confusion. They may also mask the signs of increased intracranial pressure or neurological deterioration.
Choice B Reason: This is incorrect. Darkening the room may not be helpful for a client who is emerging from a coma, as it may increase their disorientation and agitation. The nurse should provide adequate lighting and orient the client to time, place, and person frequently.
Choice C Reason: This is incorrect. Applying restraints may worsen the restlessness and agitation of a client who is emerging from a coma, as they may perceive them as a threat or a restriction. Restraints may also increase the risk of injury, infection, or skin breakdown. The nurse should use restraints only as a last resort and with a physician's order.
Choice D Reason: This is correct. Reducing stimuli is an appropriate intervention for a client who is emerging from a coma, as it can help calm them and prevent sensory overload. The nurse should limit noise, visitors, and unnecessary procedures, and provide a quiet and comfortable environment.
A nurse in an emergency department is assessing a client who was biten on the left leg by a poisonous snake. The client has placed elastic bandages snugly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?
A. Remove both of the elastic bandages from the leg.
Reason: Removing the elastic bandages is not recommended. These bandages help slow the spread of venom by compressing the lymphatic vessels. Removing them could worsen the envenomation.
B. Discharge the client.
Reason: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.
C. Obtain a prescription for the appropriate anti-venom.
Reason: This is the correct action. Antivenom treatment is crucial for serious snake envenomation. The sooner it can be administered, the better the outcome.
D. Obtain a prescription for pain medication.
Reason: While pain management is important, it is not the priority in this situation. Antivenom takes precedence over pain medication.
Full Explanation
Choice A: Removing the elastic bandages is not recommended. These bandages help slow the spread of venom by compressing the lymphatic vessels. Removing them could worsen the envenomation.
Choice B: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.
Choice C: This is the correct action. Antivenom treatment is crucial for serious snake envenomation. The sooner it can be administered, the better the outcome.
Choice D: While pain management is important, it is not the priority in this situation. Antivenom takes precedence over pain medication.
I have edited the text according to your instructions. Here is the edited text:
A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snugly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?
A. Remove both of the elastic bandages from the leg.
Reason: This is correct. The nurse should remove both of the elastic bandages from the leg, as they can impair blood flow and increase tissue damage. The nurse should also elevate the leg and keep it immobile to reduce venom absorption.
B. Discharge the client.
Reason: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.
C. Obtain a prescription for the appropriate anti-venom.
Reason: This is incorrect. The nurse should not obtain a prescription for the appropriate anti-venom, as this is not within their scope of practice. The nurse should notify the physician and provide supportive care until the physician arrives and decides whether to administer anti-venom or not.
D. Obtain a prescription for pain medication.
Reason: This is incorrect. The nurse should not obtain a prescription for pain medication, as this may mask the symptoms of venom toxicity or cause adverse reactions with anti-venom. The nurse should use non- pharmacological methods to relieve pain, such as ice packs or distraction.
Full Explanation
Choice A Reason: This is correct. The nurse should remove both of the elastic bandages from the leg, as they can impair blood flow and increase tissue damage. The nurse should also elevate the leg and keep it immobile to reduce venom absorption.
Choice B Reason: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.
Choice C Reason: This is incorrect. The nurse should not obtain a prescription for the appropriate anti-venom, as this is not within their scope of practice. The nurse should notify the physician and provide supportive care until the physician arrives and decides whether to administer anti-venom or not.
Choice D Reason: This is incorrect. The nurse should not obtain a prescription for pain medication, as this may mask the symptoms of venom toxicity or cause adverse reactions with anti-venom. The nurse should use non- pharmacological methods to relieve pain, such as ice packs or distraction.