The nurse is assessing a client who is having pain in the right upper abdominal area. To assess the quality of the client’s abdominal pain, which approach should the nurse use?
Identify effective pain relief measures.
Ask the client to describe the pain.
Provide a numeric pain scale.
Observe body language and movement.
The Correct Answer is B
Choice A rationale
Identifying effective pain relief measures is important, but it does not directly assess the quality of the pain. This approach focuses on management rather than understanding the pain’s characteristics.
Choice B rationale
Asking the client to describe the pain is the most direct way to assess its quality. This allows the nurse to gather detailed information about the pain’s nature, intensity, and characteristics, which is crucial for accurate diagnosis and treatment.
Choice C rationale
Providing a numeric pain scale helps quantify the pain’s intensity but does not provide qualitative details about the pain’s nature. It is useful for monitoring pain levels over time but not for initial assessment.
Choice D rationale
Observing body language and movement can give clues about pain but is subjective and less reliable than directly asking the client. It should be used as a supplementary method rather than the primary approach.
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Correct Answer is D
Explanation
Choice A rationale
Risk for infection is a concern for clients with neuropathy, as they may have reduced sensation and be unaware of injuries that can become infected. However, the primary concern in promoting foot care is preventing the occurrence of wounds or skin breakdown in the first place.
Choice B rationale
Self-care deficit is relevant for clients with neuropathy who may have difficulty performing foot care independently. However, the priority is to prevent skin breakdown and wounds, which can lead to more severe complications.
Choice C rationale
Impaired physical mobility is a common issue for clients with neuropathy, but it is not the primary concern for foot care. The focus should be on preventing skin breakdown and ensuring proper foot care to avoid complications.
Choice D rationale
Risk for impaired skin integrity is the priority for promoting foot care in clients with neuropathy. Neuropathy can compromise the ability to detect injuries or wounds on the feet, leading to unnoticed wounds that can become infected and cause serious complications.
Preventing skin breakdown and maintaining skin integrity is crucial in this scenario.
Correct Answer is B
Explanation
Choice A rationale
Whether the popsicles contain pulp or fruit is not relevant to the clear liquid diet, which focuses on the clarity and digestibility of the liquids.
Choice B rationale
The color and flavor of gelatin used are important because certain colors, especially red or purple, can interfere with medical tests and are often avoided in clear liquid diets.
Choice C rationale
If the popsicles are completely frozen is not relevant to the dietary restrictions. The focus should be on the ingredients and their suitability for a clear liquid diet.
Choice D rationale
The number of popsicles available does not impact their suitability for the child’s diet. The nurse should focus on the content and appropriateness of the popsicles.