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 C
Explanation
Choice A rationale
Tilting the pelvis forwards and backwards exercises the pelvic joints, not the hinge joints.
Choice B rationale
Turning the head to the right and left exercises the neck joints, not the hinge joints.
Choice C rationale
Bending the arm by flexing the ulnar to the humerus exercises the hinge joints, such as the elbow, which is a hinge joint.
Choice D rationale
Extending the arm at the side and rotating in circles exercises the shoulder joint, which is a ball-and-socket joint, not a hinge joint.
Correct Answer is C
Explanation
Choice A rationale
Giving the client a hug and saying, “It is okay to cry when you are sad,” may be comforting, but it may also be seen as intrusive and not respecting the client’s personal space. Physical touch should be used cautiously and only when the nurse is certain that it is welcome and appropriate. Additionally, this response does not encourage the client to express their feelings or provide an opportunity for the nurse to understand the underlying cause of the client’s distress.
Choice B rationale
Saying, “I am sorry to disturb you at a difficult time. This can wait until later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.
Choice C rationale
While touching the client’s forearm, asking, “Would you like to talk about it?” is the best response as it shows empathy and offers the client an opportunity to express their feelings. This response respects the client’s personal space while also providing a gentle touch that can be comforting. It opens the door for communication and allows the nurse to provide emotional support and address any concerns the client may have.
Choice D rationale
Saying, “This is a bad time. I can see you are upset. I can come back later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.