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 A
Explanation
Choice A rationale
Positive external places are often used in guided imagery to help clients focus on pleasant and calming environments. This technique can help distract from pain and promote relaxation by engaging the mind in a soothing and peaceful visualization.
Choice B rationale
Tranquil sounds can also be beneficial in relaxation techniques, but they are not the primary focus in guided imagery for chronic pain. Guided imagery typically involves visualizing a serene place rather than focusing solely on sounds.
Choice C rationale
Emotional reflection may not be as effective in reducing chronic pain through guided imagery. This technique is more about visualizing positive and calming environments rather than reflecting on emotions.
Choice D rationale
Motivational phrases are useful in other therapeutic techniques but are not the primary focus in guided imagery for chronic pain. Guided imagery focuses more on visualizing serene and peaceful places.
Correct Answer is D
Explanation
Choice A rationale
Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it does not directly indicate an understanding of standard precautions, which emphasize hand hygiene as a primary measure.
Choice B rationale
Removing the needle before discarding used syringes is not recommended as it increases the risk of needlestick injuries. Standard precautions emphasize the safe disposal of sharps in puncture-resistant containers without manipulating the needle.
Choice C rationale
Donning a face mask before administering medication is not a standard precaution for handling syringes and needles. Standard precautions focus more on hand hygiene and the use of gloves when there is a risk of exposure to blood or body fluids.
Choice D rationale
Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the transmission of infections and is a clear indication of understanding standard precautions.