The nurse is assessing a client admitted with severe back pain. Which are essential components of the pain assessment? Select all that apply.
Impact on ADL's.
Family medical history.
Pain intensity rating
Characteristics of the pain.
Aggravating factors.
Correct Answer : A,C,D,E
A) Impact on ADLs: Understanding how pain affects a client's activities of daily living (ADLs) is crucial for assessing the overall impact of the pain on their life. It provides insight into the functional limitations caused by the pain and helps guide treatment planning.
B) Family medical history: While family medical history can provide context for certain conditions, it is not an essential component of a focused pain assessment. The immediate concerns are more directly related to the client's current pain experience rather than their family's medical background.
C) Pain intensity rating: Assessing the intensity of pain is a fundamental aspect of pain assessment. Using scales (e.g., 0-10) allows the nurse to quantify the pain, monitor changes over time, and evaluate the effectiveness of interventions.
D) Characteristics of the pain: Understanding the characteristics of the pain—such as its quality (sharp, dull, throbbing) and location—is essential for determining its cause and guiding appropriate treatment strategies.
E) Aggravating factors: Identifying what exacerbates the pain is critical for understanding its nature and developing effective management strategies. Knowing which activities or positions worsen the pain can help in creating a comprehensive care plan tailored to the client's needs.
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Correct Answer is B
Explanation
A) Have the client smile, frown, and puff out their cheeks: This test assesses the facial nerve (cranial nerve VII), not the trigeminal nerve (cranial nerve V). While important for evaluating facial movement, it does not specifically test the motor function of the trigeminal nerve, which is responsible for mastication.
B) Palpate the masseter muscles when the client clenches their teeth: This is the correct test for assessing the motor function of the trigeminal nerve. The trigeminal nerve innervates the muscles responsible for chewing, and palpating the masseter muscles during clenching allows the nurse to evaluate muscle strength and function. It provides insight into the motor capabilities associated with this cranial nerve.
C) Assess constriction of the client's pupils with direct and indirect light: This test evaluates the function of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III). It does not assess the trigeminal nerve and is not relevant for this assessment.
D) Ask the patient to turn their head left and right with resistance: This action tests the spinal accessory nerve (cranial nerve XI), which is involved in neck movement. It does not relate to the function of the trigeminal nerve, making it an inappropriate choice for this specific assessment.
Correct Answer is D
Explanation
A) Changes in peripheral vision in response to light: While peripheral vision is important in a comprehensive eye assessment, it is not specifically evaluated through the PERRLA acronym. PERRLA focuses on how the pupils respond to light and accommodation, not on peripheral vision changes.
B) Involuntary blinking in the presence of bright light: Involuntary blinking is part of a reflex action known as the blink reflex, which helps protect the eyes from bright lights and foreign objects. However, this response is not what the "A" in PERRLA refers to, which is more specifically about pupillary reactions to focus.
C) Pupillary dilation when looking at a near object: When focusing on a near object, the pupils actually constrict rather than dilate. This process, known as accommodation, is important for clear vision at close distances but does not pertain to the dilation of pupils.
D) Pupillary constriction when looking at a near object: The "A" in PERRLA stands for accommodation, which specifically refers to the pupils constricting when a person looks at a nearby object. This reaction helps the eyes focus properly and is a normal finding in a healthy neurological assessment. Thus, option D accurately describes the "A" in the PERRLA assessment.