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 D
Explanation
A) Interrupt with frequent questions: While older adults may have questions, they typically do not interrupt frequently. This behavior is more indicative of anxiety or agitation rather than a cognitive change associated with aging.
B) Answer slowly and be confused: While some older adults may exhibit slower responses, confusion is not a normal cognitive change associated with aging. Confusion may suggest underlying issues such as delirium or dementia, rather than typical age-related cognitive changes.
C) Withdraw from strangers: Social withdrawal can occur in some older adults, but it is not a universal expectation. Many older adults remain engaged and sociable, and withdrawal is more commonly associated with mental health issues rather than cognitive changes.
D) Take longer to respond and react: It is common for older adults to take longer to process information and respond due to normal cognitive slowing. This may reflect changes in processing speed rather than a decline in cognitive function, and it is an expected part of aging.
Correct Answer is B
Explanation
A) Avoid hand and foot massages: This statement may not be accurate. Gentle massages can sometimes help with circulation and comfort for individuals with peripheral neuropathy. However, caution should be exercised to avoid injury, as the sensation may be diminished.
B) Use a mirror to inspect feet daily: This is an essential teaching point. Clients with peripheral neuropathy often have decreased sensation in their feet, making it difficult to notice injuries or sores. Using a mirror allows them to check for any signs of injury or changes that could lead to complications, such as infections or ulcers.
C) Increase medication for pain as necessary: While managing pain is important, the client should be advised to consult with their healthcare provider before making any changes to their medication regimen. Self-adjusting medication could lead to unintended side effects or complications.
D) Set the water heater at 120°F: This is not advisable for someone with peripheral neuropathy, as they may not have normal temperature sensation. A lower setting is recommended to prevent burns, as the individual may not feel when the water is too hot.