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The nurse is assessing a client admitted with severe back pain. Which are essential components of the pain assessment? Select all that apply.

A.

Impact on ADL's.

B.

Family medical history.

C.

Pain intensity rating

D.

Characteristics of the pain.

E.

Aggravating factors.

Question Solution

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) Occurs only in the clinical area: Focused assessments can be conducted in various settings, including outpatient clinics, home health visits, and emergency departments. Thus, this statement does not accurately define the difference.

B) Involves all body systems: A focused assessment is specifically targeted and does not involve an evaluation of all body systems. Instead, it concentrates on particular areas of concern, making this statement incorrect.

C) Covers the body from head to toe: This describes a comprehensive assessment rather than a focused one. A comprehensive assessment is thorough and covers the entire body, while a focused assessment zeroes in on specific issues or symptoms.

D) More in depth on specific issues: A focused assessment is designed to gather detailed information about particular health problems or concerns rather than providing a broad overview of the patient’s overall health. This targeted approach allows healthcare providers to identify and address specific needs effectively, making this the correct choice.

Correct Answer is ["B","C","E"]

Explanation

A) Alert and oriented: Being alert and oriented typically indicates adequate oxygenation, not hypoxia. Patients experiencing hypoxia are more likely to show signs of confusion or altered mental status rather than clarity.

B) Cyanosis: Cyanosis is a classic sign of hypoxia, presenting as a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is a significant indicator of inadequate oxygenation.

C) Anxiety and restlessness: These symptoms are common responses to hypoxia as the body attempts to compensate for insufficient oxygen. Patients may feel anxious or restless as they struggle to breathe or feel a sense of impending doom.

D) Oxygen saturation 96%: An oxygen saturation level of 96% is generally considered normal and indicates adequate oxygenation. Therefore, this finding does not suggest hypoxia.

E) Capillary refill 5 seconds: A prolonged capillary refill time can indicate poor perfusion and potential hypoxia. Inadequate blood flow can lead to reduced oxygen delivery to tissues, making this a relevant sign of hypoxia