The nurse is assessing a client who has suffered a cerebral ...

[lb_gilbert]

The nurse is assessing a client who has suffered a cerebral vascular accident (CVA or stroke) and has difficulty with verbal expression, but no other deficits. What approach should the nurse use to assess this client's level of pain?
 
  1. The nurse asks the client's family member to place a number on the client's pain using a scale of 0 (no pain) to 10 (most pain), since the family member knows the client best.
  2. The nurse considers the client's behavior and vital signs and determines a number from the pain scale (0-10) based on these objective findings.
  3. The nurse uses the Wong-Baker FACES pain rating scale.
  4. The nurse reviews the previous pain assessments and makes a determination based on these findings.

Question 2

During a physical assessment the client asks the nurse repeatedly, Is everything ok? The nurse concludes which for this client?
 
  1. A poor self-concept.
  2. Inappropriate affect.
  3. Confusion.
  4. Anxiety.

[aburgess]

Answer to Question 1

Correct Answer: 3

Pain is an entirely subjective and personal experience. Because this client has difficulty with verbal expression, but no other deficits, the nurse could use the FACES pain scale and ask the client to point to the picture that most closely correlates with current level of pain. The family member is not able to accurately identify the client's pain level because pain is entirely subjective and personal. The nurse incorporates objective findings into a thorough pain assessment, but pain is ultimately what the client says it is. Previous assessments can help the nurse to determine a pattern of the client's pain and pain control, but does not give the nurse any clues about the client's current pain.

Answer to Question 2

Correct Answer: 4

A client's level of anxiety is reflected in speech, body language, and facial expressions. Repeatedly asking if everything is ok could be evidence of worry about the outcome of the examination. Evidence of a poor self-concept would include poor personal hygiene practices. An inappropriate affect would be demonstrated if the client responding inappropriately to a situation, such as laughter when discussing the death of a pet. Confusion would be demonstrated by a client who is not oriented to person, place, or time.

[lb_gilbert]

Excellent

[aliotak]

TYSM