Before inserting a Foley catheter, the nurse explains that the ...

[CBme]

Before inserting a Foley catheter, the nurse explains that the client may feel some discomfort. This is an example of:
 
  1. Distraction
  2. Reducing pain perception
  3. Anticipatory response
  4. Self-care maintenance

Question 2

Which of the following is most appropriate when the nurse assesses the intensity of the client's pain?
 
  1. Ask about what precipitates the pain.
  2. Question the client about the location of the pain.
  3. Offer the client a pain scale to objectify the information.
  4. Use open-ended questions to find out about the sensation.

[whitcassie]

Answer to Question 1

ANS: 3
Pain can be prevented by anticipating painful events. Before performing procedures, the nurse considers the client's condition, aspects of the procedure that may be uncomfortable, and tech-niques to avoid causing pain. The nurse who tells the client that the urinary catheter insertion may feel uncomfortable is an example of anticipatory response. Distraction directs a client's attention to something else and thus can reduce the awareness of pain and even increase tolerance. Reduc-ing pain perception means to remove stimuli that are uncomfortable or to prevent stimuli that are painful, such as changing wet linens, or preventing constipation with fluids, diet, and exercise. Self-care maintenance implies the client is able to carry out necessary activities to care for himself or herself. This may include pain management measures.

Answer to Question 2

ANS: 3
Descriptive scales are a more objective means of measuring pain intensity. Asking the client what precipitates the pain does not assess intensity, but rather it is an assessment of the pain pattern. Asking the client about the location of pain does not assess the intensity of the client's pain. To determine the quality of the client's pain, the nurse may ask open-ended questions to find out about the sensation experienced.