Answer to Question 1
C
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A Asking the patient what precipitates the pain does not assess intensity but rather is an assessment of the pain pattern.
B Asking the patient about the location of the pain does not assess the intensity of the patient's pain.
C Offering the patient a pain scale allows the patient the opportunity to describe the intensity of the pain. Effective and unbiased pain assessment is best achieved by making a validated pain assessment using pain assessment instruments that are developmentally appropriate, reliable, valid, and applicable for clinical use.
D To determine the quality of the patient's pain, the nurse may ask open-ended questions to find out about the sensation experienced.
Answer to Question 2
A
Discharge planning with a family involves an accurate assessment of what will be needed for care at the time of discharge, along with any shortcomings in the home setting. If no one can do the dressings properly, the nurse will need to arrange for a home care service referral. Extra dressing supplies will not help the situation if the husband is afraid to use them. Only under extreme situations or in an unsafe situation will the discharge be canceled. An order for antibiotics is not a replacement for good dressing change technique.
Assessing for Apley's Grinding Sign
Assessing for McMurray's Sign
The nurse applies a pulse oximeter sensor on the client’s finger.
Patient Teaching Methods
Estimating the Intensity of a Hurricane