how should a nurse assess pain in a non verbal patient

ATI RN

ATI RN Exit Exam 2023

1. How should pain be assessed in a non-verbal patient?

A. Observe facial expressions
B. Use the Wong-Baker faces scale
C. Assess heart rate
D. Ask the patient to rate their pain

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

2. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

A. Does the doctor know you are eating that?
B. Why are you eating seaweed soup?
C. Of course, I will heat that up for you.
D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural preferences and providing client-centered care promotes trust.

3. What is the most appropriate intervention for a patient experiencing hypoglycemia?

A. Administer glucagon
B. Provide oral glucose
C. Administer IV fluids
D. Monitor blood sugar levels

Correct answer: B

Rationale: Providing oral glucose is the correct intervention for a patient experiencing hypoglycemia. Oral glucose helps quickly raise blood sugar levels, making it the preferred treatment for mild hypoglycemia. Administering glucagon (Choice A) is usually reserved for severe cases when the patient cannot take anything by mouth. Administering IV fluids (Choice C) is not the primary intervention for hypoglycemia unless the patient is severely dehydrated. Monitoring blood sugar levels (Choice D) is important but providing glucose is the immediate priority to treat hypoglycemia.

4. A healthcare professional is reviewing the medical record of a client scheduled for a CT scan with contrast media. The healthcare professional should identify which of the following findings as a contraindication to the procedure?

A. White blood cell count of 6,000/mm³
B. Urine specific gravity of 1.025
C. History of asthma
D. History of allergy to shellfish

Correct answer: D

Rationale: The correct answer is D, a history of allergy to shellfish. A known allergy to shellfish is a contraindication for the use of contrast media in a CT scan due to the potential risk of an allergic reaction, which could be severe and life-threatening. Choices A, B, and C are not contraindications to the procedure. A normal white blood cell count, urine specific gravity within the normal range, and a history of asthma do not typically interfere with the administration of contrast media for a CT scan.

5. How should fluid overload in a patient with heart failure be managed?

A. Administer diuretics
B. Increase fluid intake
C. Provide oral fluids
D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.