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. When discussing clients designating a health care proxy in situations requiring a durable power of attorney for health care (DPAHC), what information should the charge nurse include?

A. The proxy should make health care decisions for the client regardless of the client's ability to do so.
B. The proxy can make financial decisions if the need arises.
C. The proxy can make treatment decisions if the client is under anesthesia.
D. The proxy should manage legal issues for the client.

Correct answer: C

Rationale: The correct answer is C. The charge nurse should include information that the proxy can make treatment decisions if the client is under anesthesia. This is a key function of a durable power of attorney for health care. Choices A, B, and D are incorrect because a health care proxy's role is specifically related to making health care decisions, not financial decisions, legal issues, or decisions made under anesthesia.

3. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

A. Avoid eating spinach while taking this medication.
B. Massage the injection site after administration.
C. Administer the injection into the deltoid muscle.
D. Inject the medication into the abdomen.

Correct answer: D

Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.

4. A nurse is providing dietary teaching to a client who has chronic pancreatitis. Which of the following foods should the nurse instruct the client to avoid?

A. Baked chicken
B. Grilled salmon
C. Steamed broccoli
D. Fried foods

Correct answer: D

Rationale: Clients with chronic pancreatitis should avoid fried foods because they are high in fat, which can exacerbate symptoms and lead to further complications. Baked chicken (choice A), grilled salmon (choice B), and steamed broccoli (choice C) are generally healthier options and can be included in a low-fat diet suitable for individuals with chronic pancreatitis.

5. Which electrolyte imbalance is most concerning in a patient taking digoxin?

A. Monitor potassium levels
B. Monitor calcium levels
C. Monitor sodium levels
D. Monitor magnesium levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Patients taking digoxin are at risk of developing toxicity due to hypokalemia. Low potassium levels can potentiate the toxic effects of digoxin on the heart, leading to serious arrhythmias. Monitoring calcium levels (Choice B) is not the primary concern in patients taking digoxin. While calcium levels play a role in cardiac function, hypocalcemia is not directly associated with digoxin toxicity. Monitoring sodium levels (Choice C) is important for other conditions but is not the primary concern in a patient taking digoxin. Monitoring magnesium levels (Choice D) is also essential, but hypomagnesemia is not as directly linked to digoxin toxicity as hypokalemia.