what is the best method to assess pain in a non verbal patient

ATI RN

ATI RN Exit Exam Test Bank

1. What is the best method to assess pain in a non-verbal patient?

A. Observe for facial expressions
B. Observe for restlessness
C. Observe for sweating
D. Check for non-verbal cues

Correct answer: A

Rationale: The correct answer is to observe for facial expressions when assessing pain in a non-verbal patient. Facial expressions can provide vital clues about the patient's pain level and discomfort. Choices B and C, observing for restlessness and sweating, can be less specific and may indicate other issues besides pain. Choice D, checking for non-verbal cues, is too broad and does not specify the crucial aspect of focusing on facial expressions.

2. What is the best intervention for a patient experiencing hypoxia?

A. Administer oxygen
B. Reposition the patient
C. Provide humidified air
D. Provide chest physiotherapy

Correct answer: A

Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.

3. A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as an indication of digoxin toxicity?

A. Bradycardia.
B. Tachycardia.
C. Nausea.
D. Blurred vision.

Correct answer: D

Rationale: Corrected Rationale: Blurred vision is a classic sign of digoxin toxicity, indicating a potential overdose. It is crucial to recognize this symptom promptly and report it to the healthcare provider for immediate intervention. Bradycardia and nausea are common side effects of digoxin but not specific indicators of toxicity. Tachycardia is unlikely in digoxin toxicity since it usually causes a decrease in heart rate.

4. A nurse is caring for a client who has a new diagnosis of rheumatoid arthritis. Which of the following laboratory findings should the nurse expect?

A. Increased WBC count.
B. Decreased hemoglobin.
C. Decreased platelet count.
D. Positive rheumatoid factor.

Correct answer: D

Rationale: The correct answer is D: Positive rheumatoid factor. A positive rheumatoid factor is a common laboratory finding in clients with rheumatoid arthritis, indicating an autoimmune response. Option A, increased WBC count, is not typically associated with rheumatoid arthritis. Option B, decreased hemoglobin, and option C, decreased platelet count, are not specific laboratory findings for rheumatoid arthritis.

5. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

A. Consume food high in bran fiber.
B. Increase intake of milk products.
C. Sweeten foods with fructose corn syrup.
D. Increase foods high in gluten.

Correct answer: A

Rationale: The correct recommendation for a client with irritable bowel syndrome is to consume food high in bran fiber. Bran fiber promotes regularity and can help reduce symptoms of IBS. Choices B, C, and D are incorrect because increasing milk products, sweetening foods with fructose corn syrup, and consuming foods high in gluten can exacerbate symptoms of irritable bowel syndrome in some individuals.