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. A nurse is caring for a client who has Raynaud's disease. What intervention should the nurse implement?

A. Provide information about stress management.
B. Maintain a cool temperature in the client's room.
C. Administer epinephrine for acute episodes.
D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: The correct intervention for a client with Raynaud's disease is to provide information about stress management. Stress management techniques can help reduce the frequency and severity of Raynaud's episodes. Choice B is incorrect because maintaining a cool temperature can exacerbate symptoms in individuals with Raynaud's disease. Choice C is incorrect as epinephrine is not typically used for Raynaud's disease. Choice D is incorrect as glucocorticoid steroids are not the first-line treatment for Raynaud's disease.

3. A client, 12 hours postpartum, reports not having a bowel movement for 4 days. Which medication should the nurse administer?

A. Bisacodyl 10 mg rectal suppository.
B. Magnesium hydroxide 30 ml PO.
C. Famotidine 20 mg PO.
D. Loperamide 4 mg PO.

Correct answer: A

Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. The client's report of not having a bowel movement for 4 days indicates constipation, and Bisacodyl is a stimulant laxative that helps initiate bowel movements. Magnesium hydroxide is an antacid and osmotic laxative used for indigestion, not for constipation. Famotidine is an H2 receptor antagonist used to reduce stomach acid production and treat heartburn, not constipation. Loperamide is an antidiarrheal agent and would be contraindicated in a client experiencing constipation.

4. What is the best intervention for a patient with respiratory distress?

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

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient with respiratory distress because it helps improve oxygenation levels and alleviates respiratory distress directly. Providing oxygen addresses the primary issue of inadequate oxygen supply, which is crucial in managing respiratory distress. Repositioning the patient, while important for airway clearance, may not address the immediate need for oxygen. Providing bronchodilators and humidified air can be beneficial in certain respiratory conditions, but when a patient is in respiratory distress, ensuring adequate oxygenation through oxygen administration takes precedence.

5. A nurse is providing dietary teaching to a client who is at 8 weeks of gestation and has a body mass index (BMI) of 24. Which of the following instructions should the nurse include?

A. You should increase your caloric intake by 600 calories per day.
B. You should increase your caloric intake by 300 calories per day.
C. You should maintain your prepregnancy caloric intake during the first trimester.
D. You should increase your caloric intake by 150 calories per day.

Correct answer: B

Rationale: During the first trimester, it is recommended to increase caloric intake by 300 calories per day to support fetal growth and development. Choice A suggesting an increase of 600 calories is excessive and unnecessary. Choice C advising to maintain prepregnancy caloric intake could lead to inadequate nutrition for the developing fetus. Choice D recommending an increase of 150 calories is insufficient to meet the increased energy demands of pregnancy.