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 bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

A. Request a renewal of the prescription every 8 hours.
B. Check the client's peripheral pulse rate every 30 minutes.
C. Obtain a prescription for restraint within 4 hours.
D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: Obtaining a prescription for restraint within 4 hours is the correct action when managing restraints in a client with acute mania. This timeframe ensures that the use of restraints is promptly evaluated and authorized by a healthcare provider. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary and may delay appropriate care. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is important but not the immediate priority when dealing with obtaining a prescription for restraints. Documenting the client's condition every 15 minutes (Choice D) is essential for monitoring, but the priority is to secure a prescription for restraints promptly.

3. A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the professional make in the medical record?

A. Morphine 3 mg SC every 4 hr. PRN for pain
B. Morphine 3 mg Subcutaneous
C. Morphine 3.0 mg subq every 4 hr. PRN for pain
D. Morphine 3 mg SC q 4 hr. PRN for pain

Correct answer: A

Rationale: The correct entry for the medication in the medical record should include the abbreviation 'SC' (subcutaneous) for the route of administration. Choice A is the correct answer as it accurately represents the prescription received. Choice B is incorrect because it lacks the frequency and PRN indication. Choice C is incorrect due to the incorrect abbreviation 'subq' and the missing 'q' before the frequency. Choice D is incorrect because it uses 'SC' but the frequency abbreviation 'q' should be followed by the time interval.

4. A nurse is providing dietary teaching to a client with irritable bowel syndrome (IBS). What recommendation should be included?

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

Correct answer: A

Rationale: The correct answer is A: Consume foods high in bran fiber. Bran fiber is recommended for clients with IBS as it promotes regularity and helps reduce symptoms. Choices B, C, and D are incorrect. Increasing milk products may exacerbate symptoms in some individuals with IBS due to lactose intolerance. Sweetening foods with fructose corn syrup can worsen symptoms as it is a type of sugar that can lead to gastrointestinal discomfort. Increasing intake of foods high in gluten is not recommended for individuals with IBS, especially those with gluten sensitivity, as it may trigger or worsen symptoms.

5. Which electrolyte imbalance is most concerning for a patient on furosemide?

A. Hypokalemia
B. Hyponatremia
C. Hyperkalemia
D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss through increased urinary excretion, making hypokalemia the most concerning electrolyte imbalance. Hyponatremia (Choice B) is not typically associated with furosemide use. Hyperkalemia (Choice C) is less likely due to furosemide's potassium-wasting effect. Hypercalcemia (Choice D) is not a common electrolyte imbalance seen with furosemide.