A nurse is assessing a client for manifestations of pain. Which finding is a subjective indicator of pain?

The client is restless.

The client's pupils are dilated.

The client reports a burning sensation.

The client is grimacing

Answer and Explanation

The Correct Answer is C

A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.

B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.

C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.

D. Grimacing is an objective observation by the nurse, not a subjective report from the client.

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Correct Answer is D

Explanation

A. Checking pupillary response to light assesses cranial nerve II (optic nerve).

B. Observing for facial symmetry primarily assesses cranial nerves VII (facial nerve) and possibly V (trigeminal nerve).

C. Testing for sense of smell assesses cranial nerve I (olfactory nerve).

D. Eliciting the gag reflex assesses cranial nerve IX (glossopharyngeal nerve) and also cranial nerve X (vagus nerve), making it the correct action to assess cranial nerve IX.

A. an element of only objective data collection B. the responsibility of trained family members or next of kin C. concerned with collecting only subjective data D. The professional responsibilities of trained healthcare providers

Correct Answer is D

Explanation

A. Providing a safe and comfortable environment and applying critical thinking involves both objective and subjective data collection, not just one type.

B. While family members can contribute to patient care, the professional responsibilities of providing a safe environment and critical thinking in assessments fall to trained healthcare providers.

C. This process encompasses both subjective and objective data, as critical thinking requires integrating multiple types of information.

D. The actions described are essential professional responsibilities of trained healthcare providers, who must ensure a safe environment, apply critical thinking, and identify patient cues effectively.

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A nurse is assessing a client for manifestations of pain. Which finding is a subjective indicator of pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve IX?

Correct Answer is D

Explanation

Providing a safe and comfortable environment, applying critical thinking, and identifying cues presented by the patient is

Correct Answer is D

Explanation

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