A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?
Vital sign measurement
Nature of invasiveness of the surgical procedure
Visual observation for nonverbal signs of pain
Client's self-report of pain
The Correct Answer is D
A. While changes in vital signs, such as increased heart rate and blood pressure, may indicate pain, they are not specific to pain and can be influenced by other factors.
B. The type of surgery can provide some clues about the potential for pain, but it does not accurately reflect the individual's pain experience.
C. Nonverbal cues like grimacing, guarding, or restlessness can suggest pain, but they are not always reliable indicators. Some clients may not exhibit obvious signs of pain, even if they are experiencing significant discomfort.
D. This is the most reliable source of information about a client's pain intensity. Only the client can accurately describe their own pain experience, including its location, severity, and quality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This method organizes information around specific patient problems. It includes a database, problem list, care plan, and progress notes.
B. This method focuses on specific patient concerns and includes data, action, and response components.
C. This method organizes documentation into subjective, objective, assessment, and plan components. It includes all relevant information, both expected and unexpected.
D. This method focuses on documenting only significant findings or deviations from the norm. By only documenting unexpected findings, it reduces the amount of time spent on charting while still ensuring that important information is captured.
Correct Answer is C
Explanation
A. The nurse should reinforce that the client should avoid twisting at the waist when lifting or reaching. Instead, they should pivot with their feet and keep their back straight to minimize strain on the lower back.
B. Prolonged bed rest is generally not recommended for acute lower back pain. While resting is important, clients are usually encouraged to engage in light activity and movement as tolerated to prevent stiffness and promote healing. Staying in bed for extended periods can lead to more problems.
C. Ice packs can help reduce inflammation and numb the pain in the initial stages of injury. Applying ice intermittently for 15-20 minutes at a time can be beneficial during the first 48 hours after an acute injury.
D. This option is not advisable for a client experiencing acute lower back pain. Strengthening exercises should be introduced gradually and only after the acute pain has subsided. Initially, the focus should be on gentle stretching and movement rather than adding weights, which could exacerbate the injury.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.