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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This condition affects the central portion of the retina, causing blurred vision in the center of the visual field.
B. A cataract is a clouding of the lens in the eye that affects vision. This clouding can cause blurred vision, sensitivity to light, and difficulty seeing at night.
C. This is a complication of diabetes that damages the blood vessels in the retina. It can cause blurred vision, floaters, and even blindness.
D. This is a condition that damages the optic nerve. It often causes a gradual loss of peripheral vision.
Correct Answer is D
Explanation
A. This statement describes an action taken by the client and is considered objective information. It reports a measurable action rather than the client’s personal experience or feelings about their condition.
B. This is an objective finding, as it is a measurable and observable fact obtained through assessment. It
does not reflect the client’s perspective or self-reported symptoms.
C. It describes observable signs noted during the assessment and does not include any information shared by the client about how they feel.
D. It reflects the client’s personal experience of pain and provides context for the symptom, including the activity that triggered it. This type of information is essential in understanding the client’s condition from their perspective.
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