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 A
Explanation
A. Critical pathways are designed to standardize care processes, which can lead to improved efficiency, reduced length of stay, and better patient outcomes, all of which can contribute to lower healthcare costs. This is a key reason why critical pathways are used.
B. Critical pathways are typically developed by interdisciplinary teams or healthcare organizations rather than by individual providers. They are standardized plans that guide the care of groups of patients with similar conditions, rather than tailored to individual patient needs.
C. They do not need to be followed in a strict order; adjustments may be necessary based on the
patient’s response to treatment. This option oversimplifies the use of critical pathways.
D. Critical pathways primarily focus on the management of specific clinical conditions and patient care processes rather than broader health promotion activities. While they can contribute to overall care quality, their main purpose is not to guide health promotion.
Correct Answer is A
Explanation
A. This statement incorporates an inquiry into the client's emotional and psychological state, recognizing that stress may contribute to headache frequency. It reflects a holistic approach by considering factors beyond the physical symptoms, acknowledging the interplay between mental health and physical well- being.
B. This question focuses specifically on the physical symptoms of the headaches. While it’s important to understand the client’s symptoms, this statement does not consider emotional or psychosocial factors, making it less holistic.
C. Checking blood pressure is a vital assessment related to potential physiological causes of headaches. However, this action is primarily focused on physical health and does not encompass a holistic view of the client’s overall experience or emotional state.
D. This question addresses treatment and management of headaches, focusing on the effectiveness of medication. While important, it does not explore other contributing factors such as lifestyle, emotional health, or stress, and therefore lacks a holistic perspective.
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