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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Peripheral neuropathy typically results in a decreased ability to detect temperature changes due to nerve damage. Clients often experience reduced sensation or may not feel temperature variations accurately.
B. This is a common symptom of peripheral neuropathy. Many clients report a burning, tingling, or "pins and needles" sensation in their feet. This phenomenon is often associated with nerve damage, especially in conditions like diabetes.
C. Peripheral neuropathy can lead to diminished or altered sensation, including the inability to sense pressure accurately. Clients may not feel pressure on their feet, which increases the risk of injuries and ulcers.
D. Hyperreflexia refers to increased reflex responses, which may occur with upper motor neuron lesions or central nervous system issues, not peripheral nerve damage. Peripheral neuropathy usually results in diminished reflexes or areflexia.

A. Use warm water to wash the client's feet. B. Allow the client's feet to air dry. C. Soak the client's feet prior to washing. D. Apply moisturizer between the client's toes.

Correct Answer is B

Explanation

A. Warm water is appropriate for washing the feet, but it's important to avoid very hot water, which can damage the skin.
B. This is the best way to prevent moisture buildup between the toes, which can lead to fungal infections. Air drying helps to keep the skin dry and reduces the risk of infection.
C. Soaking the feet can soften the skin and make it easier to remove dead skin cells, but it's important to avoid prolonged soaking, as this can dry out the skin and increase the risk of infection.
D. Applying moisturizer between the toes can trap moisture and create a breeding ground for bacteria and fungi. It's best to apply moisturizer to the top and bottom of the feet, avoiding the areas between the toes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has peripheral neuropathy. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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