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 A
Explanation
A. Elevating the head of the bed during meals can help prevent aspiration by allowing gravity to assist in keeping food and liquids in the esophagus rather than the airway. This position reduces the risk of aspiration pneumonia significantly for clients who may have swallowing difficulties.
B. Tilting the head back while swallowing can increase the risk of aspiration, as it can cause food or liquids to flow into the airway rather than the esophagus. Proper swallowing techniques usually involve tilting the head slightly forward or maintaining a neutral position.
C. While good oral hygiene is essential for overall health and can help reduce the risk of aspiration pneumonia by minimizing bacteria in the mouth, it is not a direct action during meal times that prevents aspiration. Oral hygiene is important but should be part of a comprehensive care plan.
D. Distractions during meals, such as watching television, can lead to decreased attention to swallowing and increase the risk of aspiration. It can divert the client’s focus from the act of eating, making it harder for them to manage their swallowing effectively.
Correct Answer is C
Explanation
A. Bending at the hips can strain the back muscles. It's better to bend at the knees to lift with the leg muscles.
B. Keeping your feet together reduces stability. It's better to have a wide stance with your feet shoulder- width apart to maintain balance.
C. Standing close to the object reduces the distance the object needs to be lifted and minimizes the strain on the back muscles.
D. Twisting the spine while lifting can cause serious back injuries. It's important to avoid twisting and lift with straight back and legs.
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