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 action is not appropriate as it could stimulate the gag reflex and lead to choking or aspiration. It does not contribute to effective oral care. Instead, gentle techniques using appropriate tools should be used to clean the mouth.
B. Holding the toothbrush at a 90° angle can be effective for brushing teeth as it allows for better access to the surfaces of the teeth. However, for an unconscious patient, this angle might not be practical or safe depending on the circumstances.
C. Vigorous brushing is not recommended, especially for an unconscious client. It could cause damage to the gums, lead to discomfort, or risk aspiration of fluids. Gentle brushing is advised to clean the teeth and gums without causing injury.
D. Turning the client to the side helps prevent aspiration of saliva or any fluids that may be in the mouth. It also provides better access for oral care and minimizes the risk of choking. This position is often recommended for unconscious patients to maintain their safety during oral care.
Correct Answer is C
Explanation
A. The goal is not to avoid pressure on the stronger leg; rather, the walker is used to assist with balance and support for both legs. The client typically puts weight on both legs when using the walker, especially when moving it forward.
B. While proper hand positioning is important for stability, the specific instruction to move the walker forward 6 to 8 inches is primarily focused on facilitating safe movement and balance, rather than just ensuring hand positioning. Therefore, this is not the main purpose.
C. Moving the walker forward provides a stable base of support before the client steps forward with their weaker leg. This technique allows the client to safely shift their weight onto the walker, minimizing the risk of falls and ensuring adequate support during ambulation.
D. While maintaining the center of gravity is important for balance, the specific instruction to move the walker forward 6 to 8 inches is primarily about creating a safe distance to support the client’s weight. This action does help with balance, but it’s not the primary reason for that specific movement.
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