A nurse is caring for a client who reports having acute pain rated 6/10 following abdominal surgery. Which additional assessment finding should the nurse expect?

A. While temperature is an important vital sign, it is not directly related to cardiac rhythm or dysrhythmias. Abnormal temperature may influence heart rate indirectly (e.g., fever causing tachycardia), but it is not the priority assessment for a client with known cardiac dysrhythmias.

B. Pulse oximetry measures oxygen saturation and can indicate hypoxia. Although oxygenation is important, dysrhythmias primarily affect heart rate and rhythm rather than oxygen saturation directly. It is secondary to assessing the pulse in this context.

C. The pulse is the most critical vital sign to assess in a client with a history of cardiac dysrhythmias. Evaluating the rate, rhythm, and quality of the pulse allows the nurse to identify irregularities such as tachycardia, bradycardia, skipped beats, or other arrhythmias. Dysrhythmias can lead to decreased cardiac output, hypotension, syncope, or sudden cardiac events, so prompt identification is essential for timely intervention.

D. Respiratory rate is important for overall assessment, especially if dysrhythmias compromise cardiac output, but it is not the primary indicator of cardiac rhythm issues. It is a secondary assessment compared with the pulse.

A. Cerumen (earwax) accumulation is something the nurse can directly observe during inspection of the external auditory canal. Because it is visible and measurable, it is considered an objective finding.

B. The condition of the skin around the ear can be directly observed. Dryness and flakiness are visible physical characteristics, making this an objective assessment finding.

C. Pain is a subjective symptom, meaning it is reported by the client and cannot be directly measured or observed by the nurse. Even if the nurse elicits pain by palpation, the sensation itself is based on the client’s report, making it subjective.

D. Visualization of the cone of light during otoscopic examination is a directly observable physical sign of the tympanic membrane’s condition. This makes it an objective finding.

E. Tenderness, like pain, is based on the client’s report during palpation. Although the nurse performs the assessment, the determination of tenderness depends on the client’s perception, making it subjective.