. A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?
The patient's chart
Visual observation for nonverbal signs of pain
The client's self-report of pain severity
The nature and invasiveness of the surgical procedure
The Correct Answer is C
A. The patient's chart may provide historical information but does not reflect the current pain intensity the client is experiencing.
B. Visual observation for nonverbal signs of pain can be useful, especially for nonverbal patients, but self-reporting is the most accurate measure of pain intensity.
C. The client's self-report of pain severity is the gold standard for assessing pain intensity, as it reflects the individual’s personal experience of pain.
D. While the nature and invasiveness of the surgical procedure can provide context for expected pain levels, they do not replace the importance of the client's self-report in managing pain effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Facial drooping is a common symptom following a stroke, particularly if it affects areas of the brain responsible for facial movement.
B. Frequent diarrhea is not typically associated with stroke and may be related to other factors.
C. A steady gait is unlikely following a stroke, especially if the stroke has affected motor control or balance.
D. Vocal clarity can be affected after a stroke, but facial drooping is a more immediate and recognizable alteration in neurologic function.
Correct Answer is B
Explanation
A. Bronchovesicular sounds are normal lung sounds that are typically heard over the mainstem bronchi and are expected during auscultation.
B. Bronchial sounds are also normal and are typically heard over the trachea; they are expected lung sounds.
C. Dullness is not a lung sound but rather a descriptor of percussion notes, typically indicating fluid or solid mass in the lungs.
D. Flatness is also not a normal lung sound but refers to a percussion note that can suggest the presence of fluid or a solid mass.
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