A nurse is caring for a postoperative client who is awake, alert, and oriented. Which of the following methods should the nurse use as part of her pain management interventions to determine the intensity of the client's pain?

Visual observation for nonverbal signs of pain.

Vital sign measurement.

The client's self-report of pain severity.

The nature and invasiveness of the surgical procedure.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Visual observation for nonverbal signs of pain can be useful, especially in patients who are unable to communicate verbally. However, this method is not as accurate or reliable as obtaining the client's self-report of pain severity, which directly allows the patient to express their experience.

Choice B rationale:

Vital sign measurement, such as heart rate, blood pressure, and respiratory rate, can provide indirect information about a patient's pain level. However, vital signs can be influenced by various factors, including anxiety or other physiological responses. They may not always accurately reflect the intensity of pain and are not as specific as the client's self-report.

Choice C rationale:

The client's self-report of pain severity is the most reliable and accurate method for determining the intensity of pain. Pain is a subjective experience, and the client's self-report is crucial for effective pain management. Pain scales, such as numeric rating scales or visual analog scales, allow clients to describe their pain intensity in a standardized way.

Choice D rationale:

The nature and invasiveness of the surgical procedure are relevant factors to consider in understanding a patient's potential pain experience. However, this information alone is not sufficient for determining the current intensity of the client's pain. Pain levels can vary among individuals undergoing the same procedure due to differences in pain tolerance and perception.

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Correct Answer is B

Explanation

Choice A rationale:

Using an internet webpage translator might seem convenient, but it can lead to inaccuracies in communication due to language nuances and medical terminology. Direct communication with a human translator is more reliable.

Choice B rationale:

Arranging to complete the assessment with only the client and a translator present is the best option. This approach ensures accurate and confidential communication, allowing the nurse to gather essential information directly from the client without potential bias or misinterpretation from family members.

Choice C rationale:

Asking the client's husband to translate questions and answers for the client can lead to inaccurate or biased information. Additionally, it might not provide a safe environment for the client to openly share her concerns.

Choice D rationale:

Asking a male student nurse to translate for the client does not necessarily address the language barrier adequately. The gender of the translator is not the primary concern here. Ensuring effective communication through a professional translator is more important.

A. Contact. B. Droplet. C. Standard. D. Airborne.

Correct Answer is A

Explanation

Choice A rationale:

This choice is correct. Hepatitis B is primarily transmitted through contact with infected blood and bodily fluids. Contact precautions are designed to prevent the spread of infections that are transmitted through direct or indirect contact. These precautions include wearing gloves and gowns when in contact with the client or their environment.

Choice B rationale:

Droplet precautions are not appropriate for hepatitis B. Droplet precautions are used for infections that are spread through respiratory droplets, like coughing or sneezing. Hepatitis B is not primarily transmitted through respiratory droplets.

Choice C rationale:

Standard precautions involve the use of protective barriers such as gloves, gowns, masks, and eye protection to prevent the transmission of infections. While these precautions should always be practiced, they are not specifically tailored to hepatitis B, which has its own set of precautions.

Choice D rationale:

Airborne precautions are used for infections that are spread through small respiratory particles that remain suspended in the air for longer periods. Hepatitis B is not transmitted through airborne routes, so airborne precautions are not necessary.

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A nurse is caring for a postoperative client who is awake, alert, and oriented. Which of the following methods should the nurse use as part of her pain management interventions to determine the intensity of the client's pain?

Nursing Test Bank

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