A nurse is collecting data on a client for manifestations of pain. Which of the following findings is an objective indicator of pain?
The client rates their pain as an 8 on a scale of 0 to 10.
The client reports a burning sensation.
The client grimaces when they move.
The client states the pain is located on their abdomen.
The Correct Answer is C
A. This is a subjective indicator of pain. The pain rating is based on the client’s personal experience and perception of their pain intensity. It reflects the individual’s feelings rather than observable data.
B. This statement is also subjective. Describing pain as a "burning sensation" comes from the client's personal experience and interpretation of their symptoms, which cannot be measured or observed by others.
C. This is an objective indicator of pain. A grimace is an observable behavior that can indicate discomfort or pain. It is something that the nurse can see and assess, making it an objective finding.
D. This is another subjective indicator. While knowing the location of pain is important for diagnosis and treatment, the statement reflects the client’s personal experience of pain and cannot be measured or observed directly.
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Correct Answer is D
Explanation
A. This action is based on the nurse's responsibility to manage the client's pain effectively, but it does not reflect the client's autonomy. Instead, it focuses on the nurse's duty to provide care.
B. While this demonstrates fairness and equality in care, it does not specifically address the autonomy of the clients. Autonomy involves allowing clients to make choices tailored to their individual preferences and needs, rather than applying the same approach to everyone.
C. This option reflects the nurse's commitment to their responsibilities and maintaining trust with the client. However, it does not exemplify autonomy, as it does not involve the client's choice or decision- making.
D. This is the best example of autonomy. By allowing the client to choose when to take their medication, the nurse respects the client's right to make decisions about their own care, which is a fundamental aspect of autonomy.
Correct Answer is D
Explanation
A. This method organizes information around specific patient problems. It includes a database, problem list, care plan, and progress notes.
B. This method focuses on specific patient concerns and includes data, action, and response components.
C. This method organizes documentation into subjective, objective, assessment, and plan components. It includes all relevant information, both expected and unexpected.
D. This method focuses on documenting only significant findings or deviations from the norm. By only documenting unexpected findings, it reduces the amount of time spent on charting while still ensuring that important information is captured.
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