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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bending at the hips can strain the back muscles. It's better to bend at the knees to lift with the leg muscles.
B. Keeping your feet together reduces stability. It's better to have a wide stance with your feet shoulder- width apart to maintain balance.
C. Standing close to the object reduces the distance the object needs to be lifted and minimizes the strain on the back muscles.
D. Twisting the spine while lifting can cause serious back injuries. It's important to avoid twisting and lift with straight back and legs.
Correct Answer is A
Explanation
A. Elevating the head of the bed during meals can help prevent aspiration by allowing gravity to assist in keeping food and liquids in the esophagus rather than the airway. This position reduces the risk of aspiration pneumonia significantly for clients who may have swallowing difficulties.
B. Tilting the head back while swallowing can increase the risk of aspiration, as it can cause food or liquids to flow into the airway rather than the esophagus. Proper swallowing techniques usually involve tilting the head slightly forward or maintaining a neutral position.
C. While good oral hygiene is essential for overall health and can help reduce the risk of aspiration pneumonia by minimizing bacteria in the mouth, it is not a direct action during meal times that prevents aspiration. Oral hygiene is important but should be part of a comprehensive care plan.
D. Distractions during meals, such as watching television, can lead to decreased attention to swallowing and increase the risk of aspiration. It can divert the client’s focus from the act of eating, making it harder for them to manage their swallowing effectively.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.