A nurse is evaluating a patient for signs of pain. Which of the following is an objective sign of pain?

The patient reports a burning sensation.

The patient grimaces when they move.

The patient rates their pain as an 8 on a scale of 0 to 10.

The patient states the pain is located in their abdomen.

Answer and Explanation

The Correct Answer is B

Choice A rationale
A patient reporting a burning sensation is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice B rationale
A patient grimacing when they move is an objective sign of pain. It is observable and does not rely on the patient’s verbal report.
Choice C rationale

A patient rating their pain as an 8 on a scale of 0 to 10 is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice D rationale
A patient stating the pain is located in their abdomen is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.

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Correct Answer is D

Explanation

Choice A rationale
Monitoring volume status is important in managing increased ICP, but it is not a direct intervention to reduce ICP78.
Choice B rationale

Ensuring proper ventriculostomy transducer levels is important in monitoring ICP, but it is not a direct intervention to reduce ICP78.
Choice C rationale
Managing sedation can help control agitation and excessive muscular activity, which can potentially increase ICP. However, it is not a direct intervention to reduce ICP78.
Choice D rationale
Elevating the head of the bed 15 degrees can help promote venous drainage, enhance cerebral perfusion, and reduce ICP78.

A. “Have you experienced any nausea or vomiting with your headache?” B. “Are the lights in here bothering you?” C. “Have you noticed any confusion or clouded thinking?” D. “Have you smelled anything unusual or are you currently smelling anything strange?” E. “Did you feel weak before the headache started or are you feeling weak now?”

Correct Answer is A

Explanation

Choice A rationale
Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm a diagnosis of a migraine.
Choice B rationale
Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the question “Are the lights in here bothering you?” is less specific to migraines as it could be indicative of several other conditions as well.
Choice C rationale
While confusion or clouded thinking can occur with migraines, it is not as common as other symptoms such as nausea, vomiting, and sensitivity to light.
Choice D rationale
Unusual smells, known as olfactory hallucinations, are not typically associated with migraines. They are more commonly associated with conditions such as epilepsy.
Choice E rationale
Weakness before the headache started or currently feeling weak now is not a typical symptom of migraines. It could be indicative of a more serious condition, such as a stroke.

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A nurse is evaluating a patient for signs of pain. Which of the following is an objective sign of pain?

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Naxlex Comprehensive Predictor Exams

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