A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

Severity of the condition

Vital signs

Nonverbal behavior

Self-rating of pain

Answer and Explanation

The Correct Answer is D

A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.

B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.

C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.

D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.

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Correct Answer is A

Explanation

A. The carotid pulse should not be assessed bilaterally at the same time, as simultaneous palpation can lead to a decrease in heart rate or cause syncope due to stimulation of the carotid sinus.

B. The radial pulse can be assessed bilaterally without risk.

C. The brachial pulse can also be assessed bilaterally without concern.

D. The femoral pulse is typically assessed one side at a time, but there is no risk in palpating both femoral arteries simultaneously as there is with the carotid.

A. leg pain B. indigestion C. headache D. pruritus of the skin E. nausea F. vomiting

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Indigestion: This is a common symptom related to abdominal issues, and the nurse should assess it.

Nausea: Often indicates gastrointestinal distress and is important to evaluate.

Vomiting: A critical symptom that can signify a range of abdominal problems and warrants further assessment.

Non-essential:

Leg pain: Not typically associated with abdominal problems, making it non-essential for this assessment.

Headache: While it can be related to many conditions, it is not directly tied to abdominal problems.

Pruritus of the skin: Generally unrelated to abdominal symptoms, making it non-essential for this specific assessment.

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A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's circulatory system. Which pulse site should the nurse avoid assessing bilaterally at the same time?

Correct Answer is A

Explanation

A nurse is receiving a patient from the emergency room. To assess whether a client is having symptoms of abdominal problems, which symptom would the nurse ask the patient? For each data collection, choose whether the assessment is essential or non-essential.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

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