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 B

Explanation

A. Pigeon chest (pectus carinatum) is a structural deformity of the chest and is not associated with COPD.

B. A barrel chest is commonly seen in clients with COPD due to hyperinflation of the lungs, causing the chest to appear rounded and expanded.

C. Kyphotic refers to an abnormal curvature of the spine (kyphosis) and is not a characteristic of COPD.

D. Funnel chest (pectus excavatum) is another structural deformity and is not typically associated with COPD.

A. Anterior chest B. Neck C. Heart D. Abdomen

Correct Answer is D

Explanation

A. In the anterior chest assessment, auscultation usually follows inspection and is typically done before percussion.

B. In the neck assessment, the nurse may inspect and then auscultate (e.g., carotid arteries) before palpation.

C. In the heart assessment, auscultation follows inspection but may not involve percussion.

D. In the abdomen, the correct order is to inspect, auscultate, and then percuss to assess bowel sounds effectively before creating additional disturbances with percussion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which shape should the nurse expect a client's chest to be when assessing a client who has COPD?

Correct Answer is B

Explanation

During which part of a comprehensive physical assessment would the nurse auscultate after inspecting but before percussing?

Correct Answer is D

Explanation

Which disorder is depicted in the image below?

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