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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Metabolic alkalosis is characterized by a high pH and elevated bicarbonate levels, which is not present in these results.
B. Respiratory alkalosis would present with an increased pH and decreased PaCO2, which does not apply here.
C. The low pH (7.12) indicates acidemia, and the elevated PaCO2 (90 mm Hg) suggests hypoventilation and respiratory acidosis due to CO2 retention. The bicarbonate level is within normal limits, further supporting respiratory acidosis.
D. Metabolic acidosis would be indicated by a low pH and low bicarbonate levels; however, the bicarbonate is normal in this case, ruling out metabolic acidosis.
Correct Answer is B
Explanation
A. Lordosis is an exaggerated inward curvature of the lumbar spine.
B. Scoliosis is a lateral curvature of the spine, often characterized by an "S" or "C" shape when viewed from behind. This is the disorder depicted in the image.
C. Kyphosis is an exaggerated outward curvature of the thoracic spine, often leading to a hunchback appearance.
D. Funnel chest (pectus excavatum) is a condition where the breastbone sinks into the chest, creating a sunken appearance.
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