For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:
Severity of the condition
Vital signs
Nonverbal behavior
Self-report of pain
The Correct Answer is D
Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.
Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.
Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.
Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Scarlet fever is caused by a bacterium that produces a toxin leading to a rash. It is typically spread through respiratory droplets, and while standard precautions are necessary, an N95 respirator is not required.
Choice B reason: Tuberculosis is an airborne infectious disease that requires the use of an N95 respirator to protect against inhaling the bacteria, especially in cases of pulmonary tuberculosis. This type of respirator filters out at least 95% of airborne particles, including Mycobacterium tuberculosis.
Choice C reason: Mycoplasmal pneumonia, also known as "walking pneumonia," is caused by Mycoplasma pneumoniae and is typically less severe than other types of bacterial pneumonia. Standard precautions, including the use of surgical masks, may be sufficient unless there is a risk of aerosol-generating procedures.
Choice D reason: Scabies is caused by a mite that burrows into the skin. It is spread through direct skin-to-skin contact, and an N95 respirator is not needed for protection against scabies.
Correct Answer is D
Explanation
Choice A reason: Wearing gloves when measuring a client's blood pressure is not typically necessary unless there is a risk of exposure to bodily fluids or if the client has an infectious disease. The use of gloves is based on the type of contact and potential for exposure, not routine tasks like BP measurement.
Choice B reason: Wearing gloves for all client contact is not necessary and is not consistent with standard precautions. Gloves should be used when there is potential contact with blood, body fluids, secretions, excretions, contaminated items, or mucous membranes.
Choice C reason: Gloves are not a substitute for hand hygiene. The primary reason for wearing gloves is to provide a barrier against infection, not to reduce handwashing. Hand hygiene is still required before donning gloves and after removing them, regardless of whether the gloves are soiled or not.
Choice D reason: Wearing gloves and a gown when bathing a client with open skin lesions is correct because it protects both the healthcare worker and the client from the risk of infection. Open skin lesions can be a source of infection, and PPE is necessary to prevent the transmission of pathogens.
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