Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)
frequency
duration
location.
character
intensity
Correct Answer : A,B,C,D,E
A. The frequency of pain is essential to understand how often the patient experiences pain.
B. Duration refers to how long the pain lasts, which is an important characteristic to document.
C. The location of pain helps determine its origin and the appropriate treatment approach.
D. The character of the pain, such as sharp, dull, or aching, aids in identifying its nature and cause.
E. The intensity of pain is crucial for assessing the effectiveness of pain management and guiding treatment decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.
C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.
Correct Answer is D
Explanation
A. A murmur or swishing sound does not correspond to the diastolic pressure; it is more indicative of turbulent blood flow.
B. Clear tapping sounds are heard at systolic pressure but do not indicate diastolic pressure.
C. Knocking sounds are associated with systolic pressure, not diastolic.
D. The muffling sound heard after the first Korotkoff sounds indicates the diastolic pressure in children and some adults, which is the correct method for assessing the diastolic reading.
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