The nurse is assessing a patient’s pain. Which would be the most reliable indicator of pain in a conscious, alert, and oriented patient?

Subjective report

Patient’s vital signs

Results of an x-ray

Physical examination

Answer and Explanation

The Correct Answer is A

Choice A reason: In a conscious, alert, and oriented patient, the subjective report is the most reliable pain indicator, as pain is a subjective experience. The patient’s description of intensity, location, and quality directly reflects their perception, guided by neurological pain pathways, making this the gold standard.

Choice B reason: Vital signs like elevated heart rate or blood pressure may suggest pain but are nonspecific, as they can result from anxiety, exertion, or other conditions. They are less reliable than the patient’s verbal report, which directly conveys the pain experience.

Choice C reason: X-ray results may identify structural issues but cannot directly assess pain, a subjective sensation processed by the brain’s pain pathways. They are diagnostic, not experiential, making them unreliable for gauging pain in a conscious patient.

Choice D reason: Physical examination findings, like guarding or grimacing, are indirect pain indicators and less reliable than the patient’s subjective report. These signs may be absent or misleading in some patients, making the verbal description more accurate for pain assessment.

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Correct Answer is D

Explanation

Choice A reason: Saying “That must be terrible” and suggesting a pinched nerve is dismissive and assumes a cause without assessment. Exploring the pain’s impact gathers critical data, so this is incorrect for an appropriate response.

Choice B reason: Asking about family reactions shifts focus from the patient’s experience and is less relevant initially. Assessing how the pain affects daily activities provides functional insight, so this is not the best response for pain assessment.

Choice C reason: Sharing personal experience can seem empathetic, but it this risks bias and doesn’t assess the patient’s pain. Asking about daily activity impact is more patient-centered, so this is incorrect for professional response.

Choice D reason: Asking how pain affects daily activities encourages the patient to describe the pain’s severity and impact, aiding assessment and planning. This open-ended, patient-focused response is therapeutic, making it the correct choice for the nurse’s reply.

A. Let’s check with the physician to see if you are a candidate for this vaccine B. This vaccine is only for girls who have not yet started to become sexually active C. The vaccine cannot protect you now that you already have an HPV infection D. The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that today

Correct Answer is C

Explanation

Choice A reason: Checking with the physician delays addressing the patient’s misunderstanding. The HPV vaccine does not treat existing infections or warts, as it is preventive, making this response less direct and informative than needed.

Choice B reason: The HPV vaccine is not limited to those not yet sexually active; it is recommended up to age 26, even for those with sexual history. This statement is outdated and incorrect, as vaccination can still benefit some with prior exposure.

Choice C reason: The HPV vaccine prevents new HPV infections but does not treat existing infections or genital warts, which are caused by specific HPV strains. Since the patient already has warts, the vaccine won’t help, making this the correct response.

Choice D reason: While the HPV vaccine is approved for ages 9–26, it does not treat existing infections or warts. Starting it without clarifying its preventive role misleads the patient, making this an incorrect and misleading response.

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The nurse is assessing a patient’s pain. Which would be the most reliable indicator of pain in a conscious, alert, and oriented patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be an appropriate response by the nurse to the woman’s statement?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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