What is the most reliable indicator of pain?

Subjective report

Physical exam

Results of a CAT scan

The client's vital signs

Answer and Explanation

The Correct Answer is A

A) Subjective report: The most reliable indicator of pain is the patient's own description of their experience. Pain is inherently subjective, and individuals may perceive and express pain differently. Listening to the client's self-report provides valuable insight into their pain intensity, quality, and impact on daily life, which cannot be accurately assessed through objective measures alone.

B) Physical exam: While a physical exam can provide important information about potential sources of pain or related conditions, it may not accurately reflect the intensity or nature of the pain the patient is experiencing. Physical findings may vary widely among individuals with similar pain complaints, making this a less reliable indicator.

C) Results of a CAT scan: Imaging studies like CAT scans can identify structural issues, such as fractures or tumors, but they do not measure pain. Many patients with significant pain may have normal imaging results, while others with severe findings may report minimal discomfort, underscoring the limitations of relying solely on diagnostic tests.

D) The client's vital signs: Vital signs can indicate physiological responses to pain, such as increased heart rate or blood pressure, but they are not specific indicators of pain severity. Many factors can influence vital signs, including anxiety and other medical conditions, making them unreliable for assessing pain levels independently.

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Correct Answer is C

Explanation

A) Talking in a loud voice: While this may indicate some level of distress or confusion, it does not necessarily signal a specific neurological deficit. Clients may raise their voice for various reasons unrelated to neurological issues.

B) Grimacing with movement: This could suggest discomfort or pain but is not an explicit indicator of neurological impairment. Grimacing can occur for many reasons, including musculoskeletal issues or emotional responses, and does not specifically necessitate a focused neurological assessment.

C) Asymmetry of the client's smile: This finding is significant and raises concerns about potential neurological issues, such as a stroke or Bell's palsy. Facial asymmetry may indicate weakness or dysfunction in the cranial nerves responsible for facial movement, warranting a more thorough neurological examination to assess for underlying causes.

D) Inability to follow directions: While this may point to confusion or cognitive impairment, it is a more general indicator and could result from various factors, including anxiety or lack of understanding. It does not specifically highlight a localized neurological deficit as clearly as facial asymmetry does.

A. Information sharing is limited to those directly involved in the client's care. B. All members of the units healthcare team may have access to the client's chart. C. The Health Insurance Portability and Accountability Act (HIPAA) determines who may communicate with the client. D. The medical records are open to any hospital employee, including administration.

Correct Answer is A

Explanation

A) Information sharing is limited to those directly involved in the client's care: This statement reflects the principle of confidentiality and the ethical obligation to protect the client's private health information. Only healthcare providers directly involved in the client’s care should have access to their information, ensuring that it remains secure and confidential.

B) All members of the unit's healthcare team may have access to the client's chart: While many healthcare team members need access to the client's information for care coordination, this statement is misleading. Access should be limited to those directly involved in the client’s care to protect their confidentiality.

C) The Health Insurance Portability and Accountability Act (HIPAA) determines who may communicate with the client: While HIPAA does set guidelines for the protection of health information and governs the sharing of health data, it does not specifically determine who may communicate with the client. Instead, it focuses on protecting their privacy.

D) The medical records are open to any hospital employee, including administration: This statement is incorrect as it violates confidentiality principles. Medical records are not accessible to all hospital employees; access is restricted to authorized personnel only, ensuring that patient information is kept confidential.

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What is the most reliable indicator of pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more focused neurological assessment of this client?

Correct Answer is C

Explanation

The nurse is admitting a client to the acute care unit. Which should the nurse consider when regarding the confidentiality of the client?

Correct Answer is A

Explanation

The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

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When assessing the skin of an elderly client, the nurse notes tenting. The nurse understands what about this assessment?

Based on an understanding of the cognitive changes that normally occur with aging. what would the nurse expect a newly hospitalized older adult to do?

Which of the following statements regarding idiopathic neuropathy is true?

Which of the following is the rationale for the nurse to reassess the patient's pain after treatment?

The nurse assessing a 90-year-old patient notes that his skin is thin and turgor is non-elastic. The patient states that he always seems to be cold. What does the nurse know about these assessment findings?