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 B

Explanation

A) To determine the location of the pain: While knowing the location of the pain can be relevant for overall assessment, this is not the main reason for reassessing pain after treatment. The focus is more on understanding the response to treatment rather than just identifying where the pain is.

B) To establish the effectiveness of medication: Reassessing pain after treatment is essential to evaluate how well the medication has alleviated the pain. This helps the nurse determine if the current pain management approach is effective or if modifications are necessary to improve the patient's comfort.

C) To make changes to the patient's pain goal: While understanding pain levels can inform care planning, the primary purpose of reassessing pain is to gauge treatment effectiveness rather than directly changing the pain management goals at that moment.

D) To measure the pain's duration: Measuring the duration of pain may be useful in a broader context of pain management, but it is not the immediate rationale for reassessing pain after treatment. The focus should be on the effectiveness of the intervention rather than just how long the pain lasts.

A. Obtain an order for a catheter B. Allow the client to walk independently C. Obtain a bedside commode D. Limit fluid intake

Correct Answer is C

Explanation

A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.

B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.

C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.

D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.

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What is the most reliable indicator of pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which intervention will the nurse implement?

Correct Answer is C

Explanation

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