When caring for a patient in pain, the most important principle that the nurse must recognize is that:

the person experiencing the pain is the authority about the pain.

administering analgesics for pain will eventually lead to addiction.

behavioral signs are always congruent with statements about pain.

the extent of pain is directly related to the amount of tissue damage.

Answer and Explanation

The Correct Answer is A

A. The person experiencing the pain is the authority about the pain: This is the most important principle to recognize when caring for a patient in pain. Pain is a subjective experience, and the individual experiencing it is the best authority on their pain. Nurses should listen to and respect the patient's descriptions and assessments of their pain, as they are the ones experiencing it firsthand. This principle underscores the importance of patient-centered care and empowers patients to participate in decisions about pain management.

B. Administering analgesics for pain will eventually lead to addiction: While concerns about addiction are important to consider when administering analgesics, this statement is not the most important principle to recognize when caring for a patient in pain. Fear of addiction should not overshadow the patient's right to adequate pain relief. Nurses should prioritize effective pain management while also considering factors such as the patient's history of substance use and monitoring for signs of misuse or addiction.

C. Behavioral signs are always congruent with statements about pain: While behavioral signs can provide valuable information about a patient's pain experience, they may not always be congruent with verbal statements about pain. Some patients may exhibit stoic behaviors despite experiencing significant pain, while others may express distress more visibly. Nurses should consider both verbal and non-verbal cues when assessing pain and tailor interventions accordingly.

D. The extent of pain is directly related to the amount of tissue damage: While pain often accompanies tissue damage or injury, the extent of pain experienced by an individual is influenced by various factors beyond just tissue damage. Pain perception is subjective and can be influenced by factors such as psychological, emotional, cultural, and social factors. Therefore, pain intensity may not always directly correlate with the amount of tissue damage present.

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Correct Answer is B

Explanation

A. Use open-ended questions to find out about the sensation: While open-ended questions can help the nurse gather information about the nature and quality of the pain, they may not provide a precise measure of pain intensity. Open-ended questions are valuable for understanding the client's subjective experience of pain, but they may not be as effective as using a pain scale for quantifying pain intensity.

B. Offer the client a pain scale to quantify the current level of pain: This is the most appropriate action for assessing pain intensity. Pain scales, such as the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), allow clients to indicate their pain intensity on a scale from 0 to 10 or by marking a point along a continuum. Pain scales provide a standardized method for quantifying pain intensity, which helps healthcare providers monitor changes in pain over time and assess the effectiveness of pain management interventions.

C. Question the client about the location of the pain: While identifying the location of pain is important for understanding its source and potential underlying causes, it does not directly assess pain intensity. Location is one aspect of pain assessment but does not provide a complete picture of pain intensity on its own.

D. Ask about what precipitates the pain: Understanding what precipitates or exacerbates pain is important for comprehensive pain assessment, but it focuses more on pain triggers rather than pain intensity. While this information can be valuable for developing a holistic pain management plan, it does not directly assess the current level of pain intensity.

A. Diarrhea B. Urinary output C. Profuse sweating D. Vomiting E. Increased respiratory effort

Correct Answer is ["B","E"]

Explanation

A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.

B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.

C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.

D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.

E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.

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When caring for a patient in pain, the most important principle that the nurse must recognize is that:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is most appropriate when the nurse assesses the intensity of the client's pain?

Correct Answer is B

Explanation

The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

Correct Answer is ["B","E"]

Explanation

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The nurse is addressing a client's questions after admission to the hospital. What is an accurate description of a living will?

A client has with profuse diarrhea from food poisoning contracted at a company picnic 12 hours ago. The nurse's care for this client should include: ...

The physician has ordered replacement fluids for a client who has a fluid volume deficit with a diagnosis of gastroenteritis. The nurse would expect the use of which type of fluids initially upon admission?

The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?