A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain?
The client rates their pain as an 8 on a scale of 0 to 10.
The client states the pain is located on their abdomen.
The client reports a burning sensation.
The client grimaces when they move.
The Correct Answer is D
Answer: D. The client grimaces when they move.
Rationale:
A) The client rates their pain as an 8 on a scale of 0 to 10:
Pain ratings provided by the client are subjective and reflect their personal experience and perception of pain. While important for assessing pain severity, this rating is based on the client's personal report rather than observable evidence.
B) The client states the pain is located on their abdomen:
The location of pain, as reported by the client, is subjective information. It is based on the client's personal experience and cannot be objectively measured or observed by the nurse.
C) The client reports a burning sensation:
Describing the sensation of pain, such as a burning feeling, is a subjective experience. This description provides valuable information about the nature of the pain but does not serve as an objective indicator.
D) The client grimaces when they move:
Observing a grimace is an objective indicator of pain. It is a visible, physical response that the nurse can see and document, indicating that the client is experiencing discomfort or pain. Objective indicators are observable signs that can be noted by healthcare providers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Localized warmth is a classic sign of inflammation and can indicate the presence of an infection or injury in the affected area. Sanguineous drainage is a type of wound drainage that consists of blood and is not a sign of inflammation. Palpable pedal pulses and full range of motion can provide information about the injury, but they are not specific to inflammation. Therefore, options b, c, and d are incorrect.
Correct Answer is A
Explanation
A sentinel event is an unexpected event in a healthcare setting that causes or has the potential to cause death, serious physical or psychological injury, or loss of limb or function to a patient1. A client falling out of
bed and fracturing their hip would be considered a sentinel event because it is an unexpected event that resulted in serious physical injury.
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