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 D
Explanation
The nurse should plan to use warm water to wash the client’s feet as part of proper foot care. Warm water can help soften the skin and nails, making it easier to clean and trim the nails. It is also important to avoid soaking the feet, as this can dry out the skin and increase the risk of infection.
Correct Answer is A
Explanation
- Remove protective gown before removing gloves.
When caring for a client with Clostridium Difficile, it is important to follow strict contact precautions to prevent the spread of the bacteria. The nurse should remove the protective gown before removing gloves to avoid contaminating the gown with any bacteria that may be on the gloves. This helps to minimize the risk of spreading the bacteria to other clients or healthcare workers.
- Shake bed linens before placing them in a linen bag.
Shaking bed linens can cause any bacteria that may be on them to become airborne, increasing the risk of spreading the bacteria to other surfaces. Instead, bed linens should be rolled up and placed directly into a linen bag without shaking them.
- Use an electronic thermometer to take the client's temperature.
An electronic thermometer is preferred when taking the temperature of a client with Clostridium Difficile because it can be easily disinfected between uses, reducing the risk of spreading the bacteria.
- Remove protective gloves when leaving the client's room.
Protective gloves should be removed before leaving the client's room to avoid contaminating other surfaces or spreading the bacteria to other clients or healthcare workers.
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