A nurse is caring for a client who acquired hepatitis A from consuming contaminated food. The client’s mouth is an example of which of the following links in the chain of infection?

When performing perineal care for a female client, the nurse should use soap and water to clean the client’s perineum. This helps to remove any urine or fecal mater and prevent skin irritation or infection. The nurse should also use a clean section of the washcloth for each area cleaned and should clean from front to back to prevent the spread of bacteria from the rectal area to the urethra.

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.