A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?
Vital sign measurement
Nature of invasiveness of the surgical procedure
Visual observation for nonverbal signs of pain
Client's self-report of pain
The Correct Answer is D
A. While changes in vital signs, such as increased heart rate and blood pressure, may indicate pain, they are not specific to pain and can be influenced by other factors.
B. The type of surgery can provide some clues about the potential for pain, but it does not accurately reflect the individual's pain experience.
C. Nonverbal cues like grimacing, guarding, or restlessness can suggest pain, but they are not always reliable indicators. Some clients may not exhibit obvious signs of pain, even if they are experiencing significant discomfort.
D. This is the most reliable source of information about a client's pain intensity. Only the client can accurately describe their own pain experience, including its location, severity, and quality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This method organizes information around specific patient problems. It includes a database, problem list, care plan, and progress notes.
B. This method focuses on specific patient concerns and includes data, action, and response components.
C. This method organizes documentation into subjective, objective, assessment, and plan components. It includes all relevant information, both expected and unexpected.
D. This method focuses on documenting only significant findings or deviations from the norm. By only documenting unexpected findings, it reduces the amount of time spent on charting while still ensuring that important information is captured.
Correct Answer is B
Explanation
A. Lifting heavy loads alone can increase the risk of injury. It is important to use proper lifting techniques and to get help when needed.
B. Taking breaks allows nurses to rest and reduce the risk of musculoskeletal injuries. It helps to prevent fatigue, which can lead to poor posture and other ergonomic problems.
C. Reaching can strain muscles and increase the risk of injury. It is better to move closer to the object before lifting it.
D. Working long hours can lead to fatigue and increased stress, which can contribute to ergonomic problems. It is important to have adequate rest and recovery time.
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