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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This is too hot and can scald the client's skin. The recommended water temperature for bathing is around 37-40°C (98.6-104°F).
B. Bath oil can make the bathtub surface slippery, increasing the risk of falls.
C. While it's important to avoid prolonged exposure to hot water, limiting bath time to 20 minutes is not the primary concern for safety in this situation.
D. This is the most important safety measure to prevent falls, especially for a client with a lower extremity amputation who may have balance difficulties.
Correct Answer is B
Explanation
A. This condition affects the central portion of the retina, causing blurred vision in the center of the visual field.
B. A cataract is a clouding of the lens in the eye that affects vision. This clouding can cause blurred vision, sensitivity to light, and difficulty seeing at night.
C. This is a complication of diabetes that damages the blood vessels in the retina. It can cause blurred vision, floaters, and even blindness.
D. This is a condition that damages the optic nerve. It often causes a gradual loss of peripheral vision.
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