A nurse is caring for a postoperative client who is awake, alert, and oriented. Which of the following methods should the nurse use as part of her pain management interventions to determine the intensity of the client's pain?

Visual observation for nonverbal signs of pain.

Vital sign measurement.

The client's self-report of pain severity.

The nature and invasiveness of the surgical procedure.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Visual observation for nonverbal signs of pain can be useful, especially in patients who are unable to communicate verbally. However, this method is not as accurate or reliable as obtaining the client's self-report of pain severity, which directly allows the patient to express their experience.

Choice B rationale:

Vital sign measurement, such as heart rate, blood pressure, and respiratory rate, can provide indirect information about a patient's pain level. However, vital signs can be influenced by various factors, including anxiety or other physiological responses. They may not always accurately reflect the intensity of pain and are not as specific as the client's self-report.

Choice C rationale:

The client's self-report of pain severity is the most reliable and accurate method for determining the intensity of pain. Pain is a subjective experience, and the client's self-report is crucial for effective pain management. Pain scales, such as numeric rating scales or visual analog scales, allow clients to describe their pain intensity in a standardized way.

Choice D rationale:

The nature and invasiveness of the surgical procedure are relevant factors to consider in understanding a patient's potential pain experience. However, this information alone is not sufficient for determining the current intensity of the client's pain. Pain levels can vary among individuals undergoing the same procedure due to differences in pain tolerance and perception.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.

Choice B rationale:

This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.

Choice C rationale:

This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.

Choice D rationale:

This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.

Choice E rationale:

This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.

A. Pneumonia. B. Atelectasis. C. Pleural effusion. D. Emphysema.

Correct Answer is D

Explanation

Choice A rationale:

Pneumonia is not likely to be the correct answer. Pneumonia is often characterized by productive cough, fever, chest pain, and increased tactile fremitus due to consolidation of lung tissue. The presence of barrel chest, decreased tactile fremitus, and hyperresonant percussion sounds is not consistent with pneumonia.

Choice B rationale:

Atelectasis is not the most likely option. Atelectasis refers to collapsed or partially collapsed lung tissue, which can lead to decreased breath sounds, dullness to percussion, and decreased tactile fremitus. The symptoms mentioned in the scenario, such as prolonged expiration, wheezes, and barrel chest, are not indicative of atelectasis.

Choice C rationale:

Pleural effusion is not the most suitable choice. Pleural effusion usually presents with decreased breath sounds, dullness to percussion, and decreased tactile fremitus over the affected area due to fluid accumulation in the pleural space. The hyperresonant percussion sounds and the presence of wheezes and rhonchi do not align with pleural effusion.

Choice D rationale:

Emphysema is the most likely disorder based on the given symptoms. Barrel chest (increased anterior-posterior chest diameter), limited lung expansion, decreased tactile fremitus, hyperresonant percussion sounds, prolonged expiration, wheezes, and rhonchi are characteristic findings of emphysema. This condition involves damage to the alveoli and their supporting structures, leading to air trapping, reduced lung elasticity, and obstructed airflow. The patient's use of accessory muscles to breathe further suggests a chronic obstructive pulmonary disease (COPD) like emphysema.

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A nurse is caring for a postoperative client who is awake, alert, and oriented. Which of the following methods should the nurse use as part of her pain management interventions to determine the intensity of the client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.).

Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is D

Explanation

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