A nurse is collecting data on 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 reports a burning sensation.
The client grimaces when they move.
The client states the pain is located on their abdomen.
The Correct Answer is C
A. This is a subjective indicator of pain. The pain rating is based on the client’s personal experience and perception of their pain intensity. It reflects the individual’s feelings rather than observable data.
B. This statement is also subjective. Describing pain as a "burning sensation" comes from the client's personal experience and interpretation of their symptoms, which cannot be measured or observed by others.
C. This is an objective indicator of pain. A grimace is an observable behavior that can indicate discomfort or pain. It is something that the nurse can see and assess, making it an objective finding.
D. This is another subjective indicator. While knowing the location of pain is important for diagnosis and treatment, the statement reflects the client’s personal experience of pain and cannot be measured or observed directly.
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Correct Answer is C
Explanation
A. This approach can be frustrating for the client and may undermine their confidence and autonomy. It can also prevent the client from expressing themselves fully. Therefore, this is not an appropriate action.
B. Visual aids can enhance understanding and facilitate communication, especially for clients with speech impairments. Avoiding them would limit effective communication.
C. Providing extra time allows the client to process their thoughts and express themselves at their own pace. It shows respect for their communication needs and fosters a more supportive environment.
D. While open-ended questions encourage more detailed responses, they may be challenging for someone with impaired speech. Instead, closed-ended questions or offering choices can be more effective. Open-ended questions could lead to frustration if the client struggles to articulate their responses.
Correct Answer is A
Explanation
A. Urinary retention can lead to an increased risk of urinary tract infections. When urine remains in the bladder for prolonged periods, it can become a breeding ground for bacteria, increasing the likelihood of infection.
B. While bladder outlet obstruction can lead to urinary retention, this is more of a potential cause rather than a complication to monitor. In an immobile client, it may not be the primary concern unless there are specific signs or known conditions that suggest obstruction.
C. Proteinuria (presence of protein in the urine) is typically associated with kidney damage or disease, rather than urinary retention itself. While kidney function should always be monitored in any patient, protein in the urine is not a direct consequence of urinary retention or immobility.
D. Neurogenic bladder refers to bladder dysfunction due to nerve problems, affecting the ability to sense fullness or control urination. While this can be a concern for clients with certain neurological conditions, it is not an immediate monitoring concern for a client experiencing urinary retention solely due to immobility.
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