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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. As individuals age, balance often decreases due to factors such as changes in vision, muscle strength, and proprioception. Older adults may be more prone to falls because of diminished balance and coordination.
B. While bones may become denser in some cases due to increased calcification, this is not the typical expectation. Generally, older adults experience a decrease in bone density, which can lead to conditions such as osteoporosis. Aging bones may lose calcium and other minerals, making them more fragile.
C. Age-related changes in joints, such as decreased synovial fluid production, cartilage degeneration, and changes in ligaments, can lead to increased stiffness and discomfort in joints. Conditions like osteoarthritis can also contribute to this stiffness.
D. With aging, there is usually a decrease in muscle mass and strength, known as sarcopenia. Older adults may experience a gradual loss of muscle tissue, leading to decreased overall muscle mass and strength.
Correct Answer is B
Explanation
A. While it's important to use the PCA device responsibly, the device is designed to prevent overdose. The client should not be overly concerned about this.
B. This statement demonstrates an understanding of the PCA device's limitations and the importance of seeking additional pain relief if needed. The nurse is responsible for adjusting the medication dosage or providing alternative pain relief methods if the PCA device is not adequately controlling the client's pain.
C. Only the client should administer the medication through the PCA device. Family members or other individuals should not be allowed to use the device.
D. The PCA device is designed to provide pain relief as needed. The client should use it whenever they experience pain, rather than waiting until the pain becomes severe.
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