A nurse is evaluating a patient for signs of pain. Which of the following is an objective sign of pain?

The patient reports a burning sensation.

The patient grimaces when they move.

The patient rates their pain as an 8 on a scale of 0 to 10.

The patient states the pain is located in their abdomen.

Answer and Explanation

The Correct Answer is B

Choice A rationale
A patient reporting a burning sensation is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice B rationale
A patient grimacing when they move is an objective sign of pain. It is observable and does not rely on the patient’s verbal report.
Choice C rationale

A patient rating their pain as an 8 on a scale of 0 to 10 is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice D rationale
A patient stating the pain is located in their abdomen is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.

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

Explanation

Choice A rationale: Clients with epilepsy are at high risk of injury from falls during seizures due to sudden loss of consciousness or motor control. Climbing ladders increases the risk of severe trauma, including head injuries and fractures, if a seizure occurs at height. The American Epilepsy Society recommends avoiding elevated surfaces without safety measures. Neurological unpredictability in epilepsy necessitates minimizing exposure to high-risk environments to prevent secondary injuries during seizure episodes.

Choice B rationale: Swimming alone is contraindicated for clients with epilepsy due to the risk of drowning if a seizure occurs in water. A partner can provide immediate assistance, ensuring airway patency and preventing submersion. The CDC and Epilepsy Foundation emphasize supervised aquatic activity. Seizures may cause loss of consciousness or muscle control, making it impossible for the individual to self-rescue. Even brief seizures can lead to aspiration or hypoxic injury if not promptly addressed by a nearby observer.

Choice C rationale: Driving restrictions for clients with epilepsy vary by jurisdiction, but most guidelines, including those from ATI and the Epilepsy Foundation, recommend a seizure-free period of 6 to 12 months before resuming driving. This is based on the risk of sudden incapacitation while operating a vehicle, which endangers both the driver and the public. A 3-month seizure-free period is insufficient and not evidence-based. Neurological stability must be demonstrated over a longer duration to ensure safety.

Choice D rationale: Power tools pose a significant hazard to individuals with epilepsy due to the potential for sudden seizure activity during operation. These tools often involve sharp, fast-moving components that can cause severe injury if control is lost. The Occupational Safety and Health Administration (OSHA) advises against unsupervised use of such equipment by individuals with seizure disorders. Seizure unpredictability necessitates avoiding machinery that requires continuous attention and motor coordination to prevent traumatic injuries.

Choice E rationale: During a seizure, especially a generalized tonic-clonic seizure, it is critical to gently guide the client to the floor to prevent injury from falling. This position helps reduce the risk of head trauma and allows for safer seizure progression. The floor provides a stable surface, minimizing the chance of secondary injury. The nurse should also clear the area of sharp objects and cushion the head to protect the client during convulsions, as recommended by seizure first aid protocols.

Choice F rationale: Positioning a client on their back during postictal recovery is contraindicated due to the risk of airway obstruction. Seizures often result in decreased consciousness, increased oral secretions, or vomiting. The supine position can lead to aspiration or hypoxia. Instead, the recovery position—lying on the side—facilitates drainage of secretions and maintains airway patency. The American Red Cross and Epilepsy Foundation recommend side-lying recovery to reduce respiratory complications and promote safe postictal recovery.

A. A nurse provides nonpharmacological pain interventions to each client equally. B. A nurse fulfills a promise to a client that they will return with their pain medication. C. A nurse administers a scheduled pain medication for a client who is having pain. D. A nurse gives a client the choice of when to take a pain medication.

Correct Answer is D

Explanation

Choice A rationale
Providing nonpharmacological pain interventions to each client equally is an example of justice, not autonomy. Justice in healthcare refers to treating all patients fairly and equitably.
Choice B rationale
Fulfilling a promise to a client that they will return with their pain medication is an example of fidelity, not autonomy. Fidelity refers to being faithful to commitments and promises.
Choice C rationale
Administering a scheduled pain medication for a client who is having pain is an example of beneficence, not autonomy. Beneficence refers to taking actions that are of benefit to the patient.
Choice D rationale
Giving a client the choice of when to take a pain medication is an example of autonomy. Autonomy in healthcare refers to the patient’s right to make decisions about their own care.

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