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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering acetaminophen by mouth for pain control is important, but it is not the first intervention that should be implemented for a client who has had a traumatic fall. Pain management is crucial, but it is not the immediate priority in this situation.
Choice B rationale
Performing a thorough health history is a part of the nursing assessment, but it is not the first intervention in an acute situation such as a traumatic fall. Immediate physical needs and potential injuries need to be addressed first.
Choice C rationale
Preparing for a STAT non-contrast CT scan is the correct answer. After a traumatic fall, it is crucial to quickly assess for potential injuries, especially to the brain. A CT scan can help identify any immediate life-threatening conditions such as bleeding in the brain.
Choice D rationale
Inserting an indwelling urinary catheter to monitor urine output is an intervention that may be necessary depending on the client’s condition, but it is not the first intervention to be implemented after a traumatic fall.
Correct Answer is B
Explanation
Choice A rationale
While traumatic brain injuries (TBIs) can occur at any age, people in their 30s are not at the highest risk. Other factors, such as participation in high-risk activities or certain occupations, can increase the risk of TBI, but age alone in this group does not confer a higher risk.
Choice B rationale
People who play contact sports are at a higher risk of sustaining a TBI. Contact sports such as football, boxing, and hockey have a high incidence of TBIs, including concussions.
Choice C rationale
Abstaining from alcohol does not increase the risk of TBI. In fact, alcohol use is a risk factor for TBI, as it can increase the likelihood of falls, car accidents, and other events that can cause TBI1112.
Choice D rationale
Living in rural areas does not inherently increase the risk of TBI. However, certain factors associated with rural living, such as increased travel distances and limited access to trauma
care, can contribute to the severity of a TBI once it occurs. Subarachnoid hemorrhageSubarachnoid hemorrhage Explore
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