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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While improved rehabilitation outcomes and temporary behavior changes can occur after a neurological injury, they are not typically considered psychosocial changes. Psychosocial changes often involve alterations in the way individuals perceive, interact with, and navigate their social environments.
Choice B rationale
Improved mood stability and temper control are not typically associated with the aftermath of a neurological injury. In fact, individuals may experience mood swings, irritability, and difficulties with emotional regulation.
Choice C rationale
Changes to social cognition and challenges to inhibitory control are indeed possible psychosocial changes a client might have after sustaining a neurological injury. Social cognition involves understanding and interpreting social cues, which can be affected by brain injury.
Challenges to inhibitory control can lead to impulsive behavior and difficulties in social situations.
Choice D rationale
While a sense of purpose, improved motivation, and stable relationships can be part of a successful recovery process, they are not typically direct outcomes of a neurological injury. In
fact, relationships may be strained and motivation can be affected due to the physical and emotional challenges associated with such an injury.
Correct Answer is D
Explanation
Choice A rationale
Osmotic cerebral edema is a condition where water moves from the blood vessels into the brain due to changes in the concentration of particles in the blood. However, this is not the primary cause of cerebral edema in meningitis.
Choice B rationale
While inflammation can contribute to cerebral edema, it is not specific to the brain and does not affect the brain the most. In meningitis, the inflammation is primarily in the meninges, the membranes that cover the brain, and not the whole body.
Choice C rationale
Cerebrospinal fluid (CSF) does flow from the intraventricular space to the interstitial area of the brain, but this is a normal process and does not cause cerebral edema. In meningitis, the inflammation of the meninges can disrupt the normal flow and absorption of CSF, leading to an accumulation of fluid and increased intracranial pressure.
Choice D rationale
In meningitis, the inflammation and immune response to the infection can lead to an increase in the permeability of the blood-brain barrier. This allows fluid and immune cells to enter the brain tissue, leading to cerebral edema. Additionally, the by-products of the pathogen that causes meningitis can directly damage the brain tissue and contribute to the edema.
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