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 A
Explanation
Choice A rationale
Cushing’s Triad, which includes bradycardia (low heart rate), irregular respiration, and widened pulse pressure, is a nervous system response that could prevent brainstem ischemia. Brainstem ischemia is a condition where there is insufficient blood flow to the brainstem, which can lead to cell death.
Choice B rationale
While tachycardia (high heart rate) is a serious condition, it is not typically prevented by Cushing’s Triad.
Choice C rationale
Agonal breathing, which is characterized by gasping, labored breathing, particularly when lying flat, is not typically prevented by Cushing’s Triad.
Choice D rationale
Chest pain is not typically prevented by Cushing’s Triad. Cushing’s Triad is a response to increased intracranial pressure, not a cardiac condition.
Correct Answer is A
Explanation
Choice A rationale
Vasogenic cerebral edema is the most common type of cerebral edema associated with stroke. It involves swelling outside of brain cells, and leaky blood vessels cause it.
Choice B rationale
Osmotic cerebral edema is not typically associated with stroke. It is more commonly seen in conditions like diabetes-related ketoacidosis and hyponatremia.
Choice C rationale
Cellular, or cytotoxic, cerebral edema can occur due to traumatic brain injury and stroke. However, it is not the most common type of cerebral edema associated with stroke.
Choice D rationale
Interstitial cerebral edema is not typically associated with stroke. It is more commonly seen in conditions like hydrocephalus and meningitis.
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