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

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.

A. Client’s age B. History of sickle cell disease C. Parent who has cardiovascular disease D. Hypertension

Correct Answer is D

Explanation

Choice A rationale
Age is a non-modifiable risk factor for stroke. As people age, their risk of stroke increases. However, this is not something that can be changed or controlled.
Choice B rationale
Sickle cell disease is a genetic disorder that can increase the risk of stroke, particularly in children. However, it is not a modifiable risk factor because it is determined by the person’s genes.
Choice C rationale
Having a parent with cardiovascular disease can increase a person’s risk of stroke. However, this is a non-modifiable risk factor because it is determined by genetics.
Choice D rationale
Hypertension, or high blood pressure, is a major modifiable risk factor for stroke. It can be controlled through lifestyle changes and medication.

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

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Naxlex Comprehensive Predictor Exams

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