A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Drowsiness.

Grimacing.

Screaming.

Moaning.

Restlessness.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale:

Drowsiness alone may not be a reliable indicator of pain, as it can result from various factors such as medications or the postoperative recovery process. While pain might cause drowsiness in some cases, it is not a definitive nonverbal sign of pain.

Choice B rationale:

Grimacing is a nonverbal behavior that often indicates pain or discomfort. It involves facial expressions of pain, such as frowning or wincing. Grimacing is a significant indicator that the nurse should consider in assessing the client's pain level.

Choice C rationale:

Screaming is a more overt expression of pain and discomfort. However, it is less common in a postoperative setting and might also be associated with anxiety or other emotional states. While it can indicate pain, it's not as reliable a marker as grimacing, moaning, or restlessness.

Choice D rationale:

Moaning is a nonverbal behavior that can signal pain in a postoperative client. It's an audible expression of discomfort and should be considered as a potential indication of pain.

Choice E rationale:

Restlessness can be an indication of pain as well. The client may shift positions frequently or exhibit signs of agitation in response to pain. However, restlessness can also have other causes, such as anxiety or medication effects.

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Correct Answer is C

Explanation

Choice A rationale:

Asking the patient why this medication has been ordered is not the appropriate action because patients might not have accurate medical knowledge to provide a valid explanation for the prescription. The nurse should rely on healthcare professionals for accurate information.

Choice B rationale:

Verifying with the hospital administration is not necessary in this situation. The decision to prescribe medication is made by the healthcare provider, not the hospital administration.

Choice C rationale:

Verifying with the prescribing healthcare provider is the most appropriate action. The healthcare provider has the medical knowledge and rationale for prescribing a specific medication. This ensures that the nurse administers the medication safely and in alignment with the patient's condition and treatment plan.

Choice D rationale:

Asking another nurse might not yield accurate information about the rationale behind the medication order. It's best to directly communicate with the healthcare provider responsible for the patient's care.

A. Autonomy. B. Veracity. C. Confidentiality. D. Beneficence.

Correct Answer is B

Explanation

A. Autonomy:This principle refers to respecting a patient's right to make their own decisions about their healthcare. In this scenario, the nurse's actions did not directly impact the client's autonomy, as the client was not involved in the decision-making process regarding the incident report.

B. Veracity:This principle involves being truthful and transparent. By not completing an incident report, the nurse failed to uphold veracity, as this action concealed the truth about the medication error, potentially affecting future care and trust in the healthcare system.

C. Confidentiality:This principle is about protecting patient information. The nurse's failure to report the incident did not violate confidentiality, as it did not involve disclosing or mishandling the client's private information.

D. Beneficence:This principle focuses on doing good and acting in the best interest of the patient. While the nurse's intention might have been to avoid unnecessary alarm, failing to report the incident could prevent the healthcare team from learning from the mistake and improving patient safety, thus indirectly affecting beneficence.

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A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Nursing Test Bank

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Explanation

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Explanation

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