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A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?

A.

The patient's chart

B.

Visual observation for nonverbal signs of pain

C.

The client's self-report of pain severity

D.

The nature and invasiveness of the surgical procedure

Answer and Explanation

The Correct Answer is C

A. The patient's chart may provide historical information but does not reflect the current pain intensity the client is experiencing.  

 

B. Visual observation for nonverbal signs of pain can be useful, especially for nonverbal patients, but self-reporting is the most accurate measure of pain intensity.  

 

C. The client's self-report of pain severity is the gold standard for assessing pain intensity, as it reflects the individual’s personal experience of pain.  

 

D. While the nature and invasiveness of the surgical procedure can provide context for expected pain levels, they do not replace the importance of the client's self-report in managing pain effectively.  


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View Related questions

Correct Answer is D

Explanation

A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between

Correct Answer is B

Explanation

A. Pigeon chest (pectus carinatum) is a structural deformity of the chest and is not associated with COPD.

B. A barrel chest is commonly seen in clients with COPD due to hyperinflation of the lungs, causing the chest to appear rounded and expanded.

C. Kyphotic refers to an abnormal curvature of the spine (kyphosis) and is not a characteristic of COPD.

D. Funnel chest (pectus excavatum) is another structural deformity and is not typically associated with COPD.

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