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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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Correct Answer is C

Explanation

A. An audiometer is used to assess hearing ability and is not appropriate for examining the tympanic membrane.

B. An ophthalmoscope is used to examine the interior of the eye and cannot assess tympanic membrane mobility.

C. A pneumatic otoscope is specifically designed for examining the tympanic membrane and allows for assessment of its mobility by using air pressure.

D. A tuning fork is used to evaluate hearing and vibration sense, not tympanic membrane mobility.

Correct Answer is C

Explanation

A. Heroin use is generally associated with intravenous use and is less commonly linked to nasal septum perforation.

B. Ecstasy (MDMA) is primarily used in tablet form and is not typically associated with nasal use that would cause septal perforation.

C. Cocaine is frequently snorted, which can lead to irritation and damage to the nasal passages and septum, resulting in perforation.

D. Marijuana is usually smoked rather than snorted, and it is not commonly associated with nasal septum perforation.

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