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?
The patient's chart
Visual observation for nonverbal signs of pain
The client's self-report of pain severity
The nature and invasiveness of the surgical procedure
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 A
Explanation
A. The carotid pulse should not be assessed bilaterally at the same time, as simultaneous palpation can lead to a decrease in heart rate or cause syncope due to stimulation of the carotid sinus.
B. The radial pulse can be assessed bilaterally without risk.
C. The brachial pulse can also be assessed bilaterally without concern.
D. The femoral pulse is typically assessed one side at a time, but there is no risk in palpating both femoral arteries simultaneously as there is with the carotid.
Correct Answer is B
Explanation
A. Gynecomastia refers to breast tissue enlargement in males and does not typically relate to the menstrual cycle.
B. Cyclic pain refers to breast pain that is linked to the menstrual cycle, commonly occurring before menstruation and subsiding during or after menstruation.
C. Mammary pain is a broader term that may refer to any breast pain, but it does not specify the cyclical nature related to menstruation.
D. Noncyclic pain refers to breast pain not related to the menstrual cycle and does not follow the described pattern.