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 C
Explanation
A. Response to verbal stimuli does not directly assess the function of cranial nerves III, IV, and VI.
B. Affect, feelings, or emotions are related to the assessment of other neurological functions and do not evaluate the ocular cranial nerves specifically.
C. Eye movements are the primary function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye movement and provide essential information about their function.
D. Insight, judgment, and planning relate more to cognitive function and do not directly assess the function of the cranial nerves in question.
Correct Answer is D
Explanation
A. The iliac pulse is located near the pelvis and is not used for assessing circulation in the lower extremities.
B. The femoral pulse is located in the upper thigh, not near the posterior tibial area.
C. The popliteal pulse is found at the back of the knee and is higher than the posterior tibial location.
D. The posterior tibial pulse is correctly located behind the medial malleolus on the inner side of the ankle. This location is where the posterior tibial artery is accessible and is commonly used to assess blood flow to the lower extremities.