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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 ["B","D","E","F"]

Explanation

A. Hypoactive oil and sweat glands: Pregnancy typically causes increased activity in oil and sweat glands, not decreased.

B. Increased skin pigmentation: Increased pigmentation is common during pregnancy, often affecting areas like the areolas and abdomen.

C. Persistent migraine headaches: While some women may experience headaches in pregnancy, they are not an expected or typical finding and may require further assessment.

D. Facial edema: Mild facial edema can occur as pregnancy progresses, especially due to increased blood volume and fluid retention.

E. Melasma: Melasma, or "mask of pregnancy," is a common finding characterized by dark patches on the face due to hormonal changes.

F. Linea nigra: Linea nigra is a dark line that often appears on the abdomen during pregnancy as a result of hormonal changes.

Correct Answer is A

Explanation

A. Respiratory acidosis: The pH is low (indicating acidosis), and the Paco₂ is elevated, which signifies that carbon dioxide retention is causing the acidosis. This pattern indicates respiratory acidosis, as the elevated HCO₃ suggests a compensatory response.

B. Respiratory alkalosis: Respiratory alkalosis would show a high pH with a low Paco₂. This is not consistent with the client’s lab results.

C. Metabolic acidosis: Metabolic acidosis would show a low pH with a low HCO₃. In this case, the HCO₃ is slightly elevated, ruling out metabolic acidosis.

D. Metabolic alkalosis: Metabolic alkalosis would show a high pH with an elevated HCO₃, which does not match the client’s results.

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