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 D
Explanation
A. Petechiae are small, pinpoint hemorrhages and are considered objective data that can be observed and documented by the nurse.
B. Blood pressure is a vital sign and objective data that can be measured using a sphygmomanometer.
C. Cyanosis is a physical sign indicating low oxygenation in the blood and is objective data that can be observed.
D. Nausea is a subjective symptom reported by the client, reflecting their internal experience and cannot be measured or observed directly.
Correct Answer is D
Explanation
A. Rounded describes a normal abdomen but does not convey the greater extent of fullness seen in this case.
B. Scaphoid describes a concave abdomen, which does not apply to this situation.
C. Flat indicates no significant contour changes, which does not apply here.
D. Protuberant is the correct term, as it describes an abdomen that is significantly distended and is characteristic of conditions like pregnancy, ascites, or obesity.