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 bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.
B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.
C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.
D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.
Correct Answer is A
Explanation
A. This is the correct answer as conjunctivitis, commonly known as pink eye, is characterized by redness, swelling, and discharge from the eye, which is likely what the image shows.
B. Cataracts typically present as clouding of the lens of the eye, leading to blurred vision but do not present with redness or discharge like conjunctivitis.
C. This condition often involves increased intraocular pressure and can lead to vision loss, but it does not usually cause the symptoms depicted in the image of conjunctivitis.
D. This is primarily associated with central vision loss and does not produce the external symptoms of redness or discharge typical of conjunctivitis.