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. Generalized joint discomfort is not commonly associated with contact dermatitis; this condition typically affects the skin locally rather than causing systemic joint symptoms.
B. Systemic symptoms such as elevated temperature are generally not expected with contact dermatitis, as it is usually a localized skin reaction.
C. Pruritus (itching) is a common symptom of contact dermatitis, so denial of pruritus would not be expected.
D. Contact dermatitis often occurs due to exposure to a skin irritant, making a report of such exposure a typical finding in the assessment.
Correct Answer is A
Explanation
A. +4 pitting edema is characterized by severe pitting that creates a deep indentation (greater than 8 mm) that remains for a prolonged period. This description matches the findings in option
B. This describes +1 pitting edema, which is not consistent with +4 edema.
C. This option describes +2 or +3 pitting edema, as the indentation subsides rapidly, which does not align with +4.
D. Although this describes deep pitting, the depth is less than 8 mm, which is not consistent with +4 edema.