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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 A

Explanation

A. Wheezes are continuous high-pitched sounds that occur during expiration (or sometimes inspiration) and are common in conditions like asthma due to narrowed airways.

B. Crackles are discontinuous sounds often described as popping or crackling and are not typically high-pitched.

C. Rhonchi are low-pitched, snoring-like sounds caused by the obstruction of larger airways and are not characterized as high-pitched.

D. Stridor is a high-pitched sound usually associated with upper airway obstruction and is not typically heard with asthma.

Correct Answer is ["B","C","D"]

Explanation

A. Pale yellow urine is typically associated with good hydration; dehydration would likely result in darker urine.

B. Poor skin turgor is a classic sign of dehydration, indicating a lack of adequate fluid in the tissues.

C. Hypotension (low blood pressure) can occur with dehydration due to decreased blood volume.

D. Flat neck veins may indicate a decrease in venous return due to low blood volume associated with dehydration.

E. Bradycardia (slow heart rate) is not typically a finding associated with dehydration; instead, dehydration often leads to tachycardia (increased heart rate) as the body attempts to compensate for low blood volume.

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