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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 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. Cranial nerve VII (facial nerve) is not primarily responsible for hearing; however, it does have some sensory function in the ear region. The primary cranial nerve responsible for hearing is cranial nerve VIII (vestibulocochlear), which is not listed among the options.

B. Cranial nerve X (vagus nerve) is primarily involved in autonomic functions and does not directly relate to hearing.

C. Cranial nerve I (olfactory nerve) is responsible for the sense of smell.

D. Cranial nerve II (optic nerve) is responsible for vision.

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