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. +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.
Correct Answer is C
Explanation
A. This would show a regular rhythm with a consistent rate (60-100 bpm) and clear P waves before each QRS complex, which is not present in asystole.
B. This indicates a slow heart rate (below 60 bpm) but would still display P waves and QRS complexes; asystole shows no electrical activity.
C. This is the correct interpretation as it represents a flatline on the ECG, indicating no electrical activity in the heart.
D. This would show a rapid heart rate (above 100 bpm) with present P waves, which is not the case in asystole.