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 C
Explanation
A. This is a dark vertical line that can appear on the abdomen during pregnancy, typically extending from the pubic area to the navel, which is not what is depicted in the image of a Mongolian Spot.
B. A chronic skin condition that results in red, itchy, scaly patches; this does not match the appearance of a Mongolian Spot.
C. This is the correct answer as it refers to a blue-gray pigmentation commonly found on the backs and buttocks of infants, particularly in individuals of Asian or African descent.
D. These are small, white cysts that can appear on the skin, typically on the face, and are not consistent with the description of a Mongolian Spot.
Correct Answer is B
Explanation
A. Asystole: Asystole would show a flat line with no electrical activity, which is not seen here.
B. Ventricular fibrillation: Ventricular fibrillation is characterized by chaotic, irregular waveforms without distinct P waves, QRS complexes, or T waves. The ECG strip shows this disorganized, erratic electrical activity consistent with ventricular fibrillation.
C. Sinus tachycardia: Sinus tachycardia would display a regular rhythm with identifiable P waves, QRS complexes, and T waves at a faster rate. This is not present in the ECG strip.
D. Sinus bradycardia: Sinus bradycardia would show a slower rate but with an organized rhythm and distinct P, QRS, and T waves. This is not indicated in the strip.