A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?
Severity of the condition
Vital signs
Nonverbal behavior
Self-rating of pain
The Correct Answer is D
A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.
B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.
C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.
D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.
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Correct Answer is C
Explanation
A. This description relates more to a sensory discrimination test, not graphesthesia.
B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.
C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.
D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.
Correct Answer is B
Explanation
A. Pigeon chest (pectus carinatum) is a structural deformity of the chest and is not associated with COPD.
B. A barrel chest is commonly seen in clients with COPD due to hyperinflation of the lungs, causing the chest to appear rounded and expanded.
C. Kyphotic refers to an abnormal curvature of the spine (kyphosis) and is not a characteristic of COPD.
D. Funnel chest (pectus excavatum) is another structural deformity and is not typically associated with COPD.