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 ["A","B","C","E"]
Explanation
A. Erythema (redness) can occur at the site of a gout attack due to inflammation in the affected joint.
B. Hyperuricemia (elevated levels of uric acid in the blood) is a hallmark of gout, leading to the formation of urate crystals.
C. Pain is a prominent symptom of gout, particularly during an acute attack when joints become inflamed and tender.
D. Diarrhea is not a direct complication of gout; it is more associated with gastrointestinal issues or medications.
E. Edema (swelling) can occur in the affected joint due to inflammation associated with gout.
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.