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 ["B","C","E"]
Explanation
A. The diaphragm of the stethoscope is used for high-pitched sounds, such as lung and normal heart sounds, not low-pitched sounds.
B. The binaural (earpieces) should fit snugly in the ears to ensure proper sound transmission and clarity.
C. Short tubing provides more accurate sounds by minimizing sound distortion, making it ideal for clinical use.
D. The bell of the stethoscope is used for low-pitched sounds, such as heart murmurs, not high-pitched sounds.
E. The stethoscope works by blocking out environmental sounds to help the user focus on internal body sounds.
Correct Answer is C
Explanation
A. An audiometer is used to assess hearing ability and is not appropriate for examining the tympanic membrane.
B. An ophthalmoscope is used to examine the interior of the eye and cannot assess tympanic membrane mobility.
C. A pneumatic otoscope is specifically designed for examining the tympanic membrane and allows for assessment of its mobility by using air pressure.
D. A tuning fork is used to evaluate hearing and vibration sense, not tympanic membrane mobility.