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
Explanation
A. This is the correct answer as conjunctivitis, commonly known as pink eye, is characterized by redness, swelling, and discharge from the eye, which is likely what the image shows.
B. Cataracts typically present as clouding of the lens of the eye, leading to blurred vision but do not present with redness or discharge like conjunctivitis.
C. This condition often involves increased intraocular pressure and can lead to vision loss, but it does not usually cause the symptoms depicted in the image of conjunctivitis.
D. This is primarily associated with central vision loss and does not produce the external symptoms of redness or discharge typical of conjunctivitis.
Correct Answer is C
Explanation
A. Cranial nerves III, IV, and VIII are not involved in mouth functions; they primarily deal with eye movements and hearing.
B. Cranial nerves III, II, and VI are involved in vision and eye movement but not in mouth functions.
C. Cranial nerves IX (glossopharyngeal), X (vagus), and XII (hypoglossal) are all tested through functions such as swallowing, speech, and movement of the tongue, which occur in the mouth.
D. Option D incorrectly lists cranial nerve I twice; cranial nerve I (olfactory) is related to the sense of smell, not the mouth.