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 D
Explanation
A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.
B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.
C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.
D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.
Correct Answer is C
Explanation
A. Heroin use is generally associated with intravenous use and is less commonly linked to nasal septum perforation.
B. Ecstasy (MDMA) is primarily used in tablet form and is not typically associated with nasal use that would cause septal perforation.
C. Cocaine is frequently snorted, which can lead to irritation and damage to the nasal passages and septum, resulting in perforation.
D. Marijuana is usually smoked rather than snorted, and it is not commonly associated with nasal septum perforation.