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
Explanation
A. Obesity is a modifiable risk factor, as it can be addressed through lifestyle changes such as diet and exercise.
B. Race is a nonmodifiable risk factor; certain races may have a higher risk of stroke due to genetic and environmental factors.
C. History of smoking is a modifiable risk factor because individuals can choose to quit smoking to reduce their risk of stroke.
D. History of hypertension is also a modifiable risk factor; while having high blood pressure increases the risk of stroke, it can be managed with lifestyle changes and medications.
Correct Answer is D
Explanation
A. Rounded describes a normal abdomen but does not convey the greater extent of fullness seen in this case.
B. Scaphoid describes a concave abdomen, which does not apply to this situation.
C. Flat indicates no significant contour changes, which does not apply here.
D. Protuberant is the correct term, as it describes an abdomen that is significantly distended and is characteristic of conditions like pregnancy, ascites, or obesity.