Which of the following statements about evaluating patients in ...

[pepyto]

Which of the following statements about evaluating patients in pain is true?
 
  a. The best judge of the existence of pain is the nurse.
  b. Visible signs always accompany pain.
  c. Patients often are hesitant to report pain.
  d. Nonpharmacological interventions are better than pain medications.

Question 2

The nurse is caring for a ventilated patient in the ICU who has just undergone coronary artery bypass. The nurse is concerned that the patient may be at risk for ventilator-acquired pneumonia (VAP). What step will she take to minimize this risk?
 
  a. Not provide oral hygiene because this may cause bacterial contamination of the airway.
  b. Be careful not to use chlorhexidine in oral care because it provides a medium for bacterial growth.
  c. Not use chlorhexidine in oral care because it enhances the rate at which VAP develops.
  d. Include the use of a chlorhexidine rinse as part of oral hygiene to delay the development of VAP.

[alexisweber49]

Answer to Question 1

C
Patients often are hesitant to report pain for fear of being labeled as complainers, hypochondriacs, or addicts. The patient's self-report is the most reliable indicator of the existence and intensity of pain. Even with severe pain, periods of physiological and behavioral adaptation occur, leading to periods of minimal or no observable signs of pain. Lack of pain expression does not necessarily mean lack of pain. Nonpharmacological interventions are synergistic with medications, but are not a substitute for pharmacological management of pain.

Answer to Question 2

D
Guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene. Chlorhexidine early in the postintubation period may help delay the onset or development of VAP. Presently, chlorhexidine is recommended during the postoperative period for patients undergoing cardiac surgery. Ventilator-associated pneumonia results from the colonization of bacteria in the oral pharynx. These microorganisms then migrate from the mouth into the lungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this evidence, guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene.