A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain?
Reduced respiratory rate
Elevated blood pressure
Constricted pupils
Decreased heart rate
The Correct Answer is B
A) Reduced respiratory rate:
Acute pain typically triggers an increased respiratory rate rather than a reduced one. Pain activates the sympathetic nervous system, leading to increased respiratory effort as the body prepares to fight or flee.
B) Elevated blood pressure:
Elevated blood pressure is a common physiological response to acute pain. Pain activates the sympathetic nervous system, leading to the release of stress hormones like adrenaline, which constrict blood vessels and increase heart rate and blood pressure.
C) Constricted pupils:
Pain often causes pupil dilation rather than constriction. The body's fight-or-flight response to pain involves pupil dilation to enhance visual acuity and peripheral vision, allowing individuals to detect potential threats in their environment.
D) Decreased heart rate:
Acute pain typically results in an increased heart rate rather than a decreased one. Pain triggers the release of adrenaline, which increases heart rate as part of the body's stress response to prepare for action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) 41-year-old with hypernatremia:
Hypernatremia refers to elevated levels of sodium in the blood. While hypernatremia can lead to dehydration and electrolyte imbalances, it does not directly correlate with an increased risk of hypomagnesemia.
B) 72-year-old with chronic alcoholism:
Chronic alcoholism is a significant risk factor for hypomagnesemia. Alcohol abuse can lead to poor dietary intake of magnesium, increased renal excretion of magnesium, and impaired absorption of magnesium in the gastrointestinal tract, all contributing to magnesium deficiency.
C) 79-year-old with bone cancer:
Bone cancer does not inherently increase the risk of hypomagnesemia. However, depending on the treatment modalities and disease progression, the client may be at risk for other electrolyte imbalances or complications associated with bone cancer.
D) 46-year-old with respiratory acidosis:
Respiratory acidosis refers to an acid-base imbalance characterized by elevated levels of carbon dioxide in the blood due to impaired ventilation. While respiratory acidosis can lead to electrolyte imbalances, particularly potassium imbalances, it is not directly linked to hypomagnesemia.
Correct Answer is B
Explanation
A) The client with end-stage renal failure scheduled for dialysis is at risk for fluid volume excess rather than deficit. Dialysis is a treatment to remove excess fluid and waste products from the body, which can lead to fluid volume deficit if not managed appropriately, but the scenario does not indicate current dehydration.
B) The client with gastroenteritis and fever is at risk for fluid volume deficit due to fluid loss from vomiting, diarrhea, and fever-induced diaphoresis. Gastroenteritis commonly leads to dehydration, especially when accompanied by fever, which increases fluid loss through sweating.
C) The client with left-sided heart failure and an elevated brain natriuretic peptide (BNP) level is at risk for fluid volume excess rather than deficit. Elevated BNP levels indicate heart failure, which can result in fluid retention and volume overload rather than deficit.
D) The client who has been NPO since midnight for endoscopy is at risk for fluid volume deficit due to fasting. However, the severity and duration of fasting are not specified in the scenario, so it may not present an immediate risk compared to the client with gastroenteritis and fever.
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