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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) "You will have control of administering your own pain medication":
This statement accurately describes the function of a PCA (Patient-Controlled Analgesia) device, where the client has control over administering their own pain medication within preset limits. Empowering the client to manage their pain helps promote autonomy and individualized pain management.

B) "The pain medication is delivered into your muscle":
This statement is incorrect because PCA devices typically deliver medication intravenously, not into the muscle. It's important for the client to understand the route of administration to use the device effectively and safely.

C) "Your partner can push the PCA button for you if you are asleep":
Allowing someone else to activate the PCA button for the client can lead to overmedication and is not recommended. PCA devices are designed for the client to self-administer medication based on their own pain experience and need.

D) "A large dose of pain medication is given with each injection":
This statement is inaccurate because PCA devices are programmed to deliver a controlled dose of medication with each activation, usually within safe limits set by the healthcare provider. The doses are typically set to avoid overdosing while providing effective pain relief.

A. "It might help if I tried sleeping only on my back." B. "I’ll sleep better if I take a sleeping pill at night," C. "If could lose about 50 pounds, I might stop having so many apneic episodes." D. " I’ll get a humidifier to run at my bedside at night."

Correct Answer is C

Explanation

A. "It might help if I tried sleeping only on my back."
Sleeping on the back can actually worsen obstructive sleep apnea because gravity can cause the tongue and soft tissues to obstruct the airway more easily. The recommended position to reduce apneic episodes is to sleep on the side.

B. "I’ll sleep better if I take a sleeping pill at night."
Taking a sleeping pill can relax the muscles of the throat, which might worsen sleep apnea by increasing the likelihood of airway obstruction during sleep.

C. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Weight loss is a key factor in reducing the frequency and severity of obstructive sleep apnea. Excess weight, particularly around the neck, can increase the risk of airway obstruction during sleep.

D. "I’ll get a humidifier to run at my bedside at night."
While a humidifier can make the air more comfortable to breathe, it does not directly reduce the number of apneic episodes. It might help with symptoms like dry mouth or nasal congestion but is not a primary treatment for obstructive sleep apnea.

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A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain?

Nursing Test Bank

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Explanation

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