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. Raise the bed to a comfortable height:
Raising the bed to a comfortable height is essential for proper body mechanics and preventing back strain. It ensures the nurse can perform the procedure efficiently and safely.

B. Stand on the left side of the bed:
While a left-handed nurse might prefer to stand on the left side for better access, this choice depends on the room layout and client position. Standing on the side where the nurse is most comfortable is essential, but it is not the primary action compared to ensuring proper bed height.

C. Raise the side rail on the working side of the bed:
Raising the side rail on the working side of the bed could obstruct the nurse's access to the client and is not generally recommended during procedures requiring close access to the client.

D. Use the non-dominant hand to insert the catheter:
The dominant hand, in this case, the left hand, should be used to insert the catheter for better control and precision. The non-dominant hand is typically used to hold the genitalia and provide stability.

A. Flushed skin B. Fever C. Nausea and vomiting D. Extreme thirst

Correct Answer is C

Explanation

A) Flushed skin: Flushed skin is not typically associated with hyponatremia. Instead, hyponatremia may present with symptoms such as pallor or cool, clammy skin due to alterations in perfusion and fluid balance.

B) Fever: Fever is not a common manifestation of hyponatremia. Elevated body temperature is typically associated with conditions such as infection or inflammation rather than electrolyte imbalances like hyponatremia.

C) Nausea and vomiting: Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to neurological symptoms, including nausea and vomiting. These symptoms occur due to alterations in osmotic pressure and cellular swelling resulting from the relative excess of water compared to sodium in the extracellular fluid. Other neurological symptoms of hyponatremia can include headache, confusion, lethargy, and seizures.

D) Extreme thirst: Extreme thirst, or polydipsia, is more commonly associated with hypernatremia, which is characterized by a serum sodium level above 145 mEq/L. Hypernatremia results from dehydration or a deficit of body water relative to sodium, leading to increased thirst as the body attempts to restore fluid balance.

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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

Naxlex Comprehensive Predictor Exams

A nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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