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 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.

A. "I will have to be admitted to a long-term care in order to receive hospice care" B. "My oncologist will continue to look for a cure for my cancer while am receiving hospice care" C. "I should expect the hospice team to help me manage my dyes" D. "Hospice care services are available to patients who are terminally regardless of their life E. expectancy"

Correct Answer is C

Explanation

Answer: C. "I should expect the hospice team to help me manage my dyes."

A. "I will have to be admitted to a long-term care facility in order to receive hospice care."
This statement reflects a misunderstanding of hospice care. Hospice services can be provided in various settings, including the client’s home, hospice centers, or even long-term care facilities, but clients are not required to be admitted to a long-term care facility specifically to receive hospice care.

B. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."
Hospice care focuses on comfort and quality of life for clients with terminal illnesses, rather than curative treatment. Clients receiving hospice care have typically decided to forego curative treatment to prioritize symptom management and palliative care.

C. "I should expect the hospice team to help me manage my dyes."
This statement indicates an understanding of hospice care. The hospice team provides comprehensive support to manage symptoms, such as pain and discomfort, as well as addressing emotional, spiritual, and psychosocial needs. The goal is to ensure the client’s comfort during the end of life.

D. "Hospice care services are available to patients who are terminally ill regardless of their life expectancy."
This is not entirely accurate. Hospice care is typically available to individuals who have a life expectancy of six months or less, as determined by their healthcare provider. Therefore, life expectancy is an important criterion for hospice eligibility.

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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?

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