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

A) Delayed gastric emptying: This condition refers to a slowdown in the movement of food from the stomach to the small intestine, often leading to symptoms like nausea, vomiting, bloating, and early satiety. It is not related to breath sounds and would not be detected through auscultation of the lungs.

B) Atelectasis: This condition involves the collapse or closure of lung tissue, resulting in reduced or absent gas exchange. It commonly occurs in patients who are immobile or on bedrest for extended periods, such as the client with a lacerated spleen. Decreased breath sounds in the lower lobes of the lungs are a typical finding in atelectasis, as the collapsed or partially collapsed alveoli do not allow air to move through them, leading to diminished or absent breath sounds in the affected areas.

C) An upper respiratory infection: This condition involves infections in the nose, throat, and airways and typically presents with symptoms like cough, nasal congestion, sore throat, and sometimes fever. It can affect breath sounds, but it more commonly causes wheezing, crackles, or rhonchi rather than isolated decreased breath sounds in the lower lobes.

D) Pulmonary edema: This condition is characterized by the accumulation of fluid in the lungs, often due to heart failure or acute lung injury. Auscultation findings typically include crackles or rales, particularly in the lower lung fields, but not necessarily decreased breath sounds unless there is a significant consolidation or fluid volume.

A) Administer and teach about medications to suppress stage III sleep:
Suppressing stage III sleep is not a primary intervention for sleepwalking and could potentially disrupt the client’s overall sleep quality.

B) Encourage the child to verbalize feelings regarding sleep pattern:
While understanding feelings about sleep patterns may be helpful, it is not the immediate priority in managing sleepwalking.

C) Provide a quiet environment for nighttime sleep:
A quiet environment is generally beneficial for good sleep hygiene but does not directly address the safety concerns associated with sleepwalking.

D) Maintain patient safety during episodes of somnambulism:
Ensuring the client’s safety is the primary focus. Sleepwalking can lead to accidents or injuries; therefore, implementing safety measures to prevent harm during episodes of somnambulism is crucial. This may include securing the environment, using safety gates, and ensuring the client’s immediate surroundings are safe.