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 A
Explanation
A) Anxiety: Anxiety is a subjective finding because it represents the client's perception of their emotional state. It is a feeling of unease, worry, or fear, which the client reports experiencing. Subjective findings are based on the client's self-report or feelings.
B) Alert: Being alert is an objective finding because it refers to the client's level of consciousness and responsiveness to stimuli. In this scenario, the nurse assesses that the client is alert based on their ability to respond appropriately to questions and stimuli in the environment.
C) Pacing: Pacing is an objective finding because it describes observable behavior. In this case, the nurse observes the client pacing in the room, which is a physical activity that can be seen or measured.
D) Restless: Restlessness is an objective finding because it describes observable behavior. The nurse assesses that the client appears restless based on their observed behavior of pacing in the room. Restlessness is a physical manifestation of the client's anxiety and is observable by others.
Correct Answer is D
Explanation
A. Light-headedness when standing up:
Elevated potassium levels (hyperkalemia) can lead to muscle weakness or paralysis, cardiac dysrhythmias, and even cardiac arrest. Light-headedness when standing up is more commonly associated with orthostatic hypotension or volume depletion rather than electrolyte imbalances like hyperkalemia.
B. Weak quadriceps muscles:
Weakness in the quadriceps muscles is not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can cause muscle weakness, but it is not specific to the quadriceps.
C. Decreased deep tendon reflexes:
Decreased deep tendon reflexes are not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can lead to hyperreflexia or absent reflexes, but it is not specific to decreased deep tendon reflexes.
D. Tingling of extremities:
This is the correct answer. Hypocalcemia, indicated by the low calcium level in the scenario, can manifest with symptoms such as tingling or numbness of the extremities, muscle cramps, and tetany. Calcium plays a crucial role in nerve transmission, and low levels can lead to sensory disturbances like tingling in the extremities.
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