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 D

Explanation

A) "It's a good idea to help make sure your husband can sleep comfortably.":
This encourages the partner to administer medication, which can lead to overmedication and potential harm.

B) "Why do you think your husband needs more medication when he is asleep?":
This might cause the partner to feel defensive. It also does not provide the necessary education about the correct use of the PCA pump.

C) "Next time you think he needs more medication, call me and I'll push the button.":
This is inappropriate as well. It does not address the core issue that only the patient should be pressing the button to ensure safe and appropriate use of the PCA pump.

D) "Your husband should decide when more medication is needed.":
This educates the partner about the proper use of the PCA pump, emphasizing that only the patient should press the button to ensure they are receiving medication only when they feel pain. This minimizes the risk of overmedication and adverse effects.

A. "The health care proxy does not go into effect until I am incapable of making decisions." B. "I have to choose a family member as my health proxy." C. "If I become incapacitated, end-of-life choices will be made by my proxy." D. "I can change who I designate as my health care proxy at any time."

Correct Answer is B

Explanation

A) "The health care proxy does not go into effect until I am incapable of making decisions.": This statement is accurate. A health care proxy, also known as a durable power of attorney for health care or health care agent, is appointed to make medical decisions on behalf of the client if they become unable to do so themselves. This can include decisions related to treatment options, end-of-life care, and other medical interventions.

B) "I have to choose a family member as my health proxy.": This statement is incorrect. While some individuals may choose a family member as their health care proxy, it is not a requirement. The client can choose any competent adult who is willing to serve as their health care proxy, including a friend, relative, or even a legal representative.

C) "If I become incapacitated, end-of-life choices will be made by my proxy.": This statement is accurate. The health care proxy is responsible for making medical decisions on behalf of the client if they are unable to do so, including decisions related to end-of-life care and treatment preferences.

D) "I can change who I designate as my health care proxy at any time.": This statement is accurate. The client has the right to change their health care proxy at any time by completing a new advance directive document and revoking any previous designations. It is essential for the client to review and update their advance directives regularly to ensure they reflect their current wishes and preferences.

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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 is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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