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

Choice A rationale:

Reduced respiratory rate is not a typical manifestation of pain. In fact, pain often leads to an increased respiratory rate as the body responds to discomfort by trying to minimize it.

Choice B rationale:

Elevated blood pressure is a common manifestation of pain. When a person experiences pain, their sympathetic nervous system is activated, leading to an increase in heart rate and blood pressure. This response is designed to prepare the body to fight or flee from a potential threat, and it helps redirect blood flow to vital organs.

Choice C rationale:

Constricted pupils are not a direct manifestation of pain. In contrast, dilated pupils can be seen in response to pain as a result of sympathetic nervous system activation.

Choice D rationale:

Decreased heart rate is not typically associated with pain. Pain tends to increase heart rate as a part of the body's stress response.

Choice A rationale:

"Keep your back straight.”. Maintaining correct posture when transferring clients is essential to prevent injuries to both the nurse and the patient. The correct answer, "Keep your back straight," is crucial in ensuring that the nurse avoids straining their back muscles. When transferring patients, it's essential to use proper body mechanics and keep the spine in a neutral position. This minimizes the risk of back injuries and promotes safe patient handling. Bending or twisting the back can lead to musculoskeletal problems, such as back pain or herniated discs.

Choice B rationale:

"Keep your knees straight.”. Keeping your knees straight is not the correct choice for maintaining correct posture when transferring clients. In fact, it's essential to keep your knees slightly bent when lifting or transferring a patient. This position helps to maintain stability and distribute the weight evenly, reducing the risk of injury.

Choice C rationale:

"Tilt your head toward your chest.”. Tilting the head toward the chest is unrelated to maintaining proper posture during patient transfers. It is important to keep the head in a neutral position while transferring patients, focusing on the back and leg positioning.

Choice D rationale:

"Loosen your abdominal muscles.”. Loosening abdominal muscles is not a recommended practice during patient transfers. Maintaining core strength and stability is essential for proper body mechanics. Relaxing the abdominal muscles can lead to poor posture and decreased stability, increasing the risk of injury.