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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale:
"Depends on their friends for emotional support.”. While it's common for adolescents to rely on their friends for emotional support, this behavior is not necessarily indicative of a problem. Depending on friends for emotional support can be a healthy part of adolescent development, and it does not specifically relate to the loss of a parent.
Choice B rationale:
"Clings to their caregiver.”. The correct answer, "Clings to their caregiver," is a common response to the loss of a parent in adolescence. When adolescents experience the death of a parent, they often feel a strong need for emotional support and security. They may cling to their remaining caregiver, seeking comfort and reassurance during this challenging time.
Choice C rationale:
"Exhibits toileting problems.”. Exhibiting toileting problems can be a potential response to stress and emotional distress, but it is not the most expected or specific finding when a parent has recently died. This behavior may be more common in younger children who are still developing their coping mechanisms.
Choice D rationale:
"Reports tightness in their chest.”. While emotional distress can manifest physically, such as chest tightness, it is not the most characteristic finding when a parent has recently died. Clinging to a caregiver and seeking emotional support are more typical responses in adolescents.
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