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 C
Explanation
Choice A rationale:
Alcohol consumption is a modifiable risk factor that can have negative health consequences. However, it is not the primary factor to focus on when discussing ways to improve health. Excessive alcohol consumption can lead to liver disease, addiction, and other health issues, but it's not the most critical modifiable risk factor for many people.
Choice B rationale:
Family history is not a modifiable risk factor. It's essential information for assessing a person's risk for various health conditions, but it cannot be changed or improved upon. Therefore, it's not the primary focus when teaching someone how to improve their health.
Choice D rationale:
A sedentary lifestyle is a modifiable risk factor and is crucial for improving health. Prolonged inactivity can lead to various health problems, such as obesity, cardiovascular disease, and muscle weakness. While it's an important factor, it's not the top priority for improving health in this context.
Choice E rationale:
Weight is a modifiable risk factor, and it is closely related to diet and physical activity. Maintaining a healthy weight is essential for overall health, and it often involves a combination of dietary choices and physical activity. However, focusing on diet itself is more specific and directly actionable when providing health improvement advice. Now, let's move on to the next question.
Correct Answer is D
Explanation
The correct answer is d. "Seeing spots is a manifestation of diabetic retinopathy."
Choice A rationale:
- Clouding of the lens is not a manifestation of diabetic retinopathy.It is a characteristic of cataracts,a condition that involves a different eye structure and has a different etiology.
- Diabetic retinopathy specifically affects the retina,which is the light-sensitive tissue lining the back of the eye.It does not directly involve the lens.
- It's crucial to clarify this distinction for the client to ensure accurate understanding of their condition and potential symptoms.
Choice B rationale:
- Increased intraocular pressure is not the cause of diabetic retinopathy.It is the primary feature of glaucoma,another eye condition with distinct causes and consequences.
- Diabetic retinopathy is primarily driven by damage to the blood vessels in the retina due to prolonged high blood sugar levels.
- Explaining this difference to the client can help prevent confusion and promote appropriate preventive measures.
Choice C rationale:
- While regular eye exams are essential for early detection and management of diabetic retinopathy,the recommended frequency is more often than every 2 years.
- The American Diabetes Association recommends that individuals with diabetes have a comprehensive dilated eye exam at least annually.
- More frequent exams may be necessary depending on the individual's risk factors and the severity of their diabetes.
Choice D rationale:
- Seeing spots is a common and significant symptom of diabetic retinopathy.It occurs when blood vessels in the retina leak fluid or bleed,causing disruptions in vision.
- Other potential symptoms of diabetic retinopathy include:
- Blurred vision
- Floaters (dark specks or strings that move across the visual field)
- Difficulty seeing at night or in low light
- Loss of central vision
- Distortion of colors
- Blind spots
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