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:
"Apply lotion between the toes.”. Applying lotion between the toes is not a recommended practice for individuals with diabetic neuropathy. The rationale for this is that excess moisture between the toes can create an environment conducive to fungal infections, which individuals with diabetes are more susceptible to due to compromised immune function and poor circulation.
Choice B rationale:
"Wear open-toed shoes.”. Wearing open-toed shoes is generally not recommended for individuals with diabetic neuropathy. Open-toed shoes expose the feet to potential injury and do not provide adequate protection. It's essential to wear closed-toed, well-fitting shoes to prevent foot injuries and complications.
Choice C rationale:
"Avoid walking barefoot.”. The correct answer, "Avoid walking barefoot," is a crucial instruction for individuals with diabetic neuropathy. Walking barefoot increases the risk of injury, as patients with neuropathy may not feel pain or discomfort from small cuts or injuries to their feet. It is essential to protect the feet by wearing shoes or slippers to minimize the risk of wounds and infections.
Choice D rationale:
Correct Answer is C
Explanation
Choice A rationale:
Peripheral vascular disease does not directly place the client at a higher risk for an incisional hematoma. While it is a vascular condition, the use of anticoagulant medications is a more significant risk factor for bleeding complications.
Choice B rationale:
Urinary incontinence is not directly related to an increased risk of incisional hematoma. Incontinence is a separate issue and does not influence surgical outcomes in the context of hematoma formation.
Choice C rationale:
Taking anticoagulant medications is a significant risk factor for incisional hematoma. Anticoagulants reduce the blood's ability to clot, which can lead to excessive bleeding at the surgical site and the formation of hematomas.
Choice D rationale:
Being underweight is not a primary risk factor for incisional hematoma. While poor nutrition and overall health can influence wound healing, anticoagulant use is a more direct concern for hematoma formation in surgical patients.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.