A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?
Hypertension
Bradycardia
Decreased respiratory rate
Hypoglycaemia
The Correct Answer is A
Pain can cause an increase in sympathetic nervous system activity, leading to vasoconstriction and increased heart rate, which can result in hypertension. Pain may also increase the release of stress hormones, such as cortisol and epinephrine, which can further contribute to increased blood pressure.
Bradycardia (slow heart rate) decreased respiratory rate, and hypoglycemia are not typical findings associated with acute pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.
B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.
C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.
D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.
Correct Answer is D
Explanation
The nurse should plan to use warm water to wash the client’s feet as part of proper foot care. Warm water can help soften the skin and nails, making it easier to clean and trim the nails. It is also important to avoid soaking the feet, as this can dry out the skin and increase the risk of infection.
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