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 D
Explanation
When performing perineal care for a female client, the nurse should use soap and water to clean the client’s perineum. This helps to remove any urine or fecal mater and prevent skin irritation or infection. The nurse should also use a clean section of the washcloth for each area cleaned and should clean from front to back to prevent the spread of bacteria from the rectal area to the urethra.
Correct Answer is A
Explanation
Localized warmth is a classic sign of inflammation and can indicate the presence of an infection or injury in the affected area. Sanguineous drainage is a type of wound drainage that consists of blood and is not a sign of inflammation. Palpable pedal pulses and full range of motion can provide information about the injury, but they are not specific to inflammation. Therefore, options b, c, and d are incorrect.
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