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

Answer and Explanation

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.

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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.

A. The client’s systolic blood pressure decreases from 110 mm Hg to 105 mm Hg. B. The client reports nausea. C. The client’s heart rate increases from 100/min to 108/min. D. The client reports dizziness.

Correct Answer is A

Explanation

Postural hypotension, also known as orthostatic hypotension, is a form of low blood pressure that occurs when standing up from a sitting or lying down position 1. An eﬀective intervention for postural hypotension would be one that helps to prevent a significant drop in blood pressure when the client changes position. A small decrease in systolic blood pressure, such as from 110 mm Hg to 105 mm Hg, would indicate that the intervention is eﬀective in preventing a larger drop in blood pressure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is eﬀective?

Correct Answer is A

Explanation

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