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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- Remove protective gown before removing gloves.
When caring for a client with Clostridium Difficile, it is important to follow strict contact precautions to prevent the spread of the bacteria. The nurse should remove the protective gown before removing gloves to avoid contaminating the gown with any bacteria that may be on the gloves. This helps to minimize the risk of spreading the bacteria to other clients or healthcare workers.
- Shake bed linens before placing them in a linen bag.
Shaking bed linens can cause any bacteria that may be on them to become airborne, increasing the risk of spreading the bacteria to other surfaces. Instead, bed linens should be rolled up and placed directly into a linen bag without shaking them.
- Use an electronic thermometer to take the client's temperature.
An electronic thermometer is preferred when taking the temperature of a client with Clostridium Difficile because it can be easily disinfected between uses, reducing the risk of spreading the bacteria.
- Remove protective gloves when leaving the client's room.
Protective gloves should be removed before leaving the client's room to avoid contaminating other surfaces or spreading the bacteria to other clients or healthcare workers.
Correct Answer is A
Explanation
The chain of infection describes how an infection spreads based on six links of transmission: Infectious Agent, Reservoirs, Portal of Exit, Modes of Transmission, Portal of Entry, and Susceptible Host1. In this case, the client’s mouth is an example of a portal of entry, which is the route by which an infectious agent enters a new host1.
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