A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?
Decreased heart rate.
Hyperactive bowel sounds.
Decreased blood pressure.
Increased respiratory rate.
The Correct Answer is D
Choice A rationale:
Decreased heart rate is not an anticipated finding in response to acute pain. Pain typically triggers sympathetic nervous system activation, leading to an increased heart rate as a physiological response to the stressor.
Choice B rationale:
Hyperactive bowel sounds are not typically associated with acute pain. Acute pain is more likely to induce a sympathetic response, which can lead to decreased gastrointestinal motility and hypoactive bowel sounds.
Choice C rationale:
Decreased blood pressure is not a common response to acute pain. Pain often leads to an increase in blood pressure due to the activation of the sympathetic nervous system and the release of stress hormones.
Choice D rationale:
Increased respiratory rate is the anticipated finding in response to acute pain. Acute pain can cause an increase in the sympathetic nervous system activity, leading to a higher respiratory rate as the body prepares for a fight-or-flight response. This increased respiratory rate helps oxygenate the blood and meet the potential increased demand for energy during stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: d. Protective. Protective precautions are crucial for clients who have had an allogeneic hematopoietic stem-cell transplant due to their severely weakened immune systems.
Choice A reason:
Airborne precautions are used for infections that spread through the air, such as tuberculosis and measles. These infections require special ventilation and respiratory protection, which is not the primary concern for stem-cell transplant patients.
Choice B reason:
Contact precautions are used for infections spread by direct contact, like MRSA or C. difficile. These precautions involve wearing gloves and gowns but do not address the airborne or droplet risks that immunocompromised patients face.
Choice C reason:
Droplet precautions are for infections spread by large respiratory droplets, such as influenza or pertussis. While important, they do not provide the comprehensive protection needed for stem-cell transplant recipients.
Choice D reason:
Protective precautions involve placing the patient in a room with HEPA filtration and limiting visitors to minimize infection risk. This is essential for patients with compromised immune systems, such as those who have undergone allogeneic hematopoietic stem-cell transplants.
Correct Answer is B
Explanation
A. Autonomy:This principle refers to respecting a patient's right to make their own decisions about their healthcare. In this scenario, the nurse's actions did not directly impact the client's autonomy, as the client was not involved in the decision-making process regarding the incident report.
B. Veracity:This principle involves being truthful and transparent. By not completing an incident report, the nurse failed to uphold veracity, as this action concealed the truth about the medication error, potentially affecting future care and trust in the healthcare system.
C. Confidentiality:This principle is about protecting patient information. The nurse's failure to report the incident did not violate confidentiality, as it did not involve disclosing or mishandling the client's private information.
D. Beneficence:This principle focuses on doing good and acting in the best interest of the patient. While the nurse's intention might have been to avoid unnecessary alarm, failing to report the incident could prevent the healthcare team from learning from the mistake and improving patient safety, thus indirectly affecting beneficence.
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