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 C
Explanation
Choice A rationale:
Cranberry juice causing bad breath is not a well-known side effect or outcome associated with its consumption. This information is not a commonly taught aspect of cranberry juice use.
Choice B rationale:
Bloating is not a common or widely recognized outcome of drinking cranberry juice. While cranberry juice might have some gastrointestinal effects, bloating is not a significant concern associated with its consumption.
Choice C rationale:
Informing the client that drinking cranberry juice daily can prevent recurrent urinary tract infections is accurate. Cranberry juice is often recommended for its potential to reduce the risk of urinary tract infections due to its anti-adhesive properties that may inhibit the adherence of bacteria to the urinary tract.
Choice D rationale:
Cranberry juice's effect on lowering cholesterol is not a well-established benefit of its consumption. Cholesterol management typically involves dietary changes, exercise, and sometimes medications, but cranberry juice is not a primary intervention for this purpose.
Correct Answer is B
Explanation
Choice A rationale:
Reporting the incident to the charge nurse is important, but it's not the first action to take in this situation. The immediate concern should be addressing the potential exposure to bloodborne pathogens.
Choice B rationale:
This is the correct choice. Washing the area of the puncture thoroughly with soap and water is the first step the nurse should take after an accidental needlestick. It helps reduce the risk of infection by cleaning the wound and removing any potential contaminants.
Choice C rationale:
Going to employee health services is a valid step, but it's not the immediate action needed after an accidental needlestick. Cleaning the wound should come first.
Choice D rationale:
Completing an incident report is important for documentation purposes, but it is not the nurse's first priority in this situation. Immediate wound care takes precedence.
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