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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Auscultation at the pulmonic and mitral points would not provide the clearest hearing of the S2 heart sound. The S2 sound is composed of two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). The aortic valve sound (A2) is usually louder than P2. Mitral point is not ideal for hearing S2 clearly, as it's mostly associated with S1 sound.

Choice B rationale:

The tricuspid and aortic points are the most appropriate for hearing the S2 heart sound. The aortic valve (A2) is best heard at the second right intercostal space close to the sternum, and the tricuspid valve is best heard at the lower left sternal border.

Choice C rationale:

While the mitral and tricuspid points are important for auscultating the heart sounds, they are more associated with the S1 sound (the first heart sound). The S2 sound is best heard at the aortic and pulmonic areas.

Choice D rationale:

The aortic and pulmonic points are important for assessing the S2 heart sound, but they are not the most optimal locations. The aortic valve sound is heard most clearly at the second right intercostal space, whereas the pulmonic valve sound is heard at the second left intercostal space.

A. Rectus Femoris. B. Vastus Lateralis. C. Dorsogluteal. D. Lower abdomen. E. Deltoid.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

The choice "Rectus Femoris" is not the correct answer. The rectus femoris is a muscle located in the thigh and is not a common site for intramuscular injections due to its location and proximity to important structures.

Choice B rationale:

The correct answer is "Vastus Lateralis." Choice B is the correct answer. The vastus lateralis muscle is located on the lateral aspect of the thigh and is a suitable site for intramuscular injections. It is often used in infants and young children or in adults who have limited deltoid muscle mass.

Choice C rationale:

The correct answer is "Dorsogluteal." Choice C is the correct answer. The dorsogluteal muscle, located in the buttocks, has historically been used for intramuscular injections. However, it's important to note that due to the proximity of the sciatic nerve and the potential for incorrect injection technique, this site is used less frequently now.

Choice D rationale:

The choice "Lower abdomen" is not the correct answer. The lower abdomen is not a recommended site for intramuscular injections due to the risk of injuring underlying structures and the potential for subcutaneous injection instead of intramuscular.

Choice E rationale:

The correct answer is "Deltoid." Choice E is the correct answer. The deltoid muscle, located in the upper arm, is commonly used for intramuscular injections, especially for vaccines and smaller medication volumes. However, it has a limited muscle mass and may not be suitable for larger injection volumes.

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A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

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Naxlex Comprehensive Predictor Exams

A Medical-Surgical nurse is assessing a client's heart sounds. In which of the following points of auscultation would the nurse hear the S2 sound most clearly?

Correct Answer is B

Explanation

A nurse on a Medical-Surgical unit is preparing to administer an intramuscular injection to a client. Which of the following sites can the nurse use? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

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