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","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.

A. A nurse keeps a promise to a client not to tell their family about their diagnosis. B. A nurse provides therapeutic touch by holding a dying patient's hand. C. A nurse involves a client in making decisions about their care. D. A nurse tells the truth about forgetting to perform a procedure for a client.

Correct Answer is B

Explanation

Choice A rationale:

Keeping a promise to a client not to tell their family about their diagnosis is an example of fidelity, respecting confidentiality and maintaining trust. However, it does not directly reflect the ethical principle of beneficence, which focuses on actions that promote the patient's well-being and best interests.

Choice B rationale:

Providing therapeutic touch to a dying patient by holding their hand is an example of beneficence. This action demonstrates compassion, emotional support, and comfort to the patient in a critical and vulnerable time. It promotes the patient's well-being by addressing their emotional and psychological needs.

Choice C rationale:

Involving a client in making decisions about their care is an example of respecting their autonomy and practicing shared decision-making. While this action is important and aligns with the principle of autonomy, it is not a direct example of beneficence, which centers on actively doing good for the patient.

Choice D rationale:

Telling the truth about forgetting to perform a procedure for a client is an example of honesty and integrity, which are essential ethical principles in nursing. However, it does not directly relate to beneficence, which emphasizes actions that actively contribute to the patient's well-being and benefit.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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Correct Answer is B

Explanation

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