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 D

Explanation

Choice A rationale:

Intramuscular administration involves injecting medication into muscle tissue, which may result in slower and variable absorption rates. It is not the optimal route for providing fast and complete absorption of Furosemide.

Choice B rationale:

Subcutaneous administration delivers medication into the fatty tissue beneath the skin. While it can be used for some medications, it generally results in slower absorption compared to intravenous administration, and it may not be suitable for Furosemide, which requires rapid action in a severe heart failure situation.

Choice C rationale:

Oral administration involves taking medication by mouth, and the absorption process can be influenced by factors such as gastric emptying and gastrointestinal transit time. In an urgent scenario of severe heart failure, oral administration might be too slow and unpredictable.

Choice D rationale:

Intravenous administration allows for the fastest and most complete absorption of Furosemide. By directly delivering the medication into the bloodstream, it bypasses the absorption barriers of the gastrointestinal tract, leading to rapid onset of action and predictable effects, which is crucial in managing acute heart failure. This route is commonly used in critical situations where immediate therapeutic effects are needed.

A. "My child must be free from nits before returning to school.” B. "Toys that can't be dry cleaned or washed must be thrown out.” C. "I will treat all the family members to be on the safe side.” D. "All recently used clothing, bedding, and towels must be washed in hot water.”

Correct Answer is D

Explanation

Choice A rationale:

Requiring the child to be free from nits before returning to school might not be an accurate understanding of the situation. Nits are the eggs of head lice and may remain attached to the hair even after effective treatment. The presence of live lice is a more crucial factor to consider.

Choice B rationale:

Throwing out toys that can't be dry cleaned or washed is an unnecessary and extreme measure. Head lice do not survive long away from the human scalp, so the risk of transmission through inanimate objects like toys is minimal. Thoroughly cleaning and vacuuming the environment is more effective.

Choice C rationale:

Treating all family members is indeed a prudent approach. Head lice can spread easily within households, especially among close contacts. Treating everyone helps prevent re-infestation and disrupts the lice life cycle.

Choice D rationale:

Washing recently used clothing, bedding, and towels in hot water is a correct understanding of how to manage head lice. The high temperature kills lice and their eggs. It is an essential step in preventing the spread of lice and re-infestation.

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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 Medical-Surgical nurse is preparing to administer Furosemide to a patient who is having severe heart failure. Which route of administration should the nurse use to provide the fastest and most complete absorption of Furosemide?

Correct Answer is D

Explanation

A school nurse identifies that a child has pediculosis capitis (head lice) and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

Correct Answer is D

Explanation

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