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
Choice A rationale:
Applying the pulse oximeter probe to the toe is not the most appropriate location. While toe measurements can be used, the fingers are more commonly used due to their accessibility and accuracy. Edema in the hands could affect the accuracy of readings.
Choice B rationale:
The nurse should apply the pulse oximeter probe to the earlobe. This choice is correct because the earlobe is a well-vascularized and easily accessible area that provides accurate oxygen saturation measurements. Thickened toenails and edema of the hands might compromise readings in those locations.
Choice C rationale:
Applying the pulse oximeter probe to a skin fold is not a recommended site for oxygen saturation measurement. While there are various sites where pulse oximeters can be applied, the earlobe and finger are more suitable due to their consistent blood flow and accessibility.
Choice D rationale:
While applying the pulse oximeter probe to the finger is a common and acceptable practice, in this scenario, edema of the hands could affect the accuracy of the readings. The earlobe is a better choice as it is less likely to be affected by edema and can provide accurate readings.
Correct Answer is A
Explanation
Choice A rationale:
It's essential to ensure that the client fully understands the surgical procedure and its implications before signing the informed consent form. If the client expresses confusion or lack of understanding, the nurse should involve the surgeon to address the concerns directly. The surgeon is the most appropriate person to provide comprehensive information about the procedure, potential risks, benefits, and alternatives. This promotes patient autonomy and informed decision-making, aligning with ethical principles.
Choice B rationale:
While educating the client about the procedure is important, it's not the nurse's role to provide detailed explanations of surgical procedures. Additionally, the surgeon possesses the necessary expertise to explain medical procedures accurately. Relying on the surgeon for this explanation maintains professional boundaries and ensures accurate information dissemination.
Choice C rationale:
Encouraging the client to reread the consent form is insufficient if the client did not initially understand the explanation. The consent form might contain complex medical language, and the client might need direct communication with the surgeon to address specific concerns. Merely re-reading the form might not alleviate the client's confusion.
Choice D rationale:
Telling the client that the surgeon will explain the procedure in the operating room is inappropriate. The client's concerns should be addressed promptly, and the explanation should occur before the surgery, allowing the client to make an informed decision. Operating rooms are not the appropriate setting for obtaining informed consent.
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