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:
Autonomy refers to a patient's right to make their own decisions about their medical care. While autonomy is an important ethical principle, it is not directly related to the situation described. The nurse providing oxygen therapy to the patient without the patient's consent is not an example of respecting autonomy.
Choice B rationale:
Beneficence is the correct choice. Beneficence is the ethical principle of doing what is best for the patient's well-being. In this situation, providing oxygen therapy to a patient experiencing difficulty in breathing aligns with the principle of beneficence. Oxygen therapy aims to improve the patient's oxygenation and alleviate respiratory distress.
Choice C rationale:
Veracity refers to truthfulness and honesty in communication. While honesty is important, it is not the primary ethical principle at play in this situation. Providing oxygen therapy to improve the patient's condition is more aligned with beneficence.
Choice D rationale:
Fidelity refers to the duty to be faithful and keep promises. While fidelity is important in maintaining trust between healthcare providers and patients, it is not the primary principle relevant here. The priority is to address the patient's immediate health needs through appropriate interventions like oxygen therapy.
Correct Answer is C
Explanation
Choice A rationale:
Cleaning the wound by scrubbing the site with gauze is not an appropriate intervention for a stage 3 pressure ulcer. Scrubbing can damage the fragile tissue, increase the risk of infection, and delay wound healing. Gentle cleaning with a mild solution and avoiding trauma to the wound bed are recommended.
Choice B rationale:
Massaging reddened areas with dressing changes is contraindicated for pressure ulcers, especially stage 3 ulcers. Massaging can cause further damage to the tissues and disrupt the healing process. Dressing changes should focus on maintaining a clean and moist environment to promote healing.
Choice C rationale:
(Correct Choice) Repositioning the client at least every 2 hours is a crucial intervention to prevent further pressure ulcers and facilitate wound healing. Regular repositioning helps relieve pressure on specific areas and improves blood circulation, reducing the risk of tissue breakdown and the development of new ulcers.
Choice D rationale:
Applying a heat lamp twice a day is not recommended for stage 3 pressure ulcers. Heat can increase blood flow to the area, potentially exacerbating inflammation and delaying healing. Pressure ulcers require a clean and moist environment for optimal healing.
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