A nurse is assessing a newborn who had a circumcision 2 hr ago. Which of the following findings should the nurse identify as an indication that the newborn has acute pain?

Decrease in heart rate

Increase in vagal nerve tone

Decrease in respiratory rate

Increase in muscle tone

Answer and Explanation

The Correct Answer is D

A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to pain.

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Correct Answer is D

Explanation

A. Check with the surgery department that the procedure is correct. While important, it does not address the client's misunderstanding.
B. Notify the provider after the client signs the form. The client should not sign the form until they understand the procedure.
C. Explain to the client that both breasts are to be removed. The nurse should not provide surgical explanations beyond their scope.
D. Ask the provider to clarify the procedure with the client before she signs the form. The provider must ensure the client understands the procedure before consent is signed.

A. "This document will ensure that my health care wishes remain confidential." B. "This document will tell others what care I want when I cannot speak for myself." C. "My attorney has to prepare this document for me." D. "My family can change the document if I become mentally incapacitated."

Correct Answer is B

Explanation

A. "This document will ensure that my health care wishes remain confidential." Advance directives are meant to be shared with healthcare providers and family members, not kept confidential.
B. "This document will tell others what care I want when I cannot speak for myself." This statement correctly reflects the purpose of advance health care directives.
C. "My attorney has to prepare this document for me." While an attorney can assist, the document can be prepared without one.
D. "My family can change the document if I become mentally incapacitated." The document cannot be changed by family members once the client is incapacitated.

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A nurse is assessing a newborn who had a circumcision 2 hr ago. Which of the following findings should the nurse identify as an indication that the newborn has acute pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to witness a client who is scheduled for a bilateral mastectomy sign the informed consent form. The client states, "I am glad they are not taking both breasts." Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is teaching a client about advance health care directives. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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