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. A decrease in skinfold thickness: A decrease in skinfold thickness could be due to loss of subcutaneous fat, which might not be immediately concerning without other symptoms.
B. A triglyceride level of 150 mg/dL: A triglyceride level of 150 mg/dL is generally considered within normal limits.
C. A random blood glucose reading of 160 mg/dL: A random blood glucose reading of 160 mg/dL is elevated and could indicate impaired glucose tolerance, warranting further investigation.
D. A mole that is dark in color and tender: A dark, tender mole could be a sign of a potentially malignant melanoma and should be evaluated by a provider for further investigation and potential biopsy.

A. Instruct the client to use the call light for assistance. B. Document the type of alarm used. C. Test the alarm and battery of the device. D. Apply the sensor pad to the client's bed.

Correct Answer is C

Explanation

A. Instruct the client to use the call light for assistance. This is important but should be done after ensuring the alarm is working correctly.
B. Document the type of alarm used. Documentation is necessary but should follow ensuring the device is functioning.
C. Test the alarm and battery of the device. Ensuring the bed alarm and battery are functioning properly is critical to the safety of the client. The alarm needs to be reliable to alert staff if the client attempts to get out of bed.
D. Apply the sensor pad to the client's bed. This step is necessary but should follow testing the alarm and battery to ensure they are functioning.

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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 in a community health clinic is conducting a health screening for a male client. For which of the following findings should the nurse recommend the client follow up with his provider?

Correct Answer is D

Explanation

A nurse is preparing to apply a bed alarm for a client who is at risk for falls and attempts to get out of bed without assistance. After explaining the procedure to the client, which of the following actions should the nurse take next?

Correct Answer is C

Explanation

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