A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Drowsiness.

Grimacing.

Screaming.

Moaning.

Restlessness.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale:

Drowsiness alone may not be a reliable indicator of pain, as it can result from various factors such as medications or the postoperative recovery process. While pain might cause drowsiness in some cases, it is not a definitive nonverbal sign of pain.

Choice B rationale:

Grimacing is a nonverbal behavior that often indicates pain or discomfort. It involves facial expressions of pain, such as frowning or wincing. Grimacing is a significant indicator that the nurse should consider in assessing the client's pain level.

Choice C rationale:

Screaming is a more overt expression of pain and discomfort. However, it is less common in a postoperative setting and might also be associated with anxiety or other emotional states. While it can indicate pain, it's not as reliable a marker as grimacing, moaning, or restlessness.

Choice D rationale:

Moaning is a nonverbal behavior that can signal pain in a postoperative client. It's an audible expression of discomfort and should be considered as a potential indication of pain.

Choice E rationale:

Restlessness can be an indication of pain as well. The client may shift positions frequently or exhibit signs of agitation in response to pain. However, restlessness can also have other causes, such as anxiety or medication effects.

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Correct Answer is D

Explanation

Choice A rationale:

A macular rash on the chest and back is not indicative of a paradoxical drug reaction to lorazepam, a benzodiazepine. Paradoxical reactions involve unexpected and opposite responses to a medication, such as increased agitation and excitement instead of the intended calming effect. A rash is not consistent with this type of reaction.

Choice B rationale:

Increased appetite is not associated with a paradoxical drug reaction to lorazepam. Paradoxical reactions involve behavioral and physiological responses that are contrary to the expected effects of the medication. Increased appetite does not fit this pattern.

Choice C rationale:

Drowsiness and mild sedation are the intended effects of lorazepam, a benzodiazepine. Paradoxical reactions are characterized by unexpected and opposite responses. Drowsiness and mild sedation align with the expected pharmacological actions of benzodiazepines, making this choice incorrect for a paradoxical reaction.

Choice D rationale:

Increased agitation and insomnia are indicative of a paradoxical drug reaction to lorazepam. Benzodiazepines like lorazepam are central nervous system depressants and are commonly used to treat anxiety and promote sedation. However, in some cases, paradoxical reactions can occur, leading to increased agitation, excitement, and even insomnia. These reactions are thought to be more common in children and older adults. This choice is correct because it aligns with the characteristics of a paradoxical reaction.

A. Left fourth intercostal space at the sternal border. B. Left third intercostal space at the sternal border. C. Left second intercostal space at the midclavicular line. D. Left fifth intercostal space at the midclavicular line.

Correct Answer is D

Explanation

The correct answer is: d. Left fifth intercostal space at the midclavicular line.

Choice A: Left fourth intercostal space at the sternal border

The fourth intercostal space at the sternal border is not the typical location for the Point of Maximal Impulse (PMI). This area is more commonly associated with the tricuspid valve auscultation point. The PMI is usually found more laterally and inferiorly.

Choice B: Left third intercostal space at the sternal border

The third intercostal space at the sternal border is also not the correct location for the PMI. This area is generally used for auscultating the pulmonic valve. The PMI is located further down and towards the midclavicular line.

Choice C: Left second intercostal space at the midclavicular line

The second intercostal space at the midclavicular line is typically where the aortic valve is auscultated. The PMI is not found this high up on the chest.

Choice D: Left fifth intercostal space at the midclavicular line

This is the correct location for palpating the Point of Maximal Impulse (PMI). The PMI is usually located at the apex of the heart, which is found at the left fifth intercostal space along the midclavicular line. This is where the left ventricle is closest to the chest wall and can be felt most strongly during systole.

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A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

Correct Answer is D

Explanation

A nurse is performing a cardiovascular assessment on a healthy client. In which of the following anatomical landmarks would the nurse expect to palpate the client's Point of Maximal Impulse (PMI)?

Correct Answer is D

Explanation

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