A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)
The client draws his legs up into a fetal position.
The facial muscles relax.
The respiratory rate increases.
The shoulders droop.
The pulse is within the expected range
Correct Answer : B,D,E
A. Drawing legs up into a fetal position may indicate discomfort or agitation.
B. Facial muscle relaxation is indicative of a therapeutic response to the massage.
C. An increased respiratory rate may suggest distress or discomfort.
D. Drooping shoulders suggest relaxation and a positive response to the massage.
E. Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Swelling and tenderness around the wound are common signs of infection, indicating an inflammatory response to the presence of bacteria.
B. Brown crusting over the wound may suggest the presence of a scab or dried exudate, which is a normal part of the healing process and not necessarily indicative of infection.
C. Serosanguineous drainage is a type of wound drainage that is typically not a sign of infection but rather a mix of clear and blood-tinged fluid.
D. Urticaria and itching around the wound suggest an allergic reaction rather than a wound infection.
Correct Answer is D
Explanation
A. Diminished urine output is a later sign of hypovolemic shock and is associated with decreased perfusion to the kidneys.
B. Cold clammy skin is also a later sign of shock, indicating poor tissue perfusion.
C. Unconsciousness is a late sign of hypovolemic shock and occurs when there is significant impairment of cerebral perfusion.
D. Tachycardia is an early compensatory mechanism in response to hypovolemia, aiming to maintain cardiac output and perfusion to vital organs.
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