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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Osteoarthritis typically affects specific joints and is not necessarily bilateral throughout the body.
B. Osteoarthritis is not an autoimmune disease; it is a degenerative joint disease.
C. Moist heat can provide relief for osteoarthritis pain by improving joint flexibility and reducing stiffness.
D. Osteoarthritis is primarily a localized joint disease and does not usually result in systemic symptoms.
Correct Answer is ["B","D","E"]
Explanation
A. Dry crust on the incision line may indicate normal healing, not necessarily infection.
B. Adventitious breath sounds can be indicative of pneumonia, a potential infection.
C. Increased urine output is not a sign of infection but may suggest other issues.
D. Decreased level of consciousness suggests a systemic issue, which could include infection affecting the central nervous system.
E. Oral temperature of 38.3° C (101° F) indicates fever which is a common sign of infection.
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