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 B
Explanation
A. Leaving the client during a seizure can lead to injury. The nurse should stay with the client.
B. Placing a towel under the client's head helps protect the head from injury during a seizure.
C. Placing the client in the prone position can compromise the airway and increase the risk of aspiration.
D. Holding the client's arms and legs still can be difficult and may result in injury to the client or the nurse. The priority is to protect the client from injury during the seizure.
Correct Answer is A
Explanation
A. Acknowledges that discomfort is expected in clients at the end of life and emphasizes the need for appropriate pain management.
B. While true, this statement does not directly address the expectation of discomfort at the end of life.
C. While pain can be present in older adults, the statement does not specifically address the end-of-life context.
D. Although a valid concern, this statement does not directly address the expectation of discomfort at the end of life.
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