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 ["2"]
Explanation
To answer this question, the nurse needs to use the formula D/H x Q = X, where D is the desired dose, H is the dose on hand, Q is the quantity, and X is the amount to administer.
In this case, D is 100 mcg, H is 50 mcg, Q is 1 tablet, and X is unknown. Plugging in the values, we get:
100/50 x 1 = X
2 x 1 = X
X = 2
Correct Answer is A
Explanation
A. Heat application can help relieve pain and stiffness associated with osteoarthritis.
However, it is important to use a heat pack with a temperature below body temperature to avoid skin burns.
B. Elevation is generally more relevant for conditions involving swelling, and it may not be the primary recommendation for osteoarthritis.
C. Acetaminophen is a common pain reliever, but other medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) may also be used for osteoarthritis pain management.
D. Decreasing foods high in purines is more relevant for conditions like gout, which is not typically associated with osteoarthritis.
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