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

Answer and Explanation

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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Correct Answer is C

Explanation

A. The dosage of opioid narcotics is not unlimited and should be carefully titrated to the client's pain level.
B. Opioid narcotics are not restricted solely due to the risk of addiction, especially in end-of-life care where effective pain management is a priority.
C. This statement emphasizes the importance of maintaining a stepwise approach to pain management, preserving options for effective pain control.
D. The use of opioid narcotics is not restricted solely to when death is imminent; it depends on the client's pain and symptom management needs.

A. Vomiting Hypoglycemia B. Hypertension C. Altered mental status D. Elevated WBC’s count

Correct Answer is C

Explanation

A. Vomiting is not a specific manifestation of sepsis.
B. Hypertension is not a typical finding in sepsis; hypotension is more common.
C. Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D. While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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