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 A

Explanation

A. Edema, which is swelling caused by fluid accumulation in the tissues. Edema is a common sign of inflammation and infection in wounds.
B. Crusting over granulated tissue may indicate normal wound healing and is not necessarily a sign of infection.
C. Petechiae are small red or purple spots on the skin caused by bleeding under the skin. They are usually associated with blood disorders or trauma, not infection.
D. Urticaria (hives) is typically associated with allergic reactions and is not a typical sign of wound infection.

Correct Answer is ["0.5"]

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 of the dose form, and X is the amount to administer. In this case, D is 25 mg, H is 50 mg, Q is 1 tablet, and X is unknown. Plugging these values into the formula, we get:

25/50 x 1 = X

0.5 x 1 = X

X = 0.5

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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

A nurse is changing the dressing on a client’s wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

Correct Answer is A

Explanation

Correct Answer is ["0.5"]

Explanation

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