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. Disorientation to place is concerning but may not require immediate reporting.
B. Clear fluid draining from the ear may indicate cerebrospinal fluid leakage, which is a serious concern and requires immediate attention.
C. An elevated heart rate may be a response to the fall and should be monitored but may not require immediate reporting.
D. An edematous bruise on the forehead should be monitored but may not require immediate reporting unless there are signs of more serious injury.
Correct Answer is C
Explanation
A. Encouraging the client to talk about his feelings is important, but understanding the client's current perception of his body image comes first to guide appropriate interventions.
B. Discussing coping strategies is relevant, but understanding the client's current perception helps tailor coping strategies to his specific concerns.
C. Determining the client's perception of his body image is the first step to assess the extent of the issue and plan interventions accordingly.
D. Assisting the client to acknowledge a distorted body image may be necessary, but understanding the client's current perception precedes interventions.
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