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 B

Explanation

A. Hypovolemic shock typically results in low blood pressure (BP) and a compensatory increase in pulse rate to maintain cardiac output.
B. Low BP and high pulse rate are characteristic findings in hypovolemic shock, reflecting decreased circulating blood volume.
C. High BP is not a typical finding in hypovolemic shock; the BP tends to decrease due to reduced blood volume.
D. Low BP and low pulse rate are not consistent with the compensatory response seen in hypovolemic shock.

A. Turn off fans and heaters. B. Evacuate the entire facility of all residents and staff. C. Close the doors and windows of each resident’s apartment. D. Be sure the fireplaces in each room are burning. E. Place wet towels under the doors.

Correct Answer is ["A","C","E"]

Explanation

A. Turning off fans and heaters can help prevent the circulation of potentially contaminated air.
B. Evacuation may be necessary in extreme cases but should be done following established protocols and considering the safety of residents.
C. Closing doors and windows helps minimize the entry of external air, reducing exposure to potential contaminants.
D. Keeping fireplaces burning may increase the risk of indoor air pollution and is not a recommended action during a chemical disaster.
E. Placing wet towels under doors can help create a barrier to limit the entry of external air and contaminants.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

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