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. Acute pain is more likely to increase respiratory rate, not decrease it.
B. Acute pain does not typically cause hypoglycemia.
C. Acute pain is often associated with an increase in blood pressure (hypertension).
D. Acute pain tends to increase heart rate (tachycardia), not decrease it.

A. "Discomfort is expected in clients who are at the end-of-life." B. Opioid narcotics can cause loose stools and diarrhea in clients." C. Pain is expected in older adult clients." D. Clients are often afraid that opioid narcotics can result in addiction."

Correct Answer is D

Explanation

A. While discomfort can occur, it is not an expected or acceptable part of end-of-life care. Effective pain management is a key priority, and discomfort should be addressed promptly to ensure the client’s comfort and dignity.

B. While true, this statement does not directly address the expectation of discomfort at the end of life.
C. While pain can be present in older adults, the statement does not specifically address the end-of-life context.
D.Fear of addiction is a common concern among clients and families, even at the end of life. Nurses should educate clients and families about the importance of managing pain effectively and emphasize that addiction is not a concern when opioids are used appropriately for end-of-life care. This helps alleviate anxiety and encourages adherence to prescribed pain management regimens.

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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 collecting data on a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about pain management during the end of life. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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