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 D
Explanation
A. This statement reflects a sense of blame and responsibility but may not necessarily indicate a body image disturbance.
B. This statement may indicate frustration with physical therapy progress but does not directly address body image.
C. This statement reflects guilt or self-blame but may not necessarily indicate a body image disturbance.
D. This statement directly addresses the client's perception of their body image following the amputation.
Correct Answer is D
Explanation
A. These symptoms are more commonly associated with gastrointestinal side effects of chemotherapy.
B. These symptoms are common due to the impact of chemotherapy on the gastrointestinal system.
C. Hair loss is a common side effect of chemotherapy, but it is not associated with myelosuppression.
D. Myelosuppression can lead to decreased platelet production, resulting in an increased risk of bleeding, including gum bleeding.
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