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?
Bradycardia.
Decreased respiratory rate.
Hypoglycemia.
Hypertension.
The Correct Answer is D
Choice A rationale:
Bradycardia, a slow heart rate, is not typically associated with acute pain. In response to pain, the body usually experiences increased heart rate (tachycardia) as part of the stress response.
Choice B rationale:
A decreased respiratory rate is not an expected finding in response to acute pain. Acute pain often leads to increased respiratory rate as the body attempts to manage the pain and stress.
Choice C rationale:
Hypoglycemia, a low blood sugar level, is not a typical physiological response to acute pain. Acute pain is more likely to induce a release of stress hormones, such as cortisol and adrenaline, which can lead to increased blood sugar levels.
Choice D rationale:
Hypertension, or elevated blood pressure, is an expected physiological response to acute pain. Pain activates the body's stress response, leading to increased sympathetic nervous system activity, which can cause vasoconstriction and increased blood pressure. This response helps prepare the body to cope with the pain and stress. Monitoring blood pressure in a client reporting acute pain is essential to assess the impact of pain and determine appropriate pain management strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is: C. Decreased energy.
Choice A reason: Hypotension is not typically associated with obstructive sleep apnea (OSA). OSA is more commonly linked with hypertension due to the frequent arousals during sleep that activate the sympathetic nervous system, leading to increased blood pressure.
Choice B reason: Pneumonia is an infection of the lungs and is not a direct consequence of OSA. While OSA can affect the respiratory system, it does not cause pneumonia. However, individuals with OSA may have a higher risk of respiratory infections due to compromised breathing during sleep.
Choice C reason: Decreased energy is a common symptom of OSA. People with OSA experience repeated episodes of partial or complete upper airway obstruction during sleep, leading to disrupted sleep patterns and insufficient rest. This results in daytime sleepiness and fatigue, which are hallmark signs of the condition.
Choice D reason: Thyroid disease, specifically hypothyroidism, can be associated with OSA, but it is not a direct finding of the condition. Hypothyroidism can lead to changes in the soft tissues of the upper airway and contribute to the development of OSA, but it is not a symptom used to diagnose OSA.
Correct Answer is D
Explanation
Choice A rationale:
Using heavy pressure on the cold pack for greater effectiveness is not the correct approach when applying a cold pack to an injured area. Applying excessive pressure can lead to tissue damage, frostbite, and can be uncomfortable for the patient. Cold packs should be applied with gentle, even pressure to avoid complications.
Choice B rationale:
Leaving the cold pack in place for over 30 minutes at a time is not recommended. Prolonged exposure to cold can also cause tissue damage, including frostbite. It is generally advised to limit cold pack applications to 20-30 minutes at a time to prevent complications.
Choice C rationale:
Preparing to apply heat instead if cold is not effective is not the appropriate action in this scenario. When a healthcare provider orders a cold pack application, it is essential to follow the prescribed treatment plan. Heat should only be considered if it is specifically ordered as an alternative treatment.
Choice D rationale:
Placing a towel between the pack and the skin is the correct approach to prevent patient injury when applying a cold pack. This helps to protect the skin from direct contact with the cold pack, reducing the risk of frostbite or cold-related injuries. It ensures a barrier between the cold pack and the patient's skin, providing a safe and comfortable application.
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