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 A
Explanation
Choice A rationale:
The statement, "It's unfortunate that I have to be in the hospital for this treatment," indicates the need for further teaching. TENS therapy is often used as an outpatient treatment and does not require hospitalization. Patients typically receive instructions on how to use TENS units at home.
Choice B rationale:
The statement, "I wish I didn't have to attach the electrodes to my skin," is a common sentiment but does not necessarily indicate a need for further teaching. Attaching electrodes to the skin is a standard part of using TENS therapy, and it's essential for the treatment to be effective. Some patients may find this aspect of treatment uncomfortable or inconvenient.
Choice C rationale:
The statement, "I'll need to shave the hair off the skin where I place the electrodes," is accurate. Shaving the area where electrodes are placed can improve the contact and effectiveness of the TENS therapy. This statement does not indicate a need for further teaching but rather a good understanding of the preparation process.
Choice D rationale:
The statement, "I hope I don't have to take as many pain pills," is a positive sign that the patient understands that TENS therapy can potentially reduce the need for pain medication. It indicates a reasonable expectation for pain management and does not signal a need for further teaching. .
Correct Answer is A
Explanation
Choice A rationale:
The nurse recommends that normal sleep and rest patterns can best be acquired by suggesting that the patient exercises in the mornings. Morning exercise can help regulate the circadian rhythm and improve sleep-wake patterns. It helps to reset the internal body clock, making it easier to fall asleep at night. However, exercise should not be too close to bedtime, as it may have a stimulating effect.
Choice B rationale:
Taking a nap during the day may provide a short-term boost in alertness but is not recommended as the primary method to acquire normal sleep and rest patterns. Daytime naps should be brief (20-30 minutes) and should not interfere with nighttime sleep. Excessive daytime napping can disrupt the regular sleep cycle.
Choice C rationale:
Drinking wine is not a recommended approach for acquiring normal sleep and rest patterns. Alcohol consumption, especially in the evening, can disrupt sleep cycles and negatively affect the quality of sleep. It may lead to frequent awakenings during the night and contribute to sleep disturbances.
Choice D rationale:
Smoking cigarettes is not a recommended approach for acquiring normal sleep and rest patterns. Nicotine is a stimulant that can interfere with sleep by increasing alertness and heart rate. Smoking can contribute to sleep difficulties and should be avoided, especially close to bedtime. .
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