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
The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by: The correct answer is choice A: supporting surface and internal tissues.
Choice A rationale:
An abdominal binder is primarily used to support surface and internal tissues. It provides gentle compression and support to the abdominal area, which can reduce pain and discomfort. By holding the incision site together and supporting the surrounding tissues, it can minimize movement and strain on the incision, helping to alleviate pain.
Choice B rationale:
While an abdominal binder may indirectly contribute to back support by stabilizing the abdominal area, its primary purpose is to support the surgical site. Enhancing early ambulation is more related to patient mobility and not the primary purpose of the binder.
Choice C rationale:
Abdominal binders do not increase warmth to the incision site. In fact, excessive warmth can lead to sweating and moisture, potentially increasing the risk of infection. The primary purpose is to provide support.
Choice D rationale:
An abdominal binder does not keep sutures and staples in place. The sutures and staples are used to secure the incision, and the binder is placed over them to provide support and compression. However, the binder itself is not responsible for keeping sutures and staples in place. .
Correct Answer is B
Explanation
The correct answer is B. Responsibility.
Choice A rationale:
“Fairness.” Fairness involves treating all clients equally and without bias. While fairness is an important aspect of professionalism, it is not specifically demonstrated by evaluating the effectiveness of pain medication.
Choice B rationale:
“Responsibility.” Responsibility refers to the nurse’s duty to provide safe and effective care. By checking the client to evaluate the effectiveness of pain medication, the nurse is fulfilling their responsibility to monitor the client’s response to treatment and ensure their comfort and well-being.
Choice C rationale:
“Confidence.” Confidence involves the nurse’s self-assurance in their skills and knowledge. While confidence is important in nursing practice, it is not the primary component demonstrated in this scenario.
Choice D rationale:
“Advocacy.” Advocacy involves supporting and speaking up for the client’s needs and preferences. Although advocacy is a crucial part of nursing, the act of evaluating pain medication effectiveness is more directly related to the nurse’s responsibility to provide appropriate care.
By demonstrating responsibility, the nurse ensures that the client’s pain management is effective and that any necessary adjustments to the treatment plan are made.
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