Physical signs of unrelieved pain include which of the following? Select all that apply.

Increased blood pressure

Increased respiratory rate

Increased heart rate

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Increased blood pressure is a common physiological response to pain. When a person experiences pain, the body's sympathetic nervous system is activated, causing an increase in heart rate and blood pressure. This response is part of the body's fight-or-flight mechanism, intended to help cope with the stressful situation.

Choice B reason: Increased respiratory rate is another sign of unrelieved pain. Pain can lead to rapid, shallow breathing as the body reacts to the discomfort. This response can help deliver more oxygen to tissues during times of stress but can also contribute to feelings of anxiety and fatigue if it continues over a prolonged period.

Choice C reason: Increased heart rate is a typical response to pain. Just like increased blood pressure, the heart rate rises as part of the body's sympathetic response to pain, which prepares the body to either confront or escape the source of pain. Monitoring heart rate can therefore provide critical information about the patient's pain levels and overall physiological state.

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Correct Answer is ["B"]

Explanation

Choice A reason: Cleaning the stoma two times a week is not sufficient. Stoma care typically requires daily cleaning to prevent infection and ensure the area remains free from mucus buildup and irritation.

Choice B reason: Using a bedside humidifier is important for patients with a tracheostomy. The humidified air helps to keep the stoma and airway moist, preventing drying and crusting of secretions, which can obstruct the airway.

Choice C reason: Offering plenty of fluids to the patient helps to keep the mucus thin and easier to clear, which is crucial for maintaining a clear airway in patients with a tracheostomy.

Choice D reason: Keeping the stoma uncovered when the patient showers is incorrect. The stoma should be covered with a waterproof shield or dressing to prevent water from entering the airway, which can cause respiratory distress or infection.

A. Place the patient in restraints for safety B. Insert an NGT C. Anticipate thrombolytic therapy for ischemic stroke D. Establish IV access with normal saline E. Place the patient in the prone position

Correct Answer is ["C","D"]

Explanation

Choice A reason: Placing the patient in restraints for safety is not typically necessary unless the patient is agitated or a danger to themselves or others. This action is not directly addressing the acute condition of a stroke.

Choice B reason: Inserting an NGT (nasogastric tube) is not an immediate priority in the acute management of a stroke. This might be considered later if the patient has swallowing difficulties and needs nutritional support, but it is not a first-line intervention.

Choice C reason: Anticipating thrombolytic therapy for ischemic stroke is appropriate, as timely administration of thrombolytics can dissolve the clot and improve blood flow to the affected brain area, potentially reducing the severity of the stroke.

Choice D reason: Establishing IV access with normal saline is crucial for administering medications and maintaining hydration. It ensures that the patient can receive necessary interventions promptly.

Choice E reason: Placing the patient in the prone position is not appropriate in the management of an acute stroke. The prone position is generally used in respiratory conditions to improve oxygenation but is not relevant to stroke management.

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Physical signs of unrelieved pain include which of the following? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Which action would the nurse take while providing home care to a patient with a stoma after a tracheostomy? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["B"]

Explanation

Correct Answer is ["C","D"]

Explanation

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