The nurse is assessing a client experiencing acute pain.
What assessments should validate the client with acute pain? Select all that apply.

Restlessness.

Dilated pupils.

Constricted pupils.

Diaphoretic skin.

Increased respirations.

Decreased respirations

Answer and Explanation

Correct Answer : A,D,E

These choices validate the client with acute pain because they are signs of a sympathetic nervous system response to pain. Acute pain is a sudden and usually sharp sensation that indicates tissue damage or injury.

Choice B is wrong because dilated pupils are not a sign of acute pain. Pupils may dilate in response to fear, excitement, or drugs.

Choice C is wrong because constricted pupils are not a sign of acute pain. Pupils may constrict in response to bright light, drugs, or brain damage.

Choice F is wrong because decreased respirations are not a sign of acute pain. Respirations may decrease in response to relaxation, drugs, or respiratory depression.

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Correct Answer is B

Explanation

Heat application increases blood flow and reduces muscle spasms, which can help relieve pain and promote healing. However, heat should not be applied for longer than 30 minutes at a time, as it can cause tissue damage and inflammation.

Choice A is wrong because maximum benefits do not occur within the first five minutes.

It takes time for heat to penetrate the tissues and cause vasodilation.

Choice C is wrong because the heat should not be left in place for at least one hour to be effective.

This can lead to burns, increased edema, and decreased blood flow.

Choice D is wrong because heat can not be left in place for as long as 12 hours without harmful effects.

This can cause severe tissue damage, infection, and necrosis.

Normal ranges for heat application are between 104°F and 113°F (40°C and 45°C).

The temperature should be checked frequently and adjusted according to the patient’s comfort and tolerance.

The skin should also be inspected for signs of erythema, blisters, or burns.

A. Has the client had negative interactions with other clients in the past?. B. Does the client have hostile thoughts about others?. C. Is the client fearful of others on the unit?. D. What are the client’s cultural norms?.

Correct Answer is D

Explanation

What are the client’s cultural norms? This question is important because it helps to assess whether the client’s behavior is influenced by their cultural background and values, which may differ from those of the staff and other clients.

For example, some cultures may value privacy, modesty, or respect for elders more than others, and may avoid eye contact or social interaction as a sign of politeness or deference.

Understanding the client’s cultural norms can help to provide culturally sensitive and appropriate care.

Choice A is wrong because it assumes that the client’s behavior is caused by negative interactions with other clients, which may not be the case.

Choice B is wrong because it assumes that the client’s behavior is caused by hostile thoughts about others, which may not be the case.

Choice C is wrong because it assumes that the client’s behavior is caused by fear of others in the unit, which may not be the case.

These choices are not relevant to planning the client’s care and may reflect bias or stereotyping on the part of the staff.

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The nurse is assessing a client experiencing acute pain. What assessments should validate the client with acute pain? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client asks a nurse how long a heat application should be left in place. Which response should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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The nurse is assessing a client experiencing acute pain.
What assessments should validate the client with acute pain? Select all that apply.