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

Answer and Explanation

Correct Answer : A,B,D,E

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Correct Answer is A

Explanation

Petechiae are small, reddish-purple, flat spots on the skin or mucous membranes that occur as a result of bleeding under the skin. Petechiae can occur due to a variety of reasons such as trauma, infection, or bleeding disorders. In this scenario, the health care provider has documented the presence of petechiae on the anterior thorax, arms, and neck of the client. Therefore, the nurse should expect to observe small, reddish-purple, flat spots on the skin or mucous membranes while providing care to the client.

Option b describes purpura, which is characterized by irregularly shaped, reddish, raised spots on the skin and mucous membranes. Option c describes urticaria, which is characterized by dime-sized, purplish white, raised blotches across all affected skin surfaces. Option d describes café-au-lait spots, which are large brown spots that may be present at birth or develop later in life.

A. "The client status is deteriorating. I feel you should come now." B. "The client has hypoxemia after 10 minutes on a rebreather mask." C. 'The Pa02 is 55, PaC02 is 90. HC03 is 26 D. "The client has a history of chronic obstructive pulmonary disease and admitted with pneumonia.'

Correct Answer is B

No 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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The health care provider documents in the client's chart the presence of petechiae on the anterior thorax, arms, and neck of a client. Which sign should a nurse expect to observe while providing care?

Correct Answer is A

Explanation

The nurse calls the healthcare provider using SBAR communication. Which statement should the nurse make first?

Correct Answer is B

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