Which assessment finding should a nurse record as a symptom of pain? A client who:.

grimaces during a dressing change.

has an elevated heart rate while exercising.

is crying during a procedure.

says, “I feel achy all over.”.

Answer and Explanation

The Correct Answer is A

A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.

The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.

Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.

Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.

The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.

Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.

Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.

The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. An idiosyncratic drug effect. B. A toxic drug effect. C. An allergic drug response. D. An unexpected drug interaction.

Correct Answer is A

Explanation

An idiosyncratic drug effect is an unpredictable and uncommon reaction to a drug that is not related to the dose, the pharmacology, or the patient’s allergy or intolerance. It may be caused by genetic factors, metabolic abnormalities, or interactions with other drugs or substances. An example of an idiosyncratic drug effect is paradoxical agitation or excitement after receiving a sedative.

B. A toxic drug effect is a harmful reaction to a drug that is related to the dose or the pharmacology of the drug. It may cause symptoms such as nausea, vomiting, drowsiness, confusion, or respiratory depression. A toxic drug effect is unlikely to cause agitation after receiving a sedative unless there is an overdose or a drug interaction that increases the level of the sedative in the blood.

C. An allergic drug response is an immunological reaction to a drug that is not related to the dose or the pharmacology of the drug. It may cause symptoms such as rash, itching, swelling, fever, or anaphylaxis. An allergic drug response is unlikely to cause agitation after receiving a sedative unless there is a severe anaphylactic reaction that affects the brain or the circulation.

D. An unexpected drug interaction is a modification of the effect of one drug by another drug or substance that is not predictable based on their pharmacology. It may cause an increase or a decrease in the efficacy or toxicity of one or both drugs. An unexpected drug interaction may cause agitation after receiving a sedative if there is a synergistic effect that enhances the central nervous system stimulation of another drug or substance (such as caffeine, cocaine, or amphetamines) or if there is an antagonistic effect that reduces the central nervous system depression of the sedative (such as flumazenil, naloxone, or physostigmine). However, these interactions are usually known and avoidable by checking the patient’s history and medication list.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which assessment finding should a nurse record as a symptom of pain? A client who:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client makes minimal eye contact with others and remains alone in their room during the day. Which question is an important consideration when planning the client’s care?

Correct Answer is D

Explanation

Which statement best documents the situation when a client becomes extremely agitated after receiving a sedative?

Correct Answer is A

Explanation

A nurse has received report on four clients. What client should the nurse see first?

Which electrolyte imbalance should a nurse expect to assess in a client who reports diarrhea for the past three days?

A client has returned to the medical surgical unit with a Jackson-Pratt surgical drain. What safety measures should the nurse use to prevent client injury? (Select all that apply).

Which of these assessment findings should a nurse record as subjective?

A 10-year old is admitted to the Emergency Room in a sickle cell crisis. Put the interventions in order by priority. All options must be used.

Which client behavior is indicative of hearing loss?

The nurse is preparing to perform a physical assessment. What are the four techniques used?

A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C). Which action should a nurse take next?