Which assessment is a nonverbal sign of pain? (Select all that apply.)
Increased agitation
Decreased attention span
Grimacing
Reported pain of 5/10
Increase in heart rate
Correct Answer : A,C,E
Choice A reason: Increased agitation is a nonverbal sign of pain, because it indicates that the client is restless, uncomfortable, or distressed by the pain. Agitation can manifest as fidgeting, tossing, turning, moaning, or groaning.
Choice B reason: Decreased attention span is not a nonverbal sign of pain, but rather a cognitive or behavioral sign of pain. Decreased attention span means that the client has difficulty focusing, concentrating, or remembering things, which can be affected by pain. However, decreased attention span is not a direct expression of pain, but rather a consequence of pain.
Choice C reason: Grimacing is a nonverbal sign of pain, because it indicates that the client is experiencing facial muscle tension, contraction, or distortion due to the pain. Grimacing can manifest as frowning, wrinkling the forehead, pursing the lips, or clenching the teeth.
Choice D reason: Reported pain of 5/10 is not a nonverbal sign of pain, but rather a verbal sign of pain. Reported pain of 5/10 means that the client has communicated the intensity of their pain using a numerical scale, which is a subjective and selfreported measure of pain. However, reported pain of 5/10 is not a direct expression of pain, but rather a description of pain.
Choice E reason: Increase in heart rate is a nonverbal sign of pain, because it indicates that the client is experiencing physiological changes due to the pain. Increase in heart rate can manifest as tachycardia, palpitations, or arrhythmias.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Eradicating the disease is not the purpose of the medications, because osteoarthritis is a chronic and progressive condition that cannot be cured by drugs. Osteoarthritis is a degenerative joint disease that causes the breakdown of cartilage and bone, leading to pain, stiffness, and reduced mobility.
Choice B reason: Turning on the immune system is not the purpose of the medications, because osteoarthritis is not an autoimmune disease that involves the immune system attacking the joints. Osteoarthritis is a mechanical disease that involves the wear and tear of the joints due to aging, injury, or overuse.
Choice C reason: Reducing pain and inflammation is the purpose of the medications, because osteoarthritis is a painful and inflammatory condition that affects the quality of life of the client. The medications for osteoarthritis include analgesics, such as acetaminophen or opioids, and antiinflammatory drugs, such as nonsteroidal antiinflammatory drugs (NSAIDs) or corticosteroids, which can relieve the symptoms and improve the function of the joints.
Choice D reason: Managing weight loss is not the purpose of the medications, because osteoarthritis is not a metabolic disease that affects the weight of the client. Osteoarthritis is a structural disease that affects the joints of the client. However, managing weight is an important factor in preventing or treating osteoarthritis, as excess weight can increase the stress and damage on the joints.
Correct Answer is A
Explanation
Choice A reason: This is the highest priority client because sudden and increasing pain in a fractured arm can indicate a complication, such as compartment syndrome, infection, or nerve damage. Compartment syndrome is a condition where the pressure inside the muscles increases to dangerous levels, causing severe pain, reduced blood flow, and tissue death. Infection is a condition where microorganisms invade the wound site, causing inflammation, pus, and fever. Nerve damage is a condition where the nerves are injured by the fracture, causing numbness, tingling, or weakness. The nurse should see this client first and assess the arm for any signs of these complications, such as swelling, pallor, loss of sensation, or impaired movement. The nurse should also elevate the arm, loosen any bandages or casts, and administer pain medication as ordered.
Choice B reason: This is not the highest priority client because a fractured ankle is a common and stable condition that affects the lower extremity. A glass of water is a comfort and hydration need that can be met by the nurse or another staff member. The nurse should see this client after the more urgent clients and provide the glass of water, as well as monitor the ankle for any signs of complications, such as edema, infection, or impaired circulation.
Choice C reason: This is not the highest priority client because rheumatoid arthritis is a chronic and manageable condition that affects the joints. A scheduled pain medication is a routine and preventive need that can be met by the nurse or another staff member. The nurse should see this client after the more urgent clients and administer the pain medication, as well as assess the joints for any signs of inflammation, stiffness, or deformity.
Choice D reason: This is not the highest priority client because a discharge teaching is a discharge and education need that can be met by the nurse or another staff member. The nurse should see this client last and teach the client how to use the crutches, as well as provide any other discharge instructions, such as wound care, activity restrictions, or followup appointments.
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