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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A decreased level of rheumatoid factor is not seen in clients with rheumatoid arthritis. Rheumatoid factor is an antibody that is produced by the immune system and can bind to other antibodies. A high level of rheumatoid factor indicates an autoimmune disorder, such as rheumatoid arthritis.
Choice B reason: A negative rheumatoid factor is not seen in clients with rheumatoid arthritis. A negative rheumatoid factor means that the antibody is not detected in the blood. A negative rheumatoid factor does not rule out rheumatoid arthritis, but it may suggest a different type of arthritis or another condition.
Choice C reason: A positive rheumatoid factor is seen in clients with rheumatoid arthritis. A positive rheumatoid factor means that the antibody is detected in the blood. A positive rheumatoid factor is more likely to occur in clients with rheumatoid arthritis, especially during a flareup of the disease.
Choice D reason: Factor does not change is not seen in clients with rheumatoid arthritis. Rheumatoid factor can vary over time and may change depending on the activity of the disease. Rheumatoid factor may increase during a flareup and decrease during remission.
Correct Answer is C
Explanation
Choice A reason: "I will take all prescribed medications." is not a statement that demonstrates an understanding of the teaching, because it is incomplete and vague. Taking all prescribed medications is an important part of the treatment for HIV, but it does not explain why, how, or for how long the medications are needed. Taking all prescribed medications without understanding the purpose, benefits, or risks can lead to poor adherence, compliance, or outcomes.
Choice B reason: "I will only need to take HIV medications for 6 months, and then I will be cured." is not a statement that demonstrates an understanding of the teaching, because it is incorrect and unrealistic. Taking HIV medications for 6 months is not enough to treat the infection, and there is no cure for HIV. HIV is a chronic and incurable infection that requires lifelong treatment with antiretroviral drugs, which can suppress the viral load, improve the immune function, and prevent the progression to AIDS. Stopping the medications after 6 months can cause the virus to rebound, the immune system to deteriorate, and the disease to worsen.
Choice C reason: "I will have to take medications for the rest of my life." is a statement that demonstrates an understanding of the teaching, because it is accurate and realistic. Taking medications for the rest of one's life is the reality of living with HIV, as there is no cure for the infection. Taking medications for the rest of one's life can help control the infection, maintain the health, and prolong the survival of people with HIV.
Choice D reason: "I will have to be careful and avoid crowds." is not a statement that demonstrates an understanding of the teaching, because it is unnecessary and exaggerated. Being careful and avoiding crowds is not a requirement for people with HIV, as the infection is not transmitted by casual contact, such as touching, hugging, or sharing utensils. Being careful and avoiding crowds can also be detrimental to the social and emotional wellbeing of people with HIV, as it can cause isolation, stigma, or depression.
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