A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain?
Reduced respiratory rate
Elevated blood pressure
Constricted pupils
Decreased heart rate
The Correct Answer is B
A) Reduced respiratory rate:
Acute pain typically triggers an increased respiratory rate rather than a reduced one. Pain activates the sympathetic nervous system, leading to increased respiratory effort as the body prepares to fight or flee.
B) Elevated blood pressure:
Elevated blood pressure is a common physiological response to acute pain. Pain activates the sympathetic nervous system, leading to the release of stress hormones like adrenaline, which constrict blood vessels and increase heart rate and blood pressure.
C) Constricted pupils:
Pain often causes pupil dilation rather than constriction. The body's fight-or-flight response to pain involves pupil dilation to enhance visual acuity and peripheral vision, allowing individuals to detect potential threats in their environment.
D) Decreased heart rate:
Acute pain typically results in an increased heart rate rather than a decreased one. Pain triggers the release of adrenaline, which increases heart rate as part of the body's stress response to prepare for action.
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Related Questions
Correct Answer is A
Explanation
A) Cheyne-Stokes respirations:
Cheyne-Stokes respirations are characterized by a cycle of gradually increasing and then decreasing respirations followed by a period of apnea. This pattern repeats in a regular cycle. It is commonly observed in clients with conditions affecting the central nervous system, such as traumatic brain injury, stroke, or brain tumors. Cheyne-Stokes respirations can also occur during the dying process. The alternating periods of hyperventilation and apnea result from fluctuations in oxygen and carbon dioxide levels in the blood.
B) Kussmaul respirations:
Kussmaul respirations are deep, rapid, and labored breathing patterns often observed in clients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.
C) Apneustic respirations:
Apneustic respirations are characterized by prolonged inspiratory gasps followed by insufficient expiration. This irregular breathing pattern typically indicates damage to the pons, a part of the brainstem involved in regulating breathing. Apneustic respirations are different from the pattern described in the scenario.
D) Stridor:
Stridor is a high-pitched, noisy respiratory sound heard on inspiration that indicates upper airway obstruction, such as from swelling, foreign body aspiration, or tumors. It is not associated with the alternating pattern of hyperventilation and apnea described in Cheyne-Stokes respirations.
Correct Answer is C
Explanation
A. Airborne:
Airborne precautions are used for infections transmitted via small droplet nuclei that remain suspended in the air for long periods and can be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. Pertussis is not transmitted via the airborne route.
B. Contact:
Contact precautions are used for infections spread by direct or indirect contact with the client or their environment. Examples include Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Pertussis is primarily spread through respiratory droplets rather than contact with contaminated surfaces.
C. Droplet:
Pertussis is primarily spread through respiratory droplets when an infected person coughs or sneezes. The nurse should initiate droplet precautions to prevent the transmission of the bacteria to others. These include wearing a surgical mask when within 3 feet of the client, placing the client in a private room or cohorting with another client who has the same infection, and ensuring that visitors wear masks and practice hand hygiene.
D. Protective:
Protective precautions, also known as reverse isolation, are used to protect clients who have compromised immune systems from exposure to pathogens. This precaution is not relevant for a client with pertussis; instead, the focus is on preventing transmission to others through droplet precautions.
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