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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Placing the soiled linen on the floor before bagging it is unsanitary and violates infection control principles. It increases the risk of spreading pathogens to other surfaces, potentially contaminating the environment.
B. Placing clean linen that touched the floor in the soiled linen bag prevents cross-contamination and maintains cleanliness. It adheres to infection control standards by ensuring that only soiled items are disposed of appropriately.
C. Holding the soiled linen against her body while carrying it to the linen bag risks transferring pathogens to the caregiver's clothing and skin, compromising personal hygiene and promoting contamination.
D. Shaking the soiled linen to remove any toilet paper remnants is ineffective and hazardous. It disperses potentially infectious particles, increasing the risk of contamination and compromising infection control efforts.
Correct Answer is B
Explanation
A) Utilitarianism: Utilitarianism focuses on the greatest good for the greatest number of people. In this scenario, the nurse's decision not to administer the pain medication is not based on maximizing overall benefit but rather on avoiding harm to the individual client.
B) Non-maleficence: Non-maleficence is the ethical principle of doing no harm. The nurse's decision not to administer the pain medication is rooted in the desire to avoid causing harm to the client by potentially hastening their death.
C) Fidelity: Fidelity refers to the obligation to fulfill commitments and responsibilities. While important, fidelity is not directly relevant to the nurse's decision in this scenario.
D) Veracity: Veracity refers to truthfulness and honesty. While honesty is crucial in communicating with the client and their family about their condition and care, it is not the primary ethical principle guiding the nurse's decision in this situation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.