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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Propranolol is a beta-blocker medication commonly used to treat hypertension, angina, and certain heart rhythm disorders. However, it is contraindicated in clients with a history of asthma or other obstructive airway diseases due to its potential to cause bronchoconstriction and exacerbate respiratory symptoms.

B. Migraines:
Propranolol is actually commonly used for the prophylactic treatment of migraines, particularly in individuals with frequent or severe migraines. It helps reduce the frequency and severity of migraine attacks by blocking the release of certain chemicals in the brain.

C. Glaucoma:
Propranolol can be used in the treatment of glaucoma, particularly when other treatments have been ineffective. It works by reducing intraocular pressure, which can help prevent vision loss associated with glaucoma.

D. Depression:
Propranolol is not contraindicated in clients with depression. In fact, it may sometimes be used off-label to manage certain symptoms of anxiety or performance anxiety. However, it is important to monitor clients with depression closely when prescribing propranolol, as it may interact with other medications used to treat depression or worsen certain depressive symptoms.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30" to 45". D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.

B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.

C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.

D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.

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A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

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