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 C
Explanation
A) Lactated Ringer's:
Lactated Ringer's solution is an isotonic crystalloid solution that contains electrolytes similar to those found in plasma. It is commonly used for fluid resuscitation and maintenance therapy but is not typically used for treating hypernatremia, as it contains sodium chloride and could exacerbate the client's condition.
B) Dextrose 10% in water:
Dextrose 10% in water is a hypertonic solution primarily used to provide calories and treat hypoglycemia. It does not address the underlying electrolyte imbalance in hypernatremia.
C) 0.45% sodium chloride:
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution used to treat hypernatremia by diluting the excess sodium in the bloodstream. It provides free water to rehydrate cells without adding excessive sodium. This solution is appropriate for clients with hypernatremia who require IV fluid therapy.
D) Dextrose 5% in 0.9% sodium chloride:
Dextrose 5% in 0.9% sodium chloride, also known as D5NS, is a hypertonic solution containing both dextrose and sodium chloride. While it provides water and calories, the sodium content may exacerbate hypernatremia rather than correct it. Therefore, it is not the most appropriate choice for a client with hypernatremia.
Correct Answer is B
Explanation
A. Functional incontinence: Functional incontinence occurs when a person has difficulty reaching the toilet due to physical or cognitive impairments, such as mobility issues or dementia. Kegel exercises, which focus on strengthening the pelvic floor muscles, would not directly address the underlying causes of functional incontinence.
B. Stress incontinence: Stress incontinence is characterized by the involuntary leakage of urine during activities that increase abdominal pressure, such as coughing, sneezing, laughing, or exercising. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help support the bladder and reduce the occurrence of stress incontinence.
C. Urinary retention: Urinary retention refers to the inability to empty the bladder completely. While Kegel exercises may help improve bladder control, they are not typically used to address urinary retention, which often requires other interventions such as medications, catheterization, or surgery.
D. Fecal incontinence: Fecal incontinence involves the involuntary leakage of stool. Kegel exercises are not effective for addressing fecal incontinence, as they primarily target the pelvic floor muscles involved in urinary control, not bowel control. Treatment for fecal incontinence may include dietary modifications, medications, pelvic floor rehabilitation, or surgical interventions, depending on the underlying cause.
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