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 A
Explanation
A. Gloves: When removing PPE for a client requiring airborne precautions, gloves should be removed first because they are considered the most contaminated item. Removing gloves first helps prevent contamination of other PPE and the healthcare provider's hands.
B. Mask: After removing gloves, the mask should be removed by grasping the ties or ear loops without touching the front of the mask. Removing the mask prevents the potential spread of infectious agents when the client is no longer in the immediate vicinity.
C. Gown: Following the removal of the mask, the gown should be removed, taking care to avoid touching the front of the gown. Removing the gown minimizes the risk of contamination to the healthcare provider's clothing or skin.
D. Goggles: If goggles were worn as part of the PPE for airborne precautions, they should be removed last after gloves, mask, and gown. Removing goggles last helps prevent any potential contamination of the eyes during the removal process.
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