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
Choice A rationale:
Reduced respiratory rate is not a typical manifestation of pain. In fact, pain often leads to an increased respiratory rate as the body responds to discomfort by trying to minimize it.
Choice B rationale:
Elevated blood pressure is a common manifestation of pain. When a person experiences pain, their sympathetic nervous system is activated, leading to an increase in heart rate and blood pressure. This response is designed to prepare the body to fight or flee from a potential threat, and it helps redirect blood flow to vital organs.
Choice C rationale:
Constricted pupils are not a direct manifestation of pain. In contrast, dilated pupils can be seen in response to pain as a result of sympathetic nervous system activation.
Choice D rationale:
Decreased heart rate is not typically associated with pain. Pain tends to increase heart rate as a part of the body's stress response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Piaget's formal operational stage is characterized by abstract thinking, hypothesis testing, and logical reasoning, but it does not include the development of object permanence. This stage typically occurs during adolescence, not in early childhood when object permanence is established.
Choice B rationale:
The preoperational stage is characterized by the development of symbolic thought and egocentrism but not object permanence. Object permanence starts to develop during the sensorimotor stage.
Choice C rationale:
Concrete operational thinking is focused on logical and systematic thinking related to concrete objects and events. It does not include the development of object permanence, which occurs in the earlier sensorimotor stage.
Choice D rationale:
Object permanence is a concept that develops during Piaget's sensorimotor stage, which typically occurs from birth to about two years of age. During this stage, children learn that objects continue to exist even when they are out of sight. They develop the ability to represent objects mentally and understand the concept of permanence.
Correct Answer is A
Explanation
Choice A rationale:
Establishing whether the client's grieving is healthy or complicated is the first step in the nursing process when caring for a client experiencing grief. This step falls under the assessment phase of the nursing process and is essential for understanding the client's needs and planning appropriate care.
Choice B rationale:
Developing client-specific goals and outcomes comes after the assessment phase in the planning stage of the nursing process. While important, it is not the first action the nurse should take in this situation.
Choice C rationale:
Incorporating the treatment into the client's care occurs during the implementation phase of the nursing process and follows assessment and planning. This is not the first action.
Choice D rationale:
Determining whether coping strategies were successful is part of the evaluation phase of the nursing process, which occurs after the implementation of care. It is not the first step in this situation. Now, let's proceed to the final question.
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