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
Explanation
Choice A rationale:
Constipation in a client on bedrest is a common issue, and one of the primary interventions is to increase fluid intake. Adequate hydration helps soften the stool, making it easier to pass, and can prevent constipation. This intervention is based on sound nursing principles and is the most appropriate choice.
Choice B rationale:
Encouraging the client to drink cold fluids is not a specific intervention for constipation. While staying hydrated is important, the temperature of the fluids is not as relevant to relieving constipation as the overall fluid intake.
Choice C rationale:
Requesting a prescription for mineral oil is not the first-line intervention for constipation. Mineral oil can have potential side effects and should only be used when other measures have failed. Increasing fluid intake and dietary fiber are typically the initial steps taken.
Choice D rationale:
Placing the client on a low-fiber diet is not an appropriate intervention for constipation. A low-fiber diet can exacerbate constipation by reducing the bulk and softness of the stool. This choice is counterproductive to addressing the issue.
Correct Answer is C
Explanation
Choice A rationale:
The "Region" in the PQRST mnemonic refers to the location of the pain. It helps identify where the pain is occurring in the body. While this information is important, it does not address the quality or nature of the pain, which is what the nurse is asking the client to describe.
Choice B rationale:
"Severity" in the PQRST mnemonic relates to how intense the pain is. It helps in assessing the degree of pain the client is experiencing, but it does not address the quality or nature of the pain, which is what the nurse is inquiring about.
Choice C rationale:
"Quality" in the PQRST mnemonic pertains to the description of the pain itself. It helps the nurse understand the characteristics of the pain, such as whether it is sharp, dull, burning, throbbing, etc. This information is essential for a more accurate assessment of the pain's underlying cause, making it the correct choice in this scenario.
Choice D rationale:
"Precipitating cause" in the PQRST mnemonic is concerned with what factors or actions might trigger the pain. While this information is valuable, it does not directly address the nature or quality of the pain, which is what the nurse is trying to assess.
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