A nurse is assessing a newborn who had a circumcision 2 hr ago. Which of the following findings should the nurse identify as an indication that the newborn has acute pain?

Decrease in heart rate

Increase in vagal nerve tone

Decrease in respiratory rate

Increase in muscle tone

Answer and Explanation

The Correct Answer is D

A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to pain.

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Correct Answer is C

Explanation

A. Ask the client to tilt her head back when swallowing. Tilting the head back can increase the risk of aspiration. Clients with dysphagia should be instructed to tuck their chin to their chest when swallowing.
B. Offer the client larger portions of food during the meal. Smaller portions are safer for clients with dysphagia to reduce the risk of choking and aspiration.
C. Use spoons, instead of cups, when serving liquids to the client. This is correct. Using spoons can help control the amount of liquid the client receives, reducing the risk of aspiration.
D. Encourage the client to complete the meal within 15 min. Rushing a meal increases the risk of choking and aspiration. Clients with dysphagia should eat slowly and take small bites.

A. Liver failure B. Dehydration C. Immunosuppression D. Peripheral edema

Correct Answer is B

Explanation

A. Liver failure: Liver failure is not a common complication of Clostridium difficile infection.
B. Dehydration: Clostridium difficile causes severe diarrhea, which can lead to dehydration in the early stages.
C. Immunosuppression: Immunosuppression is not a direct complication of Clostridium difficile infection.
D. Peripheral edema: Peripheral edema is not commonly associated with Clostridium difficile infection.

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A nurse is assessing a newborn who had a circumcision 2 hr ago. Which of the following findings should the nurse identify as an indication that the newborn has acute pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has dysphagia at meal time. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who has a Clostridium difficile infection. The nurse should monitor for which of the following complications during the early stages of this infection?

Correct Answer is B

Explanation

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

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