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. Fresh vegetables Fresh vegetables are generally not associated with triggering migraines.
B. Frozen yogurt While some people may have individual triggers, frozen yogurt is not a common migraine trigger.
C. Red wine: Red wine contains tyramine, which is known to trigger migraines in many people.
D. Orange juice Orange juice is not commonly associated with triggering migraines.

A. Keep the client's bed in its highest position with the side rails up. B. Provide adult diapers for the client to wear while in bed. C. Store the client's personal possessions in the closet in her room. D. Ask the client to give a return demonstration of how to use the call light.

Correct Answer is D

Explanation

A. Keep the client's bed in its highest position with the side rails up. Keeping the bed in its highest position increases the risk of falls, especially for a client with urinary incontinence who may attempt to get up quickly. This does not adhere to safety guidelines.
B. Provide adult diapers for the client to wear while in bed. While providing diapers may be necessary, it is not the primary safety intervention. It is more important to address the client's mobility and ensure they can safely access the bathroom.
C. Store the client's personal possessions in the closet in her room. Keeping the room tidy and ensuring personal items are stored safely can reduce clutter and fall risks but does not directly address incontinence management or safety goals.
D. Ask the client to give a return demonstration of how to use the call light. Ensuring the client knows how to use the call light is crucial for safety. It allows them to call for assistance when needed, reducing the risk of falls when they need to use the bathroom.

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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 providing nutritional teaching to a client who has chronic migraine headaches. The nurse should inform the client that which of the following dietary items can trigger a migraine?

Correct Answer is C

Explanation

A nurse in a long-term care facility is admitting a client who has occasional urinary incontinence. To adhere to The Joint Commission's National Patient Safety Goals, which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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