A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Drowsiness.

Grimacing.

Screaming.

Moaning.

Restlessness.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale:

Drowsiness alone may not be a reliable indicator of pain, as it can result from various factors such as medications or the postoperative recovery process. While pain might cause drowsiness in some cases, it is not a definitive nonverbal sign of pain.

Choice B rationale:

Grimacing is a nonverbal behavior that often indicates pain or discomfort. It involves facial expressions of pain, such as frowning or wincing. Grimacing is a significant indicator that the nurse should consider in assessing the client's pain level.

Choice C rationale:

Screaming is a more overt expression of pain and discomfort. However, it is less common in a postoperative setting and might also be associated with anxiety or other emotional states. While it can indicate pain, it's not as reliable a marker as grimacing, moaning, or restlessness.

Choice D rationale:

Moaning is a nonverbal behavior that can signal pain in a postoperative client. It's an audible expression of discomfort and should be considered as a potential indication of pain.

Choice E rationale:

Restlessness can be an indication of pain as well. The client may shift positions frequently or exhibit signs of agitation in response to pain. However, restlessness can also have other causes, such as anxiety or medication effects.

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Correct Answer is A

Explanation

Choice A rationale:

Placing the client in airborne isolation is a priority because measles is highly contagious and spread through airborne droplets. Airborne precautions are necessary to prevent the transmission of pathogens that can remain suspended in the air for longer periods. Measles is known for its high infectivity, and isolating the client in a negative pressure room equipped with HEPA filtration can help prevent the spread of the virus to other patients and healthcare workers.

Choice B rationale:

While advising family members not to bring flowers into the room is a reasonable infection control measure, it is not the priority action in this scenario. The immediate concern is to prevent the spread of the highly contagious measles virus through airborne transmission.

Choice C rationale:

Obtaining a sputum sample for culture is not the priority action in this situation. Measles is a viral infection, and sputum cultures are typically used to identify bacterial infections. Additionally, the primary mode of transmission for measles is through airborne droplets, so preventing its spread takes precedence over obtaining a sputum sample.

Choice D rationale:

Placing the client on contact precaution is not the correct choice for managing measles. Measles is primarily transmitted through the airborne route, so airborne precautions, not contact precautions, are necessary to prevent its transmission.

A. "Do not adjust the oxygen flow rate.” B. "Check your oxygen equipment once each week.” C. "Store unused oxygen tanks horizontally.” D. "Use wool blankets on your bed.”

Correct Answer is A

Explanation

Choice A rationale:

Instructing the client not to adjust the oxygen flow rate is crucial to ensure the appropriate amount of oxygen is delivered. Oxygen flow rates are prescribed by a healthcare provider based on the client's needs, and altering the flow rate without medical guidance can lead to inadequate oxygen delivery or oxygen toxicity.

Choice B rationale:

Weekly equipment checks are important, but this choice is not the most critical instruction. Clients should be instructed to check their oxygen equipment daily for proper functioning and to address any issues promptly. Waiting a whole week could lead to potential problems going unnoticed.

Choice C rationale:

Storing unused oxygen tanks horizontally is incorrect. Oxygen tanks should be stored upright to prevent leaks and ensure proper functioning. Storing them horizontally can cause valve damage and leakage, which could lead to hazards.

Choice D rationale:

Using wool blankets on the bed is not a suitable instruction for a client using oxygen therapy. Wool blankets can generate static electricity, which might pose a fire hazard in the presence of oxygen-enriched environments.

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A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Nursing Test Bank

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