A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain? (Select all that apply)
Restlessness
Clenching
Grimacing
Drowsiness
Groaning
Correct Answer : A,B,C,E
Choice A reason: Restlessness can be a sign of discomfort or pain, especially in a postoperative client. It may manifest as constant shifting or an inability to remain still, indicating that the client is trying to find a position that alleviates the pain.
Choice B reason: Clenching, such as tightly gripping the handrails of the bed or making fists, can indicate that the client is trying to manage pain or discomfort through tension in the muscles.
Choice C reason: Grimacing, or making a pained facial expression, is a clear nonverbal cue of pain. It often involves furrowing the brow, closing the eyes tightly, or contorting the mouth.
Choice D reason: Drowsiness is not typically a direct indicator of pain. It may be related to medication effects, fatigue, or the body's response to healing post-surgery. However, it does not specifically signal pain.
Choice E reason: Moaning, groaning, or making other vocal sounds can be a response to pain, particularly in clients who are unable to articulate their pain verbally due to sedation or other factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Regular morning exercise can actually promote better sleep. It helps to regulate the body's clock and can lead to deeper, more restful sleep. However, exercising too close to bedtime may have the opposite effect.
Choice B reason: Going to bed at the same time every evening can help establish a consistent sleep-wake cycle, which is beneficial for people who have insomnia. This regularity can make it easier to fall asleep and wake up naturally.
Choice C reason: Alcohol consumption before bedtime can disrupt sleep patterns. While it may initially help someone fall asleep, it often leads to poorer quality of sleep and can cause awakenings throughout the night.
Choice D reason: If unable to sleep, getting out of bed can be a good strategy. It's part of stimulus control therapy for insomnia, which advises leaving the bed if you can't sleep, so you don't associate the bed with wakefulness
Correct Answer is C
Explanation
Choice A reason: Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is not an appropriate method for disposing of soiled dressings. This approach does not comply with standard infection control protocols, as it could potentially expose healthcare workers and others to biohazardous materials.
Choice B reason: Simply discarding the dressing in the bedside trash receptacle is also inappropriate and unsafe. This method does not contain the biohazardous material properly and could lead to contamination and spread of infectious agents.
Choice C reason: Placing the dressing in a biohazardous waste container is the correct method for disposing of dressings saturated with blood and purulent drainage. According to infection control guidelines, materials that are soaked with potentially infectious agents should be disposed of in designated biohazardous waste containers. These containers are typically red or yellow and are labeled to indicate that they contain materials that require special handling.
Choice D reason: Double bagging the dressing, labeling it "biohazard," and sending it for decontamination is an unnecessary step for routine disposal of soiled dressings. While double bagging may be used in situations where there is a significant spill or leak risk, it is not typically required for standard disposal of wound dressings.
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