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 A
Explanation
Choice A reason: The carotid pulse sites should not be checked bilaterally at the same time because palpating both carotid arteries simultaneously can restrict blood flow to the brain and may also stimulate the vagus nerve, potentially causing bradycardia or even syncope.
Choice B reason: The popliteal pulse, located at the back of the knee, can be checked bilaterally without the risk of restricting blood flow to vital organs or stimulating a vagal response.
Choice C reason: The femoral pulse, found in the groin area, can also be checked bilaterally as it does not pose the same risks as the carotid pulse when checked simultaneously.
Choice D reason: The brachial pulse, located on the inside of the arm just above the elbow, is another site that can be checked bilaterally without significant risk.
Correct Answer is A
Explanation
Choice A reason: Decreased energy is a common symptom of OSA due to disrupted sleep patterns and the body's struggle to maintain adequate oxygen levels during apneic episodes. This can lead to excessive daytime sleepiness and fatigue.
Choice B reason: While thyroid disease can be associated with sleep disorders, it is not a direct finding of OSA. However, hypothyroidism can contribute to the development of OSA due to myxedematous changes leading to airway obstruction.
Choice C reason: Pneumonia is not a direct finding of OSA. However, individuals with OSA may be at increased risk for respiratory infections due to repeated episodes of upper airway collapse during sleep, which can lead to aspiration.
Choice D reason: Hypotension is generally not associated with OSA. In fact, OSA is more commonly linked with hypertension due to the sympathetic nervous system activation that occurs with each apneic episode.
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