A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)
The client draws his legs up into a fetal position.
The facial muscles relax.
The respiratory rate increases.
The shoulders droop.
The pulse is within the expected range
Correct Answer : B,D,E
A. Drawing legs up into a fetal position may indicate discomfort or agitation.
B. Facial muscle relaxation is indicative of a therapeutic response to the massage.
C. An increased respiratory rate may suggest distress or discomfort.
D. Drooping shoulders suggest relaxation and a positive response to the massage.
E. Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Critical pathway provides a specific, timeline-based plan of care with expected outcomes and interventions, including activity levels.
B. Standards of care are important but may not offer specific guidance for the individual client's daily activity level.
C. Guidelines may provide general recommendations but may lack specificity.
D. This is general information source but not as specific or current as the institution's critical pathway.
Correct Answer is D
Explanation
A. Hypovolemic shock is typically associated with hypotension, not hypertension.
B. Hypovolemic shock usually leads to tachypnea as the body compensates for decreased oxygen delivery.
C. Purpura is not a common finding in hypovolemic shock.
D. Reduced urine output is a characteristic finding in hypovolemic shock due to decreased blood flow to the kidneys.
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