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 C
Explanation
A. This is a technique used for assessing the fundus and is not related to corneal reflexes.
B. This is used for general eye examination but does not specifically test corneal reflexes.
C. This tests the corneal reflex, where a blink response indicates the reflex is intact.
D. This is used for assessing corneal abrasions or ulcers but is not a method to test corneal reflexes.
Correct Answer is B
Explanation
A. Common allergic reactions but not specific to anaphylaxis.
B. Can be a sign of anaphylaxis, reflecting a systemic allergic response.
C. Anaphylaxis is more commonly associated with tachycardia.
D. Hives are a common allergic reaction and can occur in anaphylaxis, but they are not specific to it.
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