A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessment?
An increase in the pulse rate
A decrease in body temperature
A decrease in blood pressure
An increase in respiratory depth
The Correct Answer is A
Pain, especially severe acute pain like abdominal pain, triggers a sympathetic nervous system (SNS) response, often referred to as the "fight or flight" reaction. This leads to measurable changes in vital signs.
Rationale for correct answer:
A. An increase in the pulse rate: Pain stimulates the sympathetic nervous system, resulting in tachycardia (increased heart rate).
Rationale for incorrect answers:
B. A decrease in body temperature: Pain does not typically cause a drop in temperature. Hypothermia is more likely in shock, exposure, or metabolic disorders-not as a direct result of pain.
C. A decrease in blood pressure: In the early stages of pain, the SNS response often causes a mild increase in blood pressure.
D. An increase in respiratory depth: Acute abdominal pain usually causes patients to take shallow breaths to minimize movement and discomfort (known as splinting).
Take-home points:
- Increased heart rate (tachycardia) is a common and expected physiological response to severe pain due to SNS activation.
- Nurses must interpret changes in vital signs in the context of the patient's symptoms to detect early signs of deterioration or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The hypothalamus is the primary center for thermoregulation. When a client sustains a head injury, especially involving the hypothalamus or brainstem, the body may lose its ability to properly regulate temperature. This can lead to a neurogenic fever, which is a non-infectious fever caused by damage to the thermoregulatory center.
Rationale for correct answer:
D. Ineffective thermoregulation: This nursing diagnosis reflects an actual disruption in temperature regulation due to neurological impairment. It encompasses both fever and hypothermia, making it the most comprehensive and accurate for this client.
Rationale for incorrect answers:
A. Risk for imbalanced body temperature: This diagnosis is used when the risk factors are present, but the condition has not yet occurred.
B. Hyperthermia refers to an elevated body temperature due to external heat or failure of heat loss mechanisms (e.g., heatstroke, environmental exposure).
C. Hypothermia is defined as a core body temperature below 35°C (95°F). There’s no indication that the client is hypothermic, and with the mention of neurogenic fever, the temperature is expected to increase, not decrease.
Take-home points:
- Ineffective thermoregulation is the most appropriate nursing diagnosis for clients with neurologically driven temperature abnormalities, such as neurogenic fever.
- Nurses must differentiate between external causes of hyperthermia and central (neurogenic) causes, especially in clients with head injuries.
Correct Answer is ["C","D","E"]
Explanation
In clients who have had a stroke, especially those with facial drooping, dysphagia (difficulty swallowing), or immobility, the nurse must choose a method of taking temperature that minimizes risk (e.g., aspiration or injury) and provides consistent, accurate readings.
Rationale for correct answer:
C. Axillary: Safe, noninvasive, and easy to perform even in clients with limited mobility. While it is less accurate than core sites, it’s a reasonable alternative when oral and rectal sites are contraindicated.
D. Tympanic: Quick, noninvasive, and reflects core temperature well. Not affected by oral or facial dysfunctions. Can be performed even when the client has limited cooperation.
E. Temporal artery: Noninvasive, fast, and generally well tolerated. Can be used in immobile or neurologically impaired clients without requiring cooperation.
Rationale for incorrect answers:
A. Oral: Oral temperature measurement requires the client to close their mouth tightly around the probe, which is compromised by facial drooping and dysphagia.
B. Rectal: While rectal temperature is accurate, it is invasive and can be uncomfortable, particularly in older or immobile clients.
Take-home points:
- Avoid oral and rectal routes in clients with neurologic deficits, swallowing issues, or limited mobility due to safety concerns.
- Axillary, tympanic, and temporal artery methods are safe, noninvasive, and appropriate for clients with stroke-related impairments.
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