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 ["A","B","C","D"]
Explanation
Pneumonia typically causes fever, tachypnea, increased heart rate, and reduced oxygen saturation. Treatment goals include reducing fever and infection, improving oxygenation, and relieving respiratory distress.
Rationale for correct answers:
A. Temperature: 37°C (98.6°F): This indicates that the fever has resolved, showing the antibiotics may be working and inflammation is decreasing.
B. Radial pulse: 98: The heart rate decreased from 112 to 98 bpm, reflecting reduced sympathetic response (less fever, improved oxygenation).
C. Respiratory rate: 18: A drop from 22 to 18 breaths/min indicates eased breathing, improved oxygen exchange, and reduced respiratory distress.
D. Oxygen saturation: 96%: An increase from 94% to 96% on 2 L oxygen suggests better gas exchange and alveolar function.
Rationale for incorrect answers:
E. Blood pressure: 134/78: Clinically stable but not the best indicator of pneumonia recovery. BP has remained within the normal range and is slightly lower than baseline (138/82).
Take-home points:
- Positive treatment outcomes in pneumonia include lowered fever, normalized respiratory rate, improved oxygen saturation, and decreasing heart rate.
- While blood pressure stability is important, it is less specific for tracking pneumonia recovery compared to respiratory and oxygenation parameters.
Correct Answer is B
Explanation
When nurses measure BP, they are not simply evaluating blood flow, but rather the pressure exerted by circulating blood on the walls of the arteries during the cardiac cycle.
Rationale for correct answer:
B. Force of blood against arterial walls: Blood pressure specifically refers to the force exerted by the blood on the walls of the arteries as the heart pumps. Systolic pressure is the peak force during ventricular contraction, while diastolic pressure is the residual force during relaxation.
Rationale for incorrect answers:
A. Flow of blood through the circulation: Blood pressure is related to blood flow but does not measure it directly.
C. Force of blood against venous walls: While venous pressure exists, it is much lower than arterial pressure and is not what is measured during routine BP assessment.
D. Flow of blood through the heart: This refers to cardiac output or blood volume, not pressure. Blood pressure reflects resistance and force in the arteries, not the amount of blood passing through the heart chambers.
Take-home points:
- Blood pressure is the force of blood against the arterial walls, not a direct measure of blood flow or heart volume.
- Accurate understanding of BP helps nurses assess for hypertension, hypotension, and perfusion status, and supports safe clinical decision-making.
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