An adult client reports incision pain rated 8/10 two hours after surgery, which systemic response should the nurse expect to find on physical assessment?
Heart rate 54 beats/min, blood pressure 88/50 mm Hg, respiratory rate 10 breaths/min, warm dry skin.
Heart rate 76 beats/min, blood pressure 118/72 mm Hg, respiratory rate 16 breaths/min, pinpoint pupils.
Heart rate 68 beats/min, blood pressure 110/70 mm Hg, respiratory rate 18 breaths/min, moist warm skin.
Heart rate 113 beats/min, blood pressure 150/92 mm Hg, respiratory rate 24 breaths/min, cool clammy skin.
The Correct Answer is D
Choice A reason: These vital signs indicate bradycardia, hypotension, and bradypnea. This is more characteristic of a parasympathetic response, shock, or opioid overdose rather than an acute pain response. Acute pain typically triggers the "fight or flight" mechanism, which would cause these values to increase rather than decrease.
Choice B reason: These values represent a normal, stable hemodynamic state (euthermia, normotension, and normal heart rate). A patient reporting severe pain (8/10) would unlikely exhibit such baseline vitals. Furthermore, pinpoint pupils are often a sign of opioid toxicity rather than a physiological reaction to an acute painful stimulus.
Choice C reason: While these readings are within normal ranges, they do not reflect the physiological stress associated with severe post-surgical pain. Severe pain stimulates the sympathetic nervous system, leading to measurable changes in vital signs that reflect the body's acute stress response to the perceived injury or trauma.
Choice D reason: Severe acute pain triggers the sympathetic nervous system, resulting in tachycardia, hypertension, and tachypnea. The "fight or flight" response causes peripheral vasoconstriction and diaphoresis, which manifests as cool, clammy skin. These findings correlate accurately with the physiological stress of a high pain intensity rating like 8/10.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A problem-focused or emergency-based assessment prioritizes the collection of data strictly related to a specific, urgent medical issue. In cases of respiratory distress, the nurse bypasses broad history-taking to focus immediately on airway patency and gas exchange to facilitate rapid life-saving interventions and stabilize the patient's acute condition.
Choice B reason: A follow-up assessment is conducted after an initial diagnosis or intervention to evaluate the effectiveness of a treatment plan. Because this patient is presenting with a new, acute emergency in the department, the nurse is not evaluating previous care but is instead triaging and managing an active, critical situation.
Choice C reason: Psychosocial history focuses on the patient's mental health, social support systems, and lifestyle factors. While important in a holistic care plan, gathering this data during an acute respiratory crisis is inappropriate and potentially dangerous, as it delays the critical physical interventions needed to restore oxygenation and ventilation.
Choice D reason: A comprehensive health assessment involves a detailed head-to-toe examination and a complete medical history. This is typically performed during a baseline admission or annual physical. In an emergency setting with a cyanotic patient, there is insufficient time for a comprehensive review; the priority remains focused physiological stabilization.
Correct Answer is C
Explanation
Choice A reason: Restating is a specific communication technique where the nurse repeats the patient's message back using similar words. While it serves to validate that the nurse heard the patient, it is a localized tool rather than the overarching foundation upon which the entire therapeutic relationship and information exchange are built.
Choice B reason: Summarizing involves condensing the key points of a conversation into a brief overview. This is useful for closing an interview or ensuring mutual understanding of a complex plan, but it lacks the continuous, empathetic engagement required to truly connect with the patient's underlying emotional or physical concerns.
Choice C reason: Active listening is the core foundation of all therapeutic interactions. It involves fully attending to the patient's verbal and nonverbal cues without judgment. By giving undivided attention, the nurse fosters trust, encourages the patient to share sensitive information, and identifies subtle clinical nuances that might otherwise be overlooked.
Choice D reason: Paraphrasing is the act of rephrasing the patient's words into the nurse's own language to clarify meaning. Like restating, it is a valuable verification technique, but it is considered a supportive skill. It cannot be effectively performed without the primary, comprehensive application of active listening skills first.
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