Identify two physical signs of unrelieved pain.

Heart rate.

Blood pressure.

Respiratory rate.

Answer and Explanation

Correct Answer : A,B

Choice A reason: Increased heart rate is a physical sign of unrelieved pain, as the sympathetic response elevates pulse. This aligns with pain assessment, making it a correct sign the nurse would identify in a patient experiencing uncontrolled pain during evaluation.

Choice B reason: Elevated blood pressure is a common sign of unrelieved pain due to stress-induced sympathetic activation. This aligns with pain assessment, making it a correct physical sign the nurse would expect in a patient with ongoing pain.

Choice C reason: Respiratory rate may increase with pain but is less consistent than heart rate or blood pressure, which are direct sympathetic responses. This is incorrect, as it’s less reliable compared to the nurse’s focus on heart rate and blood pressure.

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Correct Answer is A

Explanation

Choice A reason: Elevating the ankle above heart level reduces swelling from a soccer injury by promoting venous return. This aligns with acute injury management, making it the correct action the nurse would take to address edema in the emergency department effectively.

Choice B reason: Bearing weight on a swollen ankle risks further injury before assessment. Elevation reduces swelling, making this incorrect, as it’s unsafe compared to the nurse’s priority of minimizing edema and protecting the injured ankle in the ED.

Choice C reason: Warm packs increase swelling, worsening an acute injury. Elevation is appropriate, making this incorrect, as it contradicts the nurse’s goal of reducing edema in a swollen ankle using cold and elevation per standard injury protocols.

Choice D reason: Assessing passive ROM may cause pain or harm before swelling is controlled. Elevation is the priority, making this incorrect, as it delays the nurse’s initial action to reduce edema in an acutely injured ankle from a soccer injury.

A. Swallowing challenges. B. Weight gain. C. Obesity. D. Cardiovascular problems.

Correct Answer is A

Explanation

Choice A reason: Swallowing challenges (dysphagia) are common in Parkinson disease due to motor dysfunction, increasing aspiration risk. This aligns with PD care planning, making it the correct clinical problem for the nurse to include to ensure safe nutrition and prevent complications like pneumonia.

Choice B reason: Weight gain is not typical in PD; patients often lose weight due to dysphagia or increased energy expenditure. Swallowing challenges are a priority, making this incorrect, as it’s not a primary concern in the nurse’s care plan for Parkinson disease.

Choice C reason: Obesity is uncommon in PD, as motor symptoms and dysphagia often lead to weight loss. Swallowing challenges are more relevant, making this incorrect, as it’s not a clinical problem the nurse would prioritize in the care plan for PD.

Choice D reason: Cardiovascular problems may occur in PD but are less specific than swallowing challenges, which directly impact daily function. This is incorrect, as it’s secondary to the nurse’s focus on dysphagia as a key issue in Parkinson disease management.

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Identify two physical signs of unrelieved pain.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

Correct Answer is A

Explanation

Which clinical problem would the nurse include in the care plan for a patient with Parkinson disease (PD)?

Correct Answer is A

Explanation

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