The nurse is assessing a client experiencing acute pain.
What assessments should validate the client with acute pain? Select all that apply.
Restlessness.
Dilated pupils.
Constricted pupils.
Diaphoretic skin.
Increased respirations.
Decreased respirations
Correct Answer : A,D,E
These choices validate the client with acute pain because they are signs of a sympathetic nervous system response to pain. Acute pain is a sudden and usually sharp sensation that indicates tissue damage or injury.
Choice B is wrong because dilated pupils are not a sign of acute pain. Pupils may dilate in response to fear, excitement, or drugs.
Choice C is wrong because constricted pupils are not a sign of acute pain. Pupils may constrict in response to bright light, drugs, or brain damage.
Choice F is wrong because decreased respirations are not a sign of acute pain. Respirations may decrease in response to relaxation, drugs, or respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis.
The client may or may not need to use the bedpan depending on their fluid intake and output.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis.
The client may or may not need to vomit depending on their underlying condition.
Choice C is wrong because providing oral care every four hours is not enough for a client who has been diaphoretic for the past six hours. The client may have dry mouth and dehydration due to excessive sweating and may need more frequent oral care and hydration.
Correct Answer is C
Explanation
Chicken breast, green beans, and a glass of milk. This is because chicken breast is a good source of protein, which is essential for wound healing. Green beans are rich in vitamin C, which helps with collagen synthesis and immune function. Milk is a good source of calcium and vitamin D, which are important for bone health and healing.
Choice A is wrong because cheese pizza and french fries are high in fat and sodium, which can increase inflammation and delay wound healing. Orange juice is high in sugar, which can also impair wound healing and increase the risk of infection.
Choice B is wrong because cheeseburger and potato chips are also high in fat and sodium, and have similar effects as choice A. Soda is also high in sugar and can cause dehydration, which can slow down wound healing.
Choice D is wrong because spaghetti and meatballs are high in refined carbohydrates, which can spike blood sugar levels and impair wound healing.
A roll is also a refined carbohydrate and does not provide much fiber or nutrients. Chocolate pudding is high in sugar and fat, and can also worsen wound healing.
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