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
A heart murmur is a priority assessment for a toddler who is diagnosed with fetal alcohol syndrome because it may indicate a congenital heart defect, which can affect the child’s growth, development and oxygenation. According to the health search results, fetal alcohol syndrome can cause heart and kidney problems, among other complications.
Choice A is wrong because small head size is a common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has microcephaly, which is associated with intellectual and learning disabilities.
Choice B is wrong because poor coordination is another common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has problems with motor skills and balance.
Choice C is wrong because speech and language delays are also common features of fetal alcohol syndrome, but they are not a priority assessment. They indicate that the child has problems with communication and social skills.
Correct Answer is ["A","C"]
Explanation
These interventions help the client to cope with stress by enhancing their social support and teaching them skills to manage stressors.
Choice B is wrong because sedative hypnotics may cause dependence and do not address the underlying causes of stress.
Choice D is wrong because discussing factors that contribute to stress may increase the client’s anxiety and does not provide any solutions.
The normal range for coping is to use adaptive strategies that reduce stress and promote well-being.
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