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

Answer and Explanation

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.

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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.

A. Discuss the client’s frequent questions with the family and health care provider. B. Respect the family’s wishes and deny the client has a terminal condition. C. Encourage the client to think positive thoughts and use distraction techniques. D. Honestly tell the client the condition is terminal so preparations can be made.

Correct Answer is A

Explanation

This is the most appropriate action because it respects the client’s right to know and the family’s right to privacy.

It also allows the nurse to collaborate with the family and the healthcare provider to provide the best care for the client.

Choice B is wrong because it violates the client’s autonomy and dignity.

It also prevents the client from making informed decisions about end-of-life care.

Choice C is wrong because it denies the reality of the situation and does not address the client’s concerns.

It also may increase the client’s anxiety and frustration.

Choice D is wrong because it disregards the family’s wishes and cultural values.

It also may cause harm to the client and the family by breaking their trust and creating conflict.

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The nurse is assessing a client experiencing acute pain. What assessments should validate the client with acute pain? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a client has a nursing diagnosis of Ineffective Coping, which nursing interventions would best meet the desired outcome of demonstrating appropriate coping strategies? (Select all that apply).

Correct Answer is ["A","C"]

Explanation

The family of a client that has been diagnosed with terminal cancer decided not to inform the client of the prognosis. What is the most appropriate action for a nurse to take when the client repeatedly asks about prognosis?

Correct Answer is A

Explanation

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The nurse is assessing a client experiencing acute pain.
What assessments should validate the client with acute pain? Select all that apply.