Which assessment finding should a nurse record as a symptom of pain? A client who:.
grimaces during a dressing change.
has an elevated heart rate while exercising.
is crying during a procedure.
says, “I feel achy all over.”.
The Correct Answer is A
A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.
The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.
Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.
Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.
The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.
Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.
Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.
The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should ask this question to support safe medication administration because the client is to receive medications that are highly teratogenic. Teratogens are substances that can cause congenital disorders and fetal abnormalities.
The nurse should avoid giving teratogenic medications to pregnant clients or clients who may become pregnant.
Choice A is wrong because the family history of cancer is not relevant to the teratogenic effects of the medications.
Choice C is wrong because the previous experience of severe side effects from a drug is not related to the risk of fetal harm.
Choice D is wrong because the allergy to any prescription or non-prescription drugs is not specific to the teratogenic potential of the medications.
Correct Answer is B
Explanation
Are you taking the medication as prescribed? This is because warfarin is a blood-thinning medication that affects the prothrombin time (PT) and the international normalized ratio (INR).
The PT measures how long it takes for blood to clot, and the INR is a calculation based on the PT that standardizes the results across different laboratories. A normal INR range is 0.8 to 1.1 for people who are not taking warfarin. People who take warfarin usually have a target INR range of 2 to 3, depending on their condition.
An INR of 0.8 means that the blood clots faster than normal, which increases the risk of blood clots and strokes.
This could indicate that the client is not taking enough warfarin or is taking other medications or foods that interfere with warfarin’s effect.
Choice A is wrong because bleeding gums are a sign of excessive bleeding, which could happen if the INR is too high, not too low.
Choice C is wrong because blood in stools is also a sign of excessive bleeding, which could happen if the INR is too high, not too low.
Choice D is wrong because unusual bruising is another sign of excessive bleeding, which could happen if the INR is too high, not too low.
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