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 A
Explanation
A 37-year-old who has insulin-dependent diabetes mellitus has the greatest need for special mouth care. This is because diabetes can affect the blood vessels and nerves in the mouth, leading to dry mouth, gum disease, infections, and delayed healing. Special mouth care for this client would include regular brushing and flossing, using a soft toothbrush or foam brush, rinsing with water or saline, checking for signs of inflammation or infection, and avoiding sugary or acidic foods and drinks.
Choice B is wrong because a 58-year-old who wears dentures does not have a greater need for special mouth care than a diabetic client.
Dentures can be removed and cleaned with a soft toothbrush and denture cleaner, and soaked overnight in a denture solution. The gums and mouth should also be cleaned daily with a soft toothbrush or gauze.
Choice C is wrong because a 26-year-old who is on bed rest does not have a greater need for special mouth care than a diabetic client. Bed rest can cause dry mouth and plaque accumulation, but these can be prevented by regular brushing and rinsing, drinking water frequently, and using sugar-free gum or lozenges.
Choice D is wrong because a 45-year-old who is NPO (nothing by mouth) does not have a greater need for special mouth care than a diabetic client. NPO can cause dry mouth and bad breath, but these can be alleviated by regular rinsing with water or saline, applying water-based lip balm or moisturizer, and using artificial saliva products if needed.
Correct Answer is D
Explanation
Offer a glass of warm milk. According to some studies, warm milk may have a relaxing effect on the body and help induce sleep. It also contains tryptophan, an amino acid that is converted to serotonin and melatonin, which are neurotransmitters that regulate sleep cycles.
Choice A is wrong because a warm shower may increase the body temperature and make it harder to fall asleep.
Choice C is wrong because notifying the healthcare provider is not necessary for a client with insomnia unless there are other signs of distress or complications.
Choice D is wrong because watching television may stimulate the brain and interfere with the production of melatonin, a hormone that promotes sleep.
Some other nursing interventions for insomnia are:
- Educate the patient on the proper food and fluid intake such as avoiding heavy meals, alcohol, caffeine, or smoking before bedtime.
- Evaluate the patient’s sleep hygiene such as having a regular bedtime and wake-up time, avoiding naps during the day, and limiting exposure to light at night.
- Provide a conducive environment for sleep such as reducing noise, adjusting temperature and lighting, and using comfortable bedding.
- Help the patient develop a sleeping plan such as engaging in relaxing activities before bed, avoiding checking the clock, and getting out of bed if unable to sleep after 20 minutes.
- Understand the proper use of sleep aids or other medications such as following the prescription, avoiding over-the-counter drugs without consulting the provider, and being aware of the side effects and interactions.
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