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 two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”. This client may have a dehiscence or separation of the surgical wound, which is a serious complication that requires immediate attention.
The nurse should evaluate this client first and notify the surgeon.
Choice B is wrong because bile-colored fluid draining from a nasogastric tube is an expected finding after abdominal surgery and does not indicate an urgent problem.
The nurse should monitor the client’s fluid and electrolyte balance and provide antiemetics as needed.
Choice C is wrong because a three-day postoperative client who has an ileostomy and reports the need to have a bowel movement may have a paralytic ileus or a temporary cessation of bowel motility. This is a common postoperative complication that usually resolves within 72 hours.
The nurse should assess the client’s bowel sounds, abdominal distension, and ostomy output and encourage early mobilization and oral intake as tolerated.
Choice D is wrong because a three-day postoperative client who is receiving intravenous antibiotics for a wound infection may have a surgical site infection or an infection that occurs within 30 days of surgery. This is a preventable complication that can be managed with antibiotics, wound care, and infection control measures.
The nurse should monitor the client’s vital signs, wound appearance, and laboratory values and educate the client on signs and symptoms of infection.
Correct Answer is B
Explanation
Potassium is 3.0.
This is because furosemide is a loop diuretic that can cause hypokalemia (low potassium levels) as a side effect. Hypokalemia can lead to muscle weakness, cramps, cardiac arrhythmias, and digoxin toxicity. The normal range for potassium is 3.5 to 5.0 mEq/L.
Choice A is wrong because sodium is 144 is within the normal range of 135 to 145 mEq/L.
Choice C is wrong because chloride is 99 is within the normal range of 98 to 106 mEq/L.
Choice D is wrong because calcium is 5.0 is within the normal range of 4.5 to 5.5 mg/dL.
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