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
0.8.
To find the answer, you need to use the formula: Dose ordered / Dose available = Volume to administer
In this case, the dose ordered is 250,000 units and the dose available is 300,000 units/mL. So, you need to divide 250,000 by 300,000 and get 0.8333.
Then, you need to round it to one decimal place and get 0.8 mL. Choice A is wrong because it is too low.
If you administer 0.4 mL, you will give only 120,000 units of penicillin G benzathine, which is half of the prescribed dose.
Choice C is wrong because it is too high.
If you administer 1.2 mL, you will give 360,000 units of penicillin G benzathine, which is 44% more than the prescribed dose.
Choice D is wrong because it is also too high.
If you administer 1.6 mL, you will give 480,000 units of penicillin G benzathine, which is almost double the prescribed dose.
The normal range for penicillin G benzathine dosage depends on the type and severity of infection, but it is usually between 50,000 and 2.4 million units per injection.
Correct Answer is D
Explanation
This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.
Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.
Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.
Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.
Normal ranges for vital signs are as follows :
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg
- Breathing: 12 to 18 breaths per minute
- Pulse: 60 to 100 beats per minute
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
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