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 D
Explanation
temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min. This set of vital signs indicates that the client may have an infection or sepsis, which are potential complications of an open cholecystectomy. The client has a fever, tachycardia, tachypnea, and hypotension, which are signs of systemic inflammatory response syndrome (SIRS).
Choice A is wrong because it shows mild hypothermia, hypotension, and tachycardia, which could be due to dehydration or blood loss, but not necessarily infection.
Choice B is wrong because it shows a slight fever, normal blood pressure, and bradycardia, which could be due to pain or medication, but not infection.
Choice C is wrong because it shows a low-grade fever, normal blood pressure and pulse, and mild tachypnea, which could be due to inflammation or dehydration, but not infection.
Correct Answer is C
Explanation
Orient the client to the arrangement of the room to promote independence. This strategy helps the client who is blind to navigate the environment safely and confidently. It also shows respect for the client’s autonomy and dignity.
Choice A is wrong because speaking loudly is not necessary for a client who is blind, unless they also have hearing impairment. Speaking loudly may imply that the client is less intelligent or capable, which is not true.
Choice B is wrong because touching the client prior to speaking may startle or frighten them. It is better to identify oneself verbally and ask for permission before touching the client.
Choice D is wrong because keeping the bed in the highest position may increase the risk of injury if the client tries to get out of bed alone. It also restricts the client’s mobility and independence, which may affect their self-esteem and quality of life.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.