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
“I apologize for not hearing you say that. Is there a better day for you?”.
This response shows empathy and respect for the client’s feelings and preferences.
It also invites the client to collaborate on finding a solution that works for both parties. Choice A is wrong because it is rude and defensive.
It does not acknowledge the client’s frustration or offer any alternatives. Choice C is wrong because it is dismissive and paternalistic.
It does not respect the client’s autonomy or consider the client’s reasons for not being able to come back on Friday.
Choice D is wrong because it is persuasive and manipulative.
It does not address the client’s concerns or explore other options.
The nurse-client relationship is based on trust, respect, and collaboration.
The nurse should use therapeutic communication skills to maintain a positive rapport with the client and promote their health and well-being.
Correct Answer is C
Explanation
Step 1 is to convert the measurement of 1 tablespoon to milliliters. Step 2 is to use the standard conversion factor where 1 tablespoon is equivalent to 15 mL. Step 3 is the final calculation: 1 tablespoon × 15 mL/tablespoon = 15 mL.
The final calculated answer is 15 mL.
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