Which assessment is a nonverbal sign of pain? (Select all that apply.)
Increased agitation
Decreased attention span
Grimacing
Reported pain of 5/10
Increase in heart rate
Correct Answer : A,C,E
Choice A reason: Increased agitation is a nonverbal sign of pain, because it indicates that the client is restless, uncomfortable, or distressed by the pain. Agitation can manifest as fidgeting, tossing, turning, moaning, or groaning.
Choice B reason: Decreased attention span is not a nonverbal sign of pain, but rather a cognitive or behavioral sign of pain. Decreased attention span means that the client has difficulty focusing, concentrating, or remembering things, which can be affected by pain. However, decreased attention span is not a direct expression of pain, but rather a consequence of pain.
Choice C reason: Grimacing is a nonverbal sign of pain, because it indicates that the client is experiencing facial muscle tension, contraction, or distortion due to the pain. Grimacing can manifest as frowning, wrinkling the forehead, pursing the lips, or clenching the teeth.
Choice D reason: Reported pain of 5/10 is not a nonverbal sign of pain, but rather a verbal sign of pain. Reported pain of 5/10 means that the client has communicated the intensity of their pain using a numerical scale, which is a subjective and selfreported measure of pain. However, reported pain of 5/10 is not a direct expression of pain, but rather a description of pain.
Choice E reason: Increase in heart rate is a nonverbal sign of pain, because it indicates that the client is experiencing physiological changes due to the pain. Increase in heart rate can manifest as tachycardia, palpitations, or arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Washing your hands thoroughly is an important measure to reduce the risk of infection. Hand washing is one of the most effective ways to prevent the transmission of germs that can cause diseases. Hand washing can remove dirt, bacteria, viruses, and other contaminants from the skin and prevent them from entering the body or spreading to others. The nurse should teach the client with AIDS to wash their hands frequently and properly, especially before and after eating, using the bathroom, touching their face, or handling any objects that may be contaminated.
Choice B reason: Avoiding cleaning your toothbrush with bleach is not a measure to reduce the risk of infection. Cleaning your toothbrush with bleach is not a recommended practice, as bleach is a harsh chemical that can damage the toothbrush and irritate the mouth. However, cleaning your toothbrush with bleach does not increase the risk of infection, as bleach can kill most germs that may be present on the toothbrush. The nurse should teach the client with AIDS to rinse their toothbrush with water after each use and replace it every 3 to 4 months or sooner if the bristles are worn or frayed.
Choice C reason: Avoiding raw fruits and vegetables is a measure to reduce the risk of infection. Raw fruits and vegetables may be contaminated with bacteria, parasites, or pesticides that can cause foodborne illnesses. The client with AIDS has a weakened immune system that cannot fight off these infections effectively and may develop serious complications, such as diarrhea, dehydration, or malnutrition. The nurse should teach the client with AIDS to wash, peel, or cook their fruits and vegetables before eating them and to avoid any that are bruised, moldy, or spoiled.
Choice D reason: Avoiding crowds is a measure to reduce the risk of infection. Crowds are places where many people gather and interact, such as public transportation, shopping malls, schools, or workplaces. Crowds increase the exposure to germs that can cause respiratory, gastrointestinal, or skin infections. The client with AIDS has a lowered resistance to these infections and may contract them more easily and severely. The nurse should teach the client with AIDS to avoid crowds as much as possible and to wear a mask, practice social distancing, and use hand sanitizer if they have to be in a crowded place.
Choice E reason: Not sharing toothpaste with family members is a measure to reduce the risk of infection. Sharing toothpaste with family members can transfer saliva, blood, or other body fluids that may contain germs that can cause oral, dental, or systemic infections. The client with AIDS is more susceptible to these infections and may also transmit the HIV virus to their family members through their body fluids. The nurse should teach the client with AIDS to use their own toothpaste and toothbrush and to store them separately from their family members' ones.
Correct Answer is D
Explanation
Choice A reason: Truck driver is not an occupation that increases the risk for carpal tunnel syndrome, because it does not involve repetitive or forceful flexion or extension of the wrist. Carpal tunnel syndrome is a condition that occurs when the median nerve, which runs through the carpal tunnel in the wrist, is compressed or irritated by inflammation, swelling, or pressure. Truck drivers may experience other musculoskeletal problems, such as back pain, neck pain, or shoulder pain, due to prolonged sitting, vibration, or poor posture.
Choice B reason: Nursing assistant is an occupation that increases the risk for carpal tunnel syndrome, but it is not the best answer, because it involves other factors besides repetitive motion that can contribute to the condition. Nursing assistants may perform repetitive tasks, such as lifting, transferring, or bathing patients, that can strain the wrist and the median nerve. However, they may also experience other risk factors, such as trauma, infection, arthritis, or pregnancy, that can cause carpal tunnel syndrome.
Choice C reason: Elementary school teacher is not an occupation that increases the risk for carpal tunnel syndrome, because it does not involve repetitive or forceful flexion or extension of the wrist. Elementary school teachers may perform some tasks, such as writing, typing, or grading papers, that can involve wrist movement, but they are not likely to be frequent or intense enough to cause carpal tunnel syndrome. Elementary school teachers may experience other stressrelated problems, such as headaches, fatigue, or burnout, due to the demands of their work.
Choice D reason: Assembly line worker is the best answer, because it is an occupation that increases the risk for carpal tunnel syndrome, due to the nature and duration of the work. Assembly line workers may perform repetitive, forceful, or awkward movements of the wrist, such as twisting, bending, or gripping, that can cause compression or irritation of the median nerve. Assembly line workers may also work for long hours, with little rest or variation, that can exacerbate the condition.
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