The nurse is performing an abdominal assessment on a client. During the focused interview, the client stated that he had been experiencing some abdominal pain
As the nurse assesses the client, which of the following behaviors indicates that the client may be experiencing pain or anxiety during the examination? Standard Text: Select all that apply. 1. The client's respiratory rate is 26 per minute.
2. The client moves away from the nurse's hands.
3. The client grimaces.
4. The client pulls his knees toward his stomach.
5. The client coughs loudly.
1,2,3,4
Rationale 1: The client's respiratory rate is 26 per minute. If the client's respiratory rate increases during the examination, it can indicate that the client is experiencing pain or anxiety.
Rationale 2: The client moves away from the nurse's hands. The client may move away from the nurse during the examination if the client is experiencing pain.
Rationale 3: The client grimaces. Grimacing is a facial expression that can indicate that the client is experiencing pain during the assessment.
Rationale 4: The client pulls his knees toward his stomach. The client who exhibits guarding behavior is most likely experiencing pain.
Rationale 5: The client coughs loudly. The client who coughs loudly is not necessarily experiencing pain. This is not a typical expression of pain or anxiety.
You might also like to view...
The local clinic employs a Hispanic receptionist, who is also used as an interpreter for the many non-English-speaking Latino patients who utilize the clinic. Members of the staff believe the patients should learn English, and they have refused offers
from the receptionist to learn some basic phrases. Which behavior is the staff demonstrating about culturally competent care? 1. Cultural blindness. 2. Cultural incapacity. 3. Cultural destructiveness. 4. Cultural precompetence.
An infertile patient has been found to have unfavorable cervical mucus. The nurse should expect that the patient will receive:
a. estrogen. b. progesterone. c. HCG. d. FSH.
What should the nurse include in discharge teaching as the highest priority for the child with a cardiac dysrhythmia?
a. CPR instructions b. Repeating digoxin if the child vomits c. Resting if dizziness occurs d. Checking the child's pulse after digoxin administration
Which landmark is the dividing line between the anterior and posterior cervical triangles?
a. Clavicle b. Cervical spine c. Sternocleidomastoid d. Sternum