A nurse is assessing a client with severe pain in his lower back. The client's breathing becomes shallow when he is in pain. Which of the following autonomic nervous system responses should the nurse look for in the client?
A) Headache
B) Lethargy
C) Dilated pupils
D) Irritation
C
Feedback:
When dealing with clients whose pain is poorly controlled, the nurse should look for autonomic nervous system responses such as tachycardia, hypertension, dilated pupils, perspiration, pallor, rapid and shallow breathing, urinary retention, reduced bowel motility, and elevated blood glucose levels. Headaches, lethargy, and irritation are not autonomic nervous system responses.
You might also like to view...
You are caring for a client who tells you that she has been going to a healer to increase her energy level. She further states, "The healer uses his hands but never touches me"
You recognize that the client is most likely referring to which of the following? a. Yoga c. Acupuncture b. Reiki d. Tai chi
When providing care in the person's home, full visual privacy is needed
Indicate whether the statement is true or false.
List three goals of nursing care for neonates with congenital heart disease
What will be an ideal response?
A nurse administers an IV antihypertensive medication, causing an immediate reduction in blood pressure. The baroreceptors respond by attempting to return blood pressure back to normal by accelerating the heart rate
Which term will the nurse use when documenting this phenomenon? 1. Reflex tachycardia 2. Ventricular tachycardia 3. Re-entry tachycardia 4. Supraventricular tachycardia