Question

A client is admitted to a medical unit rates their pain as a 6/10 in the right leg and groin. Which assessment finding(s) should the nurse recognize as an indicator of acute pain? Select all that apply.

Answer 1

Correct Answers:

Heart rate of 116
Blood pressure of 148/96
Increased agitation
Difficulty falling asleep

Rationale :

Heart rate of 116

🙌Correct. Tachycardia is a classic sign of acute pain due to sympathetic nervous system stimulation.

Blood pressure of 148/96

🙌Correct. Acute pain triggers elevated blood pressure through stress response activation.

Increased agitation

🙌Correct. Behavioral changes such as restlessness, agitation, and irritability are common in acute pain.

Difficulty falling asleep

🙌Correct. Pain often disrupts rest and leads to insomnia or poor sleep quality.

❌ Respiratory rate of 10

🙌Incorrect. A respiratory rate of 10 indicates bradypnea, which is not typical of acute pain.

🙌Acute pain usually causes increased respiratory rate, not decreased.

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Answer 2

Correct Answers:

Dilated pupils.
Increased heart rate.
increased blood flow to skeletal muscles.

Rationale :

Dilated pupils

👉Correct. Pupil dilation (mydriasis) occurs to improve visual awareness during stress.

Increased heart rate

👉Correct. Stress activates the sympathetic nervous system, leading to tachycardia to increase blood flow to vital organs and muscles.

Increased blood flow to skeletal muscles

👉Correct. Blood is redirected away from non-essential organs and toward skeletal muscles to prepare for “fight or flight.”

❌ Increased carbon dioxide retention

👉Incorrect. During stress, the body typically increases breathing rate to expel more CO₂, not retain it.

”❌ Decreased level of alertness

👉Incorrect. Stress typically causes increased alertness and heightened awareness, not decreased consciousness.

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Answer 3

Correct Answers:

Peripheral vasoconstriction and sweating

Rationale :

Peripheral vasoconstriction and sweating

✍️Acute pain activates the sympathetic nervous system (fight-or-flight response), leading to characteristic physiological changes such as increased heart rate, increased blood pressure, vasoconstriction, and diaphoresis (sweating).

❌ Increased gastrointestinal motility

✍️Incorrect. Acute pain typically causes decreased GI motility, leading to nausea, constipation, or reduced bowel activity.

❌ Decreased pupil size and dry mouth

✍️Incorrect. Acute pain causes pupil dilation (not constriction) and may increase sympathetic output rather than causing dry mouth as a primary sign.

❌Decreased muscle tension and tone

✍️Incorrect. Acute pain usually causes increased muscle tension, guarding, and rigidity, not relaxation.

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Answer 4

Correct Answers:

Check the medical record for a durable power of attorney for healthcare.

Rationale :

Check the medical record for a durable power of attorney for healthcare.

⭐Consent must be obtained from the legally authorized person, not automatically a family member.

⭐ If an adult child signs without legal authority, the nurse must first determine whether the client has designated a healthcare proxy or durable power of attorney (POA).

❌ Ask the patient to sign a new consent form

⭐This is not appropriate because the nurse must first confirm whether the patient is competent and legally able to consent.

⭐Jumping straight to re-signing may overlook legal documentation such as a POA.

❌ Proceed with care since the client is aware

⭐This is unsafe and violates legal/ethical standards.

Verbal agreement alone is not valid informed consent if the signature is not properly authorized.

❌ Document the consent form was previously signed and continue

⭐ This ignores a major legal discrepancy and could result in liability.

⭐The nurse must not proceed without proper consent.

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Answer 5

Correct Answers:

"I am unsure how I'll adjust to not having daily interactions at work."

Rationale :

I am unsure how I’ll adjust to not having daily interactions at work.”

👉This statement indicates a risk for social isolation because it reflects potential loss of daily social contact and workplace interaction, which are major sources of connection for many older adults transitioning into retirement.

❌ “I am planning to spend more time with family when our schedules allow.”

👉This suggests ongoing social engagement and support, which reduces risk for isolation.

❌ “I am looking forward to having more time to work on projects at home.”

👉This indicates positive engagement in meaningful activities, not isolation.

❌ “I am concerned about managing my finances on a fixed income.”

👉This relates to financial stress, not social connectedness or isolation.

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Answer 6

Correct Answers:

Intraoperative

Rationale :

Intraoperative

⭐The phase that occurs from admission to the surgical suite until transfer to the post-anesthesia care unit (PACU) is the intraoperative phase.

⭐This phase begins when the client enters the operating room and includes:

Anesthesia administration
Surgical procedure
Continuous monitoring during surgery
Ends when the client is transferred to PACU

❌ Postoperative

⭐This phase begins after PACU transfer, during recovery and healing.

❌ Rehabilitative

⭐This occurs after discharge and focuses on long-term recovery and function restoration.

❌ Preoperative

⭐This phase is before surgery, from decision for surgery up to entry into the operating room.

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Answer 7

Correct Answers:

"Tell me more about how your family is making you feel."

Rationale :

Tell me more about how your family is making you feel.”

👉This response uses therapeutic communication by encouraging the client to explore feelings openly.

👉 The client is expressing fear, sadness, and frustration, and the nurse’s role is to promote emotional expression without judgment or assumptions.

❌ “Let’s talk about your resentment toward your family.”

👉This is too interpretive and leading.

👉It assumes the client feels resentment, which may not be accurate and can shut down communication.

❌ “Have you shared your feelings with your family?”

👉This shifts focus away from the client’s current emotional expression and moves toward problem-solving too early.

❌ “I understand your anger. They shouldn’t treat you like that.”

👉This is non-therapeutic because it:

Introduces nurse judgment
May reinforce anger
Does not explore feelings further

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Answer 8

Correct Answers:

Managing symptoms and promoting comfort.

Rationale :

Managing symptoms and promoting comfort.

🙌At the end of life, the nurse’s highest priority is comfort care (palliative care).

🙌 This includes controlling pain, dyspnea, anxiety, nausea, and other distressing symptoms to ensure the client experiences a peaceful and dignified death.

❌ Maintaining a peaceful, quiet environment

🙌This is helpful but secondary to direct symptom management. Comfort must come first.

❌ Educating family members on the dying process

🙌Important, but not the priority over the client’s immediate physical comfort needs.

❌ Promoting client dignity and self-esteem

🙌Important holistic care goal, but it is part of broader care and not the immediate priority over symptom relief.

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Answer 9

Correct Answers:

"Physical therapy after discharge helps increase balance and strength."

Rationale :

“Physical therapy after discharge helps increase balance and strength.”

✅This is the most appropriate and therapeutic response because it focuses on rehabilitation and fall prevention, which are key concerns for older adults after a fall.

✅ Physical therapy helps improve strength, balance, and mobility, reducing the risk of future falls and promoting safe independence at home.

❌ “You should wait for the client to ask to be placed in a nursing home.”

✅This is inappropriate because it delays necessary discussion and ignores the family’s safety concerns. It is also non-therapeutic and dismissive.

❌ “Keeping the client busy and active will maintain their quality of life.”

✅This is too vague and does not directly address the specific concern of fall prevention or safety planning.

❌ “Consider permanently placing the client in a skilled nursing facility.”

✅This is premature and directive, and it removes client/family autonomy without assessment of other options.

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Answer 10

Correct Answers:

Ensure everyone is aware of the client's wishes moving forward

Rationale :

Ensure everyone is aware of the client's wishes moving forward

⭐The key principle here is client autonomy.

⭐A competent client has the legal and ethical right to refuse treatment, including removal from a transplant list and choosing palliative care.

⭐The nurse’s priority is to advocate for and uphold the client’s decision, ensuring the healthcare team is informed so the plan of care aligns with the client’s wishes.

❌ Ask the healthcare provider to order a social work consult

⭐This may be helpful for support services, but it does not directly ensure the client’s wishes are honored.

❌ Persuade the client to keep their name on the transplant list

⭐This is unethical and violates the principle of autonomy.

⭐The nurse must not attempt to influence the client’s decision.

❌ Connect the client with a chaplain

⭐Spiritual support can be beneficial, but it is not the priority action for respecting the client’s expressed decision.

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W8 NR226 Exam 2

No.

1 : A client is admitted to a medical unit rates their pain as a 6/10 in the right leg and groin. Which assessment finding(s) should the nurse recognize as an indicator of acute pain? Select all that apply.

Heart rate of 116

Blood pressure of 148/96

Increased agitation

Difficulty falling asleep

❌ Respiratory rate of 10

2 : A nurse is assessing a client's physiological response to stress. Which finding(s) should the nurse expect? Select all that apply.

Dilated pupils

Increased blood flow to skeletal muscles

❌ Increased carbon dioxide retention

👉Incorrect. During stress, the body typically increases breathing rate to expel more CO₂, not retain it.

”❌ Decreased level of alertness

3 : Which physiological reaction is associated with acute pain?

❌ Increased gastrointestinal motility

❌ Decreased pupil size and dry mouth

❌Decreased muscle tension and tone

4 : A nurse is implementing care to a preoperative surgical patient and notices the consent form was signed by the patient's adult child. What is the nurse's appropriate next step?

❌ Ask the patient to sign a new consent form

❌ Proceed with care since the client is aware

❌ Document the consent form was previously signed and continue

5 : The nurse is caring for an older adult preparing to enter retirement. Which statement made by the client indicates a risk for social isolation?

❌ “I am planning to spend more time with family when our schedules allow.”

❌ “I am looking forward to having more time to work on projects at home.”

❌ “I am concerned about managing my finances on a fixed income.”

6 : Which phase of the perioperative period occurs from admission to the surgical suite until transfer to the post anesthesia care unit (PACU)?

❌ Postoperative

❌ Rehabilitative

❌ Preoperative

7 : A client with terminal cancer tells their nurse, "I'm going to die, and I wish my family would stop hoping for a cure!" How should the nurse respond?

❌ “Let’s talk about your resentment toward your family.”

❌ “Have you shared your feelings with your family?”

❌ “I understand your anger. They shouldn’t treat you like that.”

8 : The nurse is caring for a client at the end of life. When planning the client's care, what intervention should the nurse prioritize?

❌ Maintaining a peaceful, quiet environment

❌ Educating family members on the dying process

❌ Promoting client dignity and self-esteem

9 : An older client suffered a fall. The client's family expresses concern for the client's safety once discharged. How should the nurse respond?

❌ “You should wait for the client to ask to be placed in a nursing home.”

❌ “Keeping the client busy and active will maintain their quality of life.”

❌ “Consider permanently placing the client in a skilled nursing facility.”

10 : A A client with end-stage renal disease wants to be removed from the kidney transplant list and focus on palliative care. What action should the nurse take to uphold the client's wishes?

❌ Ask the healthcare provider to order a social work consult

❌ Persuade the client to keep their name on the transplant list

❌ Connect the client with a chaplain

1 :
A client is admitted to a medical unit rates their pain as a 6/10 in the right leg and groin. Which assessment finding(s) should the nurse recognize as an indicator of acute pain? Select all that apply.

2 :
A nurse is assessing a client's physiological response to stress. Which finding(s) should the nurse expect? Select all that apply.

3 :
Which physiological reaction is associated with acute pain?

4 :
A nurse is implementing care to a preoperative surgical patient and notices the consent form was signed by the patient's adult child. What is the nurse's appropriate next step?

5 :
The nurse is caring for an older adult preparing to enter retirement. Which statement made by the client indicates a risk for social isolation?

6 :
Which phase of the perioperative period occurs from admission to the surgical suite until transfer to the post anesthesia care unit (PACU)?

7 :
A client with terminal cancer tells their nurse, "I'm going to die, and I wish my family would stop hoping for a cure!" How should the nurse respond?

8 :
The nurse is caring for a client at the end of life. When planning the client's care, what intervention should the nurse prioritize?

9 :
An older client suffered a fall. The client's family expresses concern for the client's safety once discharged. How should the nurse respond?

10 :
A A client with end-stage renal disease wants to be removed from the kidney transplant list and focus on palliative care. What action should the nurse take to uphold the client's wishes?