The client had surgery one day ago. What assessment is most likely related to pain?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Blood pressure of 175/90 mm Hg. Rationale: Post-surgery, pain can cause an increase in blood pressure due to the body's stress response. Elevated blood pressure is a common physiological response to pain as the body releases stress hormones that can lead to vasoconstriction, increasing blood pressure. Option B) Respirations of 10 breaths per minute is less likely related to pain as low respiratory rate is not a typical indicator of pain. Option C) Heart rate of 60 beats/minute is also less likely as pain usually causes an increase in heart rate due to sympathetic nervous system activation. Option D) Oxygen saturation of 97% is not directly related to pain assessment but is more indicative of oxygenation status. Educational Context: Understanding the physiological responses to pain is crucial for healthcare professionals to assess and manage post-operative care effectively. Recognizing the relationship between pain and vital signs helps in providing appropriate interventions to alleviate discomfort and ensure optimal recovery for the patient.

Correct Answer: C

Rationale: In the context of wound assessment, the correct answer is C) Heat. When documenting exudate from a wound, it is important to include details about the amount, consistency, and odor as they provide valuable information about the wound healing process and potential signs of infection. The option C) Heat is incorrect because heat is not typically associated with wound exudate. Heat is more indicative of inflammation or infection in the surrounding tissue rather than the characteristics of exudate itself. Educationally, understanding the components of wound assessment, including exudate characteristics, is crucial for nurses and healthcare professionals to monitor wound healing progress, detect early signs of complications, and provide appropriate interventions. By accurately documenting exudate features, healthcare providers can track changes in the wound over time and make informed decisions regarding wound care management.

Correct Answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.

Correct Answer: D

Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.

Correct Answer: A

Rationale: A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.