which assessment is not a nonverbal sing of pain

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. Which assessment is NOT a nonverbal sing of pain?

A. Decreased attention span
B. Grimacing
C. Increase in heart rate
D. Reported pain of 5/10

Correct answer: D

Rationale:

2. What is not a nursing intervention for a client with osteoporosis?

A. Nurse will encourage the intake of adequate amounts of calcium and vitamin D
B. Nurse will encourage the client to complete weight-bearing exercises
C. Nurse will encourage the client to avoid muscle strengthening exercises
D. Nurse will encourage the client to avoid repetitive movements

Correct answer: C

Rationale: The correct answer is C. Avoiding muscle strengthening exercises is not recommended for clients with osteoporosis; on the contrary, weight-bearing exercises are beneficial. Choice A is correct as ensuring adequate calcium and vitamin D intake is essential for bone health. Choice B is also correct as weight-bearing exercises help improve bone density. Choice D is incorrect because avoiding repetitive movements is not a standard nursing intervention for osteoporosis.

3. What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?

A. Fistula
B. Hemorrhage
C. Evisceration
D. infection

Correct answer: A

Rationale:

4. What is a priority intervention when caring for a client in Buck’s traction?

A. Adjust the size of the traction weights PRN as needed
B. Discontinue the traction once the client has pain relief
C. Ensure the traction weights rest on the floor
D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.