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. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?

A. Administer pain medication
B. Use proper hand hygiene and strict infection control
C. Delegate all client personal care to specific unlicensed assistive personnel
D. Plate the client in contact precautions

Correct answer: B

Rationale:

3. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?

A. The client sets the cap down in a manner that does not contaminate it.
B. The client drops the prescribed number of drops into the conjunctival sac
C. The client washes their hands before instilling the drops
D. The client ensures that they touch the administration dropper to the eye

Correct answer: D

Rationale: Touching the dropper to the eye contaminates it and can lead to infection.

4. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?

A. 15 degrees
B. 0 degrees
C. 90 degrees
D. 30 degrees

Correct answer: C

Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.