Free NCLEX RN Practice Questions Practice Question
The nurse is doing a digital removal of stool for a client with a large fecal impaction resulting from opioid use when the client feels faint, and assessment of vital signs shows a marked decrease in pulse. Which of the following is the most likely reason for the change in pulse rate?
Correct Answer: A
Rationale: During digital removal of stool, stimulation of the vagus nerve can occur, leading to bradycardia, or a marked decrease in pulse rate. This physiological response is due to the vagus nerve's role in regulating heart rate.
Option B, onset of shock, is less likely as shock typically presents with tachycardia, not bradycardia. Option C, internal bleeding, would likely cause an increase in heart rate as the body attempts to compensate for blood loss. Lastly, while anxiety can affect heart rate, it usually results in tachycardia rather than a decrease. Thus, vagal stimulation during the procedure is the most plausible explanation for the observed change in pulse.
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