The nurse caring for a client diagnosed with pancreatic cancer understands that the key to effective pain management is: (SELECT ALL THAT APPLY)
pain control options should be appropriate to the setting.
delivery of pain relief interventions should be timely and logical.
asking about pain once a shift.
belief that pain is what the client reports it is.
most effective when provided by a team approach.
Correct Answer : A,B,D,E
A. Pain control options should be appropriate to the setting because different environments (e.g., home vs. hospital) may require different approaches to pain management, ensuring that the interventions align with the patient's needs and the context.
B. Timely and logical delivery of pain relief interventions is critical for effective pain management. Delays in treatment can lead to unnecessary suffering and complicate the overall management of the patient's condition.
C. Asking about pain only once a shift is insufficient for effective pain management. Pain can fluctuate frequently, especially in a client with cancer, so regular assessment is essential to address pain promptly.
D. Believing that pain is what the client reports it to be is fundamental to effective pain management. Pain is subjective, and clients' experiences and expressions of pain should be taken seriously to guide appropriate interventions.
E. A team approach is often the most effective for pain management, as it allows for a comprehensive plan that integrates multiple perspectives and disciplines, including nursing, medical, and possibly palliative care professionals, ensuring a holistic approach to managing pain.
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Correct Answer is C
Explanation
A. A lesion of cranial nerve IX primarily affects swallowing and taste sensations rather than motor coordination or balance, so this is unlikely to explain the patient's symptoms.
B. Vestibular disease typically results in vertigo and balance issues, but the specific observations of slow alternating movements and loss of balance during the Romberg Test suggest a different underlying cause.
C. Dysfunction of the cerebellum would explain the patient's difficulties with rapid alternating movements and balance issues, as the cerebellum is responsible for coordinating motor activity and maintaining posture and balance. This aligns with the assessment findings, indicating a probable cerebellar dysfunction.
D. While an AVM in the frontal lobe could affect motor control, the specific symptoms presented, such as the inability to perform rapid movements and balance issues, are more characteristic of cerebellar dysfunction rather than a frontal lobe lesion.
Correct Answer is C
Explanation
A. While being alert for non-verbal clues for pain or discomfort is important, it does not directly address the risk for ineffective airway clearance.
B. Answering for the client during rounds with the physician may compromise the client's ability to communicate their needs and concerns, which is not appropriate.
C. Assessment of the ability to cough and swallow is crucial for clients who have undergone oral surgery, as it directly relates to their airway clearance and safety in managing secretions.
D. Providing enough time for the client to respond is important for overall communication and comfort but does not specifically address the risk for ineffective airway clearance, which requires more targeted interventions.