The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.
Determine client’s subjective measure of pain using a numerical pain scale.
Implement a 24-hour schedule of routine administration of prescribed analgesic.
Assist the client to ambulate as much as possible during waking hours.
Provide comfort measures such as topical warm application and tactile massage.
Encourage increased fluid intake and measure urinary output every 8 hours.
Correct Answer : A,B,D
Choice A rationale
Determine client’s subjective measure of pain using a numerical pain scale. Assessing the client’s pain using a numerical pain scale allows the nurse to understand the client’s perception of their pain and to monitor changes over time. This is a crucial step in managing chronic pain as it provides a baseline for evaluating the effectiveness of interventions.
Choice B rationale
Implement a 24-hour schedule of routine administration of prescribed analgesic. Chronic pain management often requires a consistent and routine administration of analgesics to maintain a stable level of pain control. This approach helps to prevent the peaks and troughs of pain that can occur with as-needed dosing.
Choice C rationale
Assist the client to ambulate as much as possible during waking hours. While ambulation can be beneficial for some clients, it may not be appropriate for all clients with chronic pain, especially if the pain is severe or if ambulation exacerbates the pain. Therefore, this intervention should be individualized based on the client’s condition.
Choice D rationale
Provide comfort measures such as topical warm application and tactile massage. Non- pharmacological interventions such as warm applications and massage can help to alleviate pain and improve comfort. These measures can be used in conjunction with pharmacological treatments to provide a more comprehensive approach to pain management.
Choice E rationale
Encourage increased fluid intake and measure urinary output every 8 hours. While maintaining adequate hydration is important, this intervention is not directly related to the management of chronic pain. It may be more relevant for clients with other conditions such as renal issues.
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Correct Answer is C
Explanation
Choice A rationale
Negligence would require proof that the nurse failed to act in a manner consistent with their training and that this failure directly caused harm to the victim. In this case, the nurse provided assistance and then left the scene after EMS arrived, which does not constitute negligence.
Choice B rationale
Assault and battery involve intentional harm or offensive contact, which is not applicable in this scenario as the nurse was providing assistance.
Choice C rationale
The Good Samaritan laws are designed to protect individuals who provide assistance at the scene of an emergency from legal liability, provided they act in good faith and within the scope of their training. In this scenario, the nurse acted to help the victim and then left the scene after EMS arrived, which is generally protected under Good Samaritan laws.
Choice D rationale
Abandonment would require that the nurse left the victim without ensuring that they were in the care of another competent individual. Since the nurse left after EMS arrived, this does not constitute abandonment.
Correct Answer is C
Explanation
Choice A rationale
Reviewing the advanced directive document is not an immediate action to address the client’s choking and vomiting. The priority is to clear the airway and prevent aspiration.
Choice B rationale
Irrigating the nasogastric tube with water is not appropriate in this situation as it may worsen the choking and does not address the immediate need to clear the airway.
Choice C rationale
Elevating the head of the bed 45 degrees helps to clear the airway and reduce the risk of aspiration by using gravity to keep the stomach contents down.
Choice D rationale
Performing oropharyngeal suctioning may stimulate gagging and vomiting, which can exacerbate the choking.