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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.

Question Solution

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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A. Tilt the pelvis forwards and backwards. B. Turn the head to the right and left. C. Bend the arm by flexing the ulnar to the humerus. D. Extend the arm at the side and rotate in circles.

Correct Answer is C

Explanation

Choice A rationale

Tilting the pelvis forwards and backwards exercises the pelvic joints, not the hinge joints.

Choice B rationale

Turning the head to the right and left exercises the neck joints, not the hinge joints.

Choice C rationale

Bending the arm by flexing the ulnar to the humerus exercises the hinge joints, such as the elbow, which is a hinge joint.

Choice D rationale

Extending the arm at the side and rotating in circles exercises the shoulder joint, which is a ball-and-socket joint, not a hinge joint.

A. Verify placement of pulse oximeter. B. Increase the oxygen to 3 L/minute. C. Switch to a non-rebreather mask. D. Remove nasal cannula. E. Remove nasal cannula.

Correct Answer is A

Explanation

Choice A rationale

Verifying the placement of the pulse oximeter is the first step to ensure the accuracy of the oxygen saturation reading. An incorrect placement can lead to inaccurate readings, and addressing this issue can help determine if further interventions are needed.

Choice B rationale

Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, this should be done after ensuring the accuracy of the initial reading.

Choice C rationale

Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low.

Choice D rationale

Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient. The goal is to improve oxygenation, not reduce it.

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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.

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Correct Answer is C

Explanation

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Explanation

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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.