Take full exam for free

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.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Contraction of the left pupil when light shines in the right eye. B. Basilar lung sounds that are diminished in the left lung. C. Active bowel sounds in the lower right quadrant. D. Capillary refill of 2 seconds in the lower right foot.

Correct Answer is B

Explanation

Choice A rationale

Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response and does not need to be documented in charting by exception. This finding is within normal limits and does not indicate any deviation from the expected outcome.

Choice B rationale

Basilar lung sounds that are diminished in the left lung should be documented because this finding deviates from the normal lung sounds and indicates a potential issue that needs further investigation. Charting by exception focuses on documenting abnormalities or deviations from the norm.

Choice C rationale

Active bowel sounds in the lower right quadrant are a normal finding and do not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

Choice D rationale

Capillary refill of 2 seconds in the lower right foot is a normal finding and does not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

A. Provide a back rub at bedtime. B. Apply wrist restraints to prevent wandering. C. Administer a PRN sedative prescription. D. Leave the door to the client’s room open slightly.

Correct Answer is D

Explanation

Choice A rationale

Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.

Choice B rationale

Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.

Choice C rationale

Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.

Choice D rationale

Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.

Take full exam for free

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.

Free Nursing Test Bank

Correct Answer is B

Explanation

Correct Answer is D

Explanation

Quick Links

Resources

Take full exam for free 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.

Free Nursing Test Bank

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is B

Explanation

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Correct Answer is D

Explanation

Which client assessment should the nurse perform during nasopharyngeal suctioning?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

The nurse is teaching a client how to do active range of motion (ROM) exercises.To exercise the hinge joints, which action should the nurse instruct the client to perform?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

The nurse is assessing a client who is having pain in the right upper abdominal area. To assess the quality of the client’s abdominal pain, which approach should the nurse use?

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to the client about sexual activity. Which approach is best for the nurse to use?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Quick Links

Resources

Take full exam for free

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.