The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?
Review the pain medications prescribed.
Monitor the client’s nonverbal behavior.
Administer PRN oral pain medication.
Ask the client what is causing the grimacing.
The Correct Answer is D
Choice A rationale
Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
Choice B rationale
Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.
Choice C rationale
Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
Choice D rationale
Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.
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Correct Answer is C
Explanation
Choice A rationale
Asking the client if they understand after each instruction may not be effective if the client is not comfortable expressing confusion or misunderstanding. It does not allow for direct observation of the client’s ability to perform the necessary tasks.
Choice B rationale
Having an interpreter repeat the wound care instructions may be helpful, but it still does not allow for direct observation of the client’s ability to perform the necessary tasks.
Choice C rationale
Having the client demonstrate prescribed wound care is the best way to evaluate the client’s understanding of self-care at home. This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.
Choice D rationale
Providing written instructions in the client’s native language may be helpful, but it does not allow the nurse to directly evaluate the client’s understanding.
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.