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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?

A.

Review the pain medications prescribed.

B.

Monitor the client’s nonverbal behavior.

C.

Administer PRN oral pain medication.

D.

Ask the client what is causing the grimacing.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Knowing when the client voided following catheter removal is crucial because it indicates the return of the client’s ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.

Choice B rationale

The time of the last dose of IV antibiotic administration is important for managing the client’s urinary tract infection, but it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.

Choice C rationale

Intake and output reports for the previous shift are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.

Choice D rationale

The color of the urine during catheter removal may provide some insight into the client’s urinary condition, but it is not as critical as knowing when the client voided after catheter removal to assess urinary function.

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.

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