A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

Inform the client that the position must be changed, and then you will give her pain medication and omit the bath.

Inform the client that she will feel better after receiving a bath and clean sheets.

Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration.

Obtain the pain medication and delay the bath and position change until the medication reaches its peak.

Answer and Explanation

The Correct Answer is D

A. Inform the client that the position must be changed, and then you will give her pain medication and omit the bath: Changing the client’s position before providing pain relief can exacerbate discomfort and anxiety. Pain should be managed prior to any interventions that may cause further distress.
B. Inform the client that she will feel better after receiving a bath and clean sheets: While hygiene and comfort are important, suggesting a bath will make the client feel better without addressing their pain first minimizes the severity of their symptoms and lacks therapeutic empathy.
C. Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration: Although this acknowledges the need for pain control, it still implies the procedures will begin immediately after medication administration, not allowing time for the analgesic to take effect.
D. Obtain the pain medication and delay the bath and position change until the medication reaches its peak: This is the most appropriate action. Administering pain medication first and allowing it to reach peak effectiveness ensures the client experiences less pain during movement and hygiene care, which demonstrates a compassionate, patient-centered approach.

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Correct Answer is C

Explanation

A. Metabolic alkalosis: This condition results from excess bicarbonate or loss of acids through vomiting or diuretics. It is not associated with rapid, shallow breathing, especially in the early phase of heart failure.
B. Metabolic acidosis: Typically seen in states of increased acid production or bicarbonate loss, such as in renal failure or diarrhea. It is not the expected initial response to hyperventilation caused by early heart failure.
C. Respiratory alkalosis: Rapid, shallow breathing (tachypnea) leads to excessive exhalation of CO₂, resulting in decreased carbonic acid and increased blood pH. This is the typical early blood gas finding in acute heart failure due to hypoxia-driven hyperventilation.
D. Respiratory acidosis: This occurs when CO₂ is retained due to hypoventilation. Since the client is hyperventilating rather than hypoventilating, respiratory acidosis would not be present initially.

A. Being present without speaking B. Presenting the reality of the situation C. Allowing the client freedom in a confined area D. Speaking in slow, brief sentences

Correct Answer is B

Explanation

A. Being present without speaking: Remaining quietly present can be grounding and non-threatening to disoriented clients. It helps establish a calming environment and builds trust without increasing sensory input.
B. Presenting the reality of the situation: Confronting a disoriented or psychotic client with reality may escalate agitation and aggression. Challenging their perception can feel threatening and lead to increased resistance or hostility.
C. Allowing the client freedom in a confined area: Providing limited autonomy in a safe space can reduce feelings of powerlessness. It supports de-escalation by allowing the client some control while ensuring safety.
D. Speaking in slow, brief sentences: Clear, simple communication helps reduce cognitive overload in disoriented clients. It decreases anxiety and supports comprehension, making it a key strategy in managing agitation.

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A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

Nursing Test Bank

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