A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?
Cheyne-Stokes respirations
Mottled skin
Constricted pupils
Grimacing
The Correct Answer is D
Choice A reason: Cheyne-Stokes respirations, alternating hyperventilation and apnea, indicate neurological dysfunction or end-of-life changes in brain tumor patients, not pain. This reflects brainstem involvement, requiring respiratory management rather than analgesics, as it is a physiological response to disease progression in palliative care.
Choice B reason: Mottled skin signals poor perfusion or impending death, common in palliative care as circulation declines. It is not a pain indicator but a sign of systemic shutdown, requiring comfort measures like warmth, not analgesics, which are irrelevant to this physiological change in terminal illness.
Choice C reason: Constricted pupils may reflect opioid effects or neurological changes in brain tumor patients but do not directly indicate pain. They suggest autonomic or brainstem dysfunction, necessitating neurological assessment, not immediate pain medication, in palliative care where comfort is prioritized based on clear pain cues.
Choice D reason: Grimacing indicates pain in palliative care patients with brain tumors, reflecting physical discomfort. As a facial expression of distress, it signals the need for analgesics to improve comfort and quality of life, aligning with palliative goals to manage pain effectively in end-stage disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Amniocentesis involves needle insertion through the uterine wall, which can irritate the uterus and trigger contractions, risking preterm labor at 33 weeks. Monitoring contractions is vital to detect early labor signs, enabling interventions like tocolytics to delay delivery. This protects the premature fetus, ensuring better outcomes by maintaining pregnancy until closer to term.
Choice B reason: Vomiting is not a typical amniocentesis complication. The procedure is localized to the uterus, with minimal systemic effects. Nausea may occur from anxiety, but vomiting is rare and not a priority for monitoring. Focus remains on uterine and fetal complications, like contractions or fluid leakage, which directly impact pregnancy safety and outcomes.
Choice C reason: Hypertension is not directly linked to amniocentesis. The procedure does not typically affect maternal cardiovascular function, as it’s a localized intervention. Monitoring for hypertension is more relevant for conditions like preeclampsia. Post-amniocentesis, the priority is uterine activity and fetal distress, not blood pressure, making this an irrelevant complication to monitor.
Choice D reason: Polyuria is not associated with amniocentesis, as the procedure does not impact renal function or fluid balance. The focus is on complications like contractions, bleeding, or amniotic fluid leakage, which pose direct risks to the pregnancy. Monitoring polyuria is unnecessary, as it does not reflect the procedure’s physiological effects or risks.
Correct Answer is D
Explanation
Choice A reason: A 10-year budget is impractical for cost containment, as healthcare costs fluctuate due to economic and technological changes. Long-term budgets lack flexibility for staffing or equipment needs, making them ineffective for ensuring cost-effective care delivery in dynamic healthcare environments.
Choice B reason: Hiring travel nurses increases costs due to high salaries and agency fees compared to permanent staff. While addressing short-term shortages, it does not promote long-term savings, as temporary labor is expensive, contrasting with strategies like workforce planning for cost containment.
Choice C reason: Reducing training programs may lower short-term costs but risks errors and lawsuits, increasing long-term expenses. Well-trained staff improve efficiency and outcomes, reducing readmissions. Training is critical for cost containment, as it enhances care quality in healthcare settings.
Choice D reason: Electronic health records (EHRs) reduce long-term costs by streamlining documentation and improving care coordination. EHRs enhance billing accuracy and reduce errors, offsetting initial costs with decreased administrative burdens and better patient outcomes, aligning with evidence-based cost containment strategies in healthcare.
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