A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority?

Pain level

Pulse oximetry

Blood pressure

Level of sedation

Answer and Explanation

The Correct Answer is D

A) Pain level:
While assessing pain is important to determine the effectiveness of the pain management, it is not the immediate priority after administering an opioid.

B) Pulse oximetry:
Monitoring oxygen saturation is critical as opioids can depress respiratory function. However, it is indirectly related to the primary effect of the medication on the central nervous system.

C) Blood pressure:
Monitoring blood pressure is important as opioids can cause hypotension, but it is not as critical as monitoring the level of sedation and respiratory status.

D) Level of sedation:
This is the priority because opioids can cause significant sedation and respiratory depression. Assessing the level of sedation helps determine if the client is at risk of further complications like respiratory arrest. Over-sedation can be a precursor to more serious complications, making this assessment crucial.

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Correct Answer is D

Explanation

A) Irritable: Irritability is more closely associated with emotional responses to stress rather than cognitive responses. While irritability can be a manifestation of stress, it primarily reflects emotional tension rather than cognitive impairment.

B) Lethargic: Lethargy is a physical response to stress rather than a cognitive one. It refers to a lack of energy, motivation, or enthusiasm, which can result from stress-induced fatigue or exhaustion.

C) Angry: Anger is also primarily an emotional response to stress rather than a cognitive one. While stress can contribute to feelings of anger or frustration, it does not directly reflect cognitive impairment or alterations in cognitive functioning.

D) Decreased attention to detail: Cognitive responses to stress can include difficulty concentrating, decreased attention to detail, memory problems, and impaired decision-making. When a client demonstrates decreased attention to detail, it indicates cognitive impairment or distraction, which can be a response to stress. This behavior suggests that the client's cognitive functioning is affected by the stress they are experiencing.

A. "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most? “ B. "How has your husband reacted to the news? “ C. "Don't worry Many patients have had this same surgery and learn to manage very well. “ D. "You sound like you are in disbelief. Why do you feel this way?"

Correct Answer is A

Explanation

A. "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?": This response acknowledges the patient's feelings while offering reassurance that life can still be fulfilling after surgery. It also invites the patient to express their concerns, allowing the nurse to address specific worries and provide tailored support.

B. "How has your husband reacted to the news?": While understanding the patient's support system is important, this response does not directly address the patient's expressed feelings of disbelief and may not be the most immediate concern for the patient at this moment.

C. "Don't worry. Many patients have had this same surgery and learn to manage very well.": While meant to offer reassurance, this response may come across as dismissive of the patient's feelings of disbelief and anxiety about the upcoming surgery.

D. "You sound like you are in disbelief. Why do you feel this way?": This response acknowledges the patient's expressed emotion but may come across as confrontational or probing, potentially making the patient feel defensive. It's important to provide support and reassurance while inviting the patient to share their concerns in a non-threatening manner.

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A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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