A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
Urinary retention
Constipation
Difficulty swallowing
Clenched teeth
The Correct Answer is D
Choice A Reason:
Urinary retention can be a side effect of opioids used in PCA, but it is not a direct indicator of unrelieved pain.
Choice B Reason:
Constipation is a potential side effect of opioid medications, but it does not directly indicate unrelieved pain.
Choice C Reason:
Difficulty swallowing is not a typical indicator of unrelieved pain but may be related to other factors such as postoperative effects or medication side effects.
Choice D Reason:
Clenched teeth can be an indicator of unrelieved pain in a client receiving patient-controlled analgesia (PCA). It suggests that the client is experiencing discomfort and may be trying to endure the pain rather than using the PCA pump to self-administer pain relief. Clients who are in pain may clench their teeth as a response to pain or discomfort.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Encouraging the client to be assertive is an important aspect of managing dependent personality disorder. It helps the client develop self-confidence, make independent decisions, and advocate for their own needs.
Empowering the client to express their opinions and assert their boundaries can contribute to their personal growth and reduce their reliance on others.
Correct Answer is A
Explanation
Choice A Reason:
Abnormal Involuntary Movement Scale is correct. The Abnormal Involuntary Movement Scale (AIMS) is a standardized tool used to assess and identify tardive dyskinesia, a side effect of antipsychotic medications. Tardive dyskinesia involves involuntary, repetitive movements, typically involving the face, mouth, and sometimes other body parts. Regular monitoring using the AIMS helps healthcare providers detect and evaluate the severity of these abnormal movements, allowing for appropriate management and intervention as needed.
Choice B Reason:
Mental Status Examination (MSE) is incorrect. The MSE is a comprehensive assessment of a person's mental state and cognitive function. While it is valuable for assessing a person's overall mental health and cognitive status, it is not specific for identifying tardive dyskinesia, which is a specific movement disorder.
Choice C Reason:
Brief Psychiatric Rating Scale (BPRS) is incorrect. The BPRS is a tool used to assess the severity of psychiatric symptoms and their changes over time. It is not specific for identifying the physical movements associated with tardive dyskinesia.
Choice D is incorrect:
Patient Health Questionnaire (PHQ) is incorrect. The PHQ is a self-report tool used to screen for symptoms of depression and anxiety. It is not designed for identifying movement disorders like tardive dyskinesia, which are characterized by abnormal physical movements.
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