A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc.
Which of the following findings should the nurse identify as an indicator of unrelieved pain?
Urinary retention
Constipation
Difficulty swallowing
Restlessness
The Correct Answer is D
Restlessness can be an indicator of unrelieved pain in a client who is receiving a spinal epidural to treat a herniated disc. Restlessness is often a manifestation of discomfort or agitation, which can be caused by inadequate pain management. When a client's pain is not adequately relieved, they may exhibit restlessness as they try to find a more comfortable position or seek relief from the discomfort.
Urinary retention (option A) is incorrect because it can be a side effect of certain medications used in pain management, such as opioids, but it is not a specific indicator of unrelieved pain. It is important to monitor for urinary retention as a potential complication of spinal epidural anaesthesia, but it is not directly related to pain relief.
Constipation (option B) is incorrect because it is another possible side effect of opioid medications, but it is not a specific indicator of unrelieved pain. It is important to address constipation as a potential adverse effect of pain management, but it is not a direct indicator of pain relief.
Difficulty swallowing (option C) is incorrect because it is not a common indicator of unrelieved pain in the context of a spinal epidural. It may be associated with other conditions or complications but is not specifically related to pain relief.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The response acknowledges the client's feelings and validates their experience without reinforcing or denying the delusion. It demonstrates empathy and invites further exploration of the client's concerns. Open-ended statements like this can encourage the client to express their thoughts and feelings, allowing for therapeutic communication and building trust between the client and nurse.
A. "The psychiatric staff is not FBI. They are here to help you." This response directly contradicts the client's belief and may lead to increased distrust or resistance. It is important to avoid directly challenging delusions or imposing one's own reality on the client, as it can escalate their distress.
C. "What makes you think the staff is following you?" While this response seeks more information, it may inadvertently reinforce or amplify the client's delusion. It could be interpreted as confirmation or validation of their belief, potentially increasing anxiety or paranoia.
D. "Why do you feel the staff is the FBI?" This response also seeks more information, but it may come across as challenging or dismissive. It could potentially trigger defensiveness or hostility in the client. It is important to approach the client's beliefs with empathy and respect rather than questioning or interrogating them.
Correct Answer is A
Explanation
RSV is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. To prevent the spread of RSV, it is important to implement droplet precautions. These precautions include wearing a mask and ensuring proper hand hygiene when in contact with the preschooler. This helps minimize the risk of transmitting the virus to other individuals.
Requesting an x-ray of the preschooler's neck is not indicated for RSV. RSV primarily affects the respiratory system, and an x-ray of the neck would not provide relevant information for the diagnosis or management of RSV.
Monitoring the preschooler's urine for protein is not specifically related to RSV. Proteinuria is not a typical manifestation or complication of RSV. Monitoring urine for protein is more relevant in conditions such as kidney disease or urinary tract infections.
Administering fluconazole to the preschooler is not indicated for RSV. Fluconazole is an antifungal medication used to treat fungal infections, and it would not be effective against a viral infection like RSV.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
                        
                            
