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 A
Explanation
a. To ensure accurate identification and avoid medication errors, the nurse should use at least two patient identifiers, such as the client's full name and date of birth. This information is critical in verifying that the right patient receives the correct medication.
b.While a telephone number could potentially be used as an identifier, it is not typically used in acute care settings due to the possibility of errors or outdated information. It is also not practical as a primary means of patient identification.
c.Knowing the client's room number is important to confirm the correct location of the client in the acute care setting. This helps ensure that the nurse administers the medications to the correct client. However, the room number alone is not sufficient for accurate client identification. Room numbers may change, and multiple clients may share the same room. Relying on the room number alone can lead to errors.
d.While the client's diagnosis is important for understanding their medical condition and providing appropriate care, it is not specifically required for identifying the client when administering medications.
Correct Answer is C
Explanation
The shoulder harnesses of the car seat should be adjusted to fit the infant properly. The straps should be positioned at or below the level of the infant's shoulders to ensure a secure fit and proper restraint.
Infants should always be placed in a rear-facing car seat in the back seat of the vehicle. If the car seat is placed in the front seat, the airbag should be turned off to prevent potential harm to the infant in case of airbag deployment.
Do not put a small cushion under the newborn's head for support: It is important to follow the manufacturer's guidelines for the specific car seat being used. Additional cushions or supports should not be added to the car seat as they can interfere with the proper fit and safety of the seat. The infant's head should be supported by the car seat itself.
Infants should be placed in a rear-facing car seat at a reclined angle of approximately 45 degrees. This helps to keep the infant's airway open and provides proper support for their head and neck.
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