A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?

Refer the family to a chronic pain support group.

Request a change in medication from the provider.

Review the child's electronic pain diary.

Set up an appointment with the school nurse.

Answer and Explanation

The Correct Answer is C

A.   Referring the family to a chronic pain support group may be beneficial but does not address the immediate need to assess the child's current condition and management.
B.   Requesting a change in medication from the provider may be necessary but should be based on a thorough assessment, including reviewing the child's pain diary.
C.   Reviewing the child's electronic pain diary allows the nurse to gather important information about the frequency, severity, triggers, and effectiveness of current interventions for migraine headaches, guiding further assessment and management.
D.   While involving the school nurse may be part of the child's care plan, it does not address the immediate need to assess the child's current condition and management.

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Correct Answer is B

Explanation

A. Skin integrity should be assessed more frequently, generally every 2 hours.

B. Continuous visual monitoring is required to ensure the safety and well-being of a client who is in mechanical restraints, to respond promptly to any distress or complications.
C. Restraints should be a last resort and not prescribed as needed.

D. The provider should evaluate the client sooner, typically within 1 hour of applying restraints.

A. Apply the patch within 1 hr of removing it from the protective pouch. B. Shave hairy areas of skin prior to application. C. Wear gloves to apply the patch to the client's skin. D. Remove the previous patch and place it in a tissue.

Correct Answer is C

Explanation

A. Transdermal nicotine patches should be applied immediately after removal from the protective pouch, but waiting for up to 1 hour is acceptable according to most manufacturers' instructions.
B. Shaving hairy areas of skin is not necessary prior to applying a transdermal nicotine patch and may cause skin irritation.
C. Wearing gloves during the application of the transdermal nicotine patch helps to prevent nicotine absorption through the nurse's skin and reduces the risk of accidental exposure.
D. The nurse should properly dispose of the previous patch according to facility protocols rather than placing it in a tissue, as used nicotine patches can still contain active medication and pose a risk of exposure.

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A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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