A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is a subjective indication that the client needs PRN pain medication?
The client's heart rate is 110/min.
The client is guarding their abdominal incision.
The client exhibits facial grimacing.
The client reports pain.
The Correct Answer is D
The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.
Explanation for the other options:
a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.
b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.
c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.
In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A nurse collecting data for a client following electroconvulsive therapy should expect that the client may experience confusion as an adverse effect. Confusion is a common side effect of electroconvulsive therapy and can last for minutes to hours after treatment.
The other options are not typical adverse effects of electroconvulsive therapy.
a) Vomitingis not a typical adverse effect of electroconvulsive therapy.
c) Incontinenceis not a typical adverse effect of electroconvulsive therapy.
d) Tinnitusis not a typical adverse effect of electroconvulsive therapy.
Correct Answer is C
Explanation
To elicit the Moro reflex, the nurse should clap hands after laying the newborn on a flat surface. The Moro reflex, also known as the startle reflex, is an involuntary motor response that infants develop shortly after birth. Loud noises and sudden movements can trigger a baby’s Moro reflex.
Option a is incorrect because turning the newborn's head quickly to one side while they are sleeping may not elicit the Moro reflex.
Option b is incorrect because placing a finger in the newborn's palm may elicit the grasp reflex, not the Moro reflex.
Option d is incorrect because holding the newborn upright with one foot touching the crib surface may not elicit the Moro reflex.
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