A nurse is caring for a client who reports a pain level of 5 on a scale from 0 to 10. The client informs the nurse that pain medications are not an
Option for managing pain. Which of the following is an appropriate response by the nurse?
"I'm sure it will work if you just give it a chance."
"You may take any herbal remedies you bring from home."
"Would you like me to give you a back massage?"
"Why do you think pain medication is not going to help you?"
The Correct Answer is C
If a client reports pain and informs the nurse that pain medications are not an option for managing their pain, the nurse can offer non-pharmacological interventions such as a back massage to help relieve the client's pain. This is an appropriate response by the nurse.
a. Telling the client that the pain medication will work if they just give it a chance is not an appropriate response as it dismisses the client's concerns and preferences.
b. The nurse should not recommend that the client take any herbal remedies without first consulting with the healthcare provider.
d. Asking the client why they think pain medication is not going to help them may be appropriate in some situations, but it is not necessarily the best initial response. The nurse should first offer non- pharmacological interventions to help relieve the client's pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["F"]
Explanation
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
Correct Answer is D
Explanation
A. Palpate the abdomen: Palpating the abdomen before auscultating bowel sounds could potentially alter the findings by stimulating peristalsis or causing discomfort in the client, particularly in cases of appendicitis or other acute abdominal conditions.
B. Administer an antiemetic:A thorough assessment, including auscultation of bowel sounds, is needed first to rule out conditions like a bowel obstruction or paralytic ileus where antiemetics may be contraindicated.
C. Offer pain medication:Pain medication can mask symptoms and interfere with the nurse's or physician's ability to accurately assess the underlying cause of the client's symptoms, such as appendicitis.
D. Auscultate bowel sounds:Auscultating bowel sounds is the first action the nurse should take because it is a non-invasive assessment that can provide critical information. It helps determine if bowel sounds are present, hyperactive, hypoactive, or absent, which can guide further interventions and diagnostic steps.
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