A nurse is caring for a client who was admitted following a report of lumbar pain. In addition to administering pain medications, which of the following interventions should the nurse implement to promote comfort?

Present information honestly.

Have another nurse present difficult information.

Do not include the client's concerns in the plan of care if they interfere with treatment.

Perform cognitive behavioral therapy with the client.

Answer and Explanation

The Correct Answer is A

A. Presenting information honestly is an essential component of promoting comfort. Honest communication helps build trust, reduces anxiety, and empowers the client to participate in their care. Providing accurate information about their condition, procedures, and pain management options allows the client to feel informed and secure, which enhances overall comfort.

B. While involving another nurse may be appropriate in certain situations, it is not necessary for promoting comfort in most routine care. The primary focus should be on open and direct communication with the client, which fosters a therapeutic relationship.

C. Excluding the client’s concerns from the plan of care is not appropriate. Addressing the client’s emotional, psychological, and personal concerns is a key aspect of holistic comfort. Ignoring these needs can increase anxiety and reduce satisfaction with care.

D. Cognitive behavioral therapy (CBT) is a specialized intervention typically provided by trained mental health professionals. While it can be effective for chronic pain management, it is not a standard nursing intervention for promoting immediate comfort during hospitalization.

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Correct Answer is C

Explanation

A. Alprazolam is a benzodiazepine used primarily for anxiety and panic disorders. Benzodiazepines are generally not recommended as first-line sleep aids in older adults due to increased risk of falls, cognitive impairment, dependence, and respiratory depression.

B. Eszopiclone is a non-benzodiazepine sedative-hypnotic used for insomnia. While it is effective for sleep initiation and maintenance, it carries risks for older adults similar to benzodiazepines, including dizziness, confusion, and increased fall risk. Therefore, it is not considered a first-line option for older adults.

C. Melatonin is a hormone that regulates the sleep-wake cycle and is considered a first-line pharmacological sleep aid for older adults. It has a favorable safety profile, minimal risk of dependency, and is effective in correcting circadian rhythm disturbances often seen in older adults. It is preferred over sedative-hypnotics and antihistamines for this population.

D. Diphenhydramine is an over-the-counter antihistamine with sedative effects. It is not recommended for older adults due to its strong anticholinergic properties, which can cause confusion, urinary retention, constipation, and increased risk of falls.

A. Retrograde amnesia B. Urinary discomfort C. Dry mouth D. Hallucinations

Correct Answer is A

Explanation

A. Retrograde amnesia is a known adverse effect of nonbenzodiazepine hypnotics (such as zolpidem, zaleplon, and eszopiclone). These medications can interfere with memory formation during the night, particularly if the client engages in activities after taking the drug without getting a full night of sleep. Nurses should monitor clients for gaps in memory or unusual behaviors and provide education on taking the medication immediately before bedtime with adequate sleep time.

B. Urinary discomfort is not commonly associated with nonbenzodiazepine hypnotics. This symptom is more likely related to urinary tract conditions or medications such as anticholinergics.

C. Dry mouth is not a typical adverse effect of nonbenzodiazepine hypnotics; it is more commonly seen with tricyclic antidepressants or certain antihistamines.

D. Hallucinations are rare but possible, usually at higher doses or in sensitive populations; however, retrograde amnesia is far more common and a primary concern when monitoring clients starting these medications.

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A nurse is caring for a client who was admitted following a report of lumbar pain. In addition to administering pain medications, which of the following interventions should the nurse implement to promote comfort?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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