A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan?
Instruct the client to take deep, rhythmic breaths.
Encourage the client to apply a heating pad for 2 hours at a time.
Apply an ice pack to the client’s back for 1 hour.
Remove distractions from the client’s room.
The Correct Answer is C
Choice A Reason:
Instructing the client to take deep, rhythmic breaths can help in managing pain by promoting relaxation and reducing muscle tension. Deep breathing exercises are a common nonpharmacological intervention for pain relief. However, for localized back pain, this method might not be as effective as applying an ice pack directly to the affected area.
Choice B Reason:
Encouraging the client to apply a heating pad for 2 hours at a time can provide relief by increasing blood flow and relaxing muscles. However, prolonged use of heat can sometimes exacerbate inflammation, especially if the pain is due to an acute injury. Therefore, it is generally recommended to alternate between heat and cold therapy.
Choice C Reason:
Applying an ice pack to the client’s back for 1 hour is effective in reducing inflammation and numbing the pain. Cold therapy is particularly useful in the initial stages of pain management as it helps to constrict blood vessels, reducing swelling and providing immediate pain relief. This method is often recommended for acute pain and injuries.
Choice D Reason:
Removing distractions from the client’s room can create a more restful environment, which may help in overall pain management. However, this action alone is unlikely to provide significant relief for localized back pain. It is more of a supportive measure rather than a primary intervention for pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
“Why do you feel upset about this?” is a response that opens up a dialogue and allows the nurse to express their feelings and concerns. It shows that the nurse manager is interested in understanding the nurse’s perspective and is willing to listen. This approach can help identify any underlying issues and work towards a resolution. It is important for managers to create an environment where employees feel heard and supported.
Choice B reason:
“You should be working harder.” is a dismissive response that does not address the nurse’s concerns. It can make the nurse feel undervalued and unappreciated, leading to decreased morale and job satisfaction. This response does not foster a supportive work environment and can exacerbate feelings of frustration and resentment. Effective management involves acknowledging employees’ efforts and addressing their concerns constructively.
Choice C reason:
“I will reprimand your team members.” is a response that may seem supportive at first glance, but it can create a negative work environment. Reprimanding team members without understanding the full context can lead to resentment and conflict within the team. It is important for managers to address performance issues in a fair and constructive manner, focusing on solutions rather than punishment.
Choice D reason:
“You must feel frustrated.” is an empathetic response that acknowledges the nurse’s feelings. It shows that the nurse manager understands the nurse’s frustration and is willing to listen. This response can help build trust and rapport between the nurse and the manager, creating a more positive and supportive work environment. Empathy is a key component of effective leadership and can help address and resolve workplace issues.
Correct Answer is C
Explanation
Choice A reason:
Dependent edema is not typically associated with extracellular fluid volume deficit. Edema usually occurs due to fluid overload or conditions that cause fluid retention, such as heart failure or kidney disease. In the case of extracellular fluid volume deficit, the body is losing more fluid than it is taking in, which would not result in edema. Instead, symptoms like dry skin, dry mucous membranes, and decreased skin turgor are more common.
Choice B reason:
Distended neck veins are also not a common finding in extracellular fluid volume deficit. Distended neck veins are usually seen in conditions where there is fluid overload or increased pressure in the venous system, such as heart failure or superior vena cava syndrome. In extracellular fluid volume deficit, the body is experiencing a reduction in fluid volume, which would not cause distended neck veins.
Choice C reason:
Postural hypotension, also known as orthostatic hypotension, is a common finding in extracellular fluid volume deficit. This condition occurs when there is a significant drop in blood pressure upon standing, leading to dizziness or lightheadedness. It is caused by the reduced blood volume, which decreases the amount of blood returning to the heart and subsequently lowers blood pressure.
Choice D reason:
Bradycardia, or a slow heart rate, is not typically associated with extracellular fluid volume deficit. In fact, the opposite is more likely to occur. Tachycardia, or a fast heart rate, is a common compensatory mechanism in response to fluid volume deficit as the body attempts to maintain adequate blood flow and pressure. Therefore, bradycardia would not be an expected finding in this scenario.
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