A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.
The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

The correct answer is choice D. “I’ll think about my grandfather’s farm to reduce pain.” This statement indicates an understanding of guided imagery, which is a relaxation technique that aims to help lower the levels of stress hormones and pain perception by imagining a scene that involves each of the senses and positive emotions.

Guided imagery can help to distract from pain signals and reduce anxiety, which can also contribute to pain.

Choice A is wrong because it does not involve creating a specific imagined reality, but rather noticing the sensation of muscle tension, which may increase awareness of pain.

Choice B is wrong because it does not involve using all of the senses and emotions, but rather listening to music, which may be relaxing but not as effective as guided imagery for pain relief.

Choice C is wrong because it does not involve imagining a scene, but rather using focused breathing to control pain, which is another relaxation technique but not guided imagery.

This is because the nurse should first assess the client’s baseline knowledge and readiness to learn before providing any teaching.

The nurse should also tailor the teaching to the client’s individual needs and preferences.

Choice B is wrong because showing the client a video demonstration of peak flow meter use may not be the most effective way of teaching if the client has different learning styles or needs.

The nurse should also involve the client in the learning process and not just rely on passive methods.

Choice C is wrong because observing the client using the peak flow meter is an evaluation step that should be done after teaching and reinforcing the correct technique.

The nurse should not assume that the client knows how to use the peak flow meter without assessing their knowledge first.

Choice D is wrong because emphasizing the importance of the daily use of the peak flow meter is a motivational strategy that should be done after assessing the client’s knowledge and providing teaching.

The nurse should also explain the rationale and benefits of using the peak flow meter, not just tell the client to do it.

A peak flow meter is a small device that measures how fast a person can forcefully blow air out of their lungs in one fast breath.

It is one indicator of airways changes that may occur in people with asthma or COPD.

To get a peak flow meter, speak to a doctor.