After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

Provide comfort measures such as topical warm application and tactile massage.

Assist the client to ambulate as much as possible during waking hours.

Determine client's subjective measure of pain using a numerical pain scale.

Encourage increased fluid intake and measure urinary output every 8 hours.

Implement a 24-hour schedule of routine administration of prescribed analgesic.

Answer and Explanation

Correct Answer : A,C,E

Choice A Reason: This is correct because providing comfort measures such as topical warm application and tactile massage can help reduce pain perception and promote relaxation by stimulating non-painful sensory receptors.

Choice B Reason: This is incorrect because assisting the client to ambulate as much as possible during waking hours can increase pain intensity and fatigue by aggravating inflamed or injured tissues. The nurse should encourage moderate physical activity within the client's tolerance level.

Choice C Reason: This is correct because determining client's subjective measure of pain using a numerical pain scale can help assess pain severity and effectiveness of pain management interventions. Pain is a subjective experience that varies among individuals.

Choice D Reason: This is incorrect because encouraging increased fluid intake and measuring urinary output every 8 hours are not directly related to pain management. These interventions are more relevant for clients with fluid imbalance or renal impairment.

Choice E Reason: This is correct because implementing a 24-hour schedule of routine administration of prescribed analgesic can help maintain a steady level of analgesia and prevent breakthrough pain. Chronic pain requires continuous treatment rather than on-demand administration.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because palpating the suprapubic region for distention can be inaccurate and unreliable, as it can be affected by factors such as obesity, abdominal muscle tone, and bowel gas.

Choice B Reason: This is correct because scanning the client's bladder after voiding can measure the post-void residual urine volume, which indicates the amount of urine left in the bladder after urination. A high post-void residual urine volume can indicate urinary retention.

Choice C Reason: This is incorrect because reviewing the chart for number of voids over last 24 hours can provide information about the frequency of urination, but not the amount or completeness of urination.

Choice D Reason: This is incorrect because evaluating the client for urinary incontinence can assess the involuntary loss of urine, but not the ability to empty the bladder completely.

A. Measure temperature at regular intervals. B. Assess for flushed, warm skin regularly. C. Vary sites for temperature measurement. D. Document the client's circadian rhythms.

Correct Answer is A

Explanation

Choice A Reason: This is correct because measuring temperature at regular intervals allows the nurse to monitor fever patterns and evaluate the effectiveness of interventions.

Choice B Reason: This is incorrect because assessing for flushed, warm skin regularly is not a reliable indicator of fever. Skin temperature may vary depending on environmental factors and blood flow.

Choice C Reason: This is incorrect because varying sites for temperature measurement may result in inaccurate readings. Different sites have different normal ranges and may be affected by external factors.

Choice D Reason: This is incorrect because documenting the client's circadian rhythms is not relevant to assessing fever patterns. Circadian rhythms are natural fluctuations in body functions that occur over a 24-hour cycle.

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After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

Correct Answer is B

Explanation

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is A

Explanation

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