An adolescent hospitalized with sickle cell anaemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?
Introduce non-pharmacologic strategies for pain reduction.
Allow adequate privacy and time for the client's phone call.
Document the concern of incongruent pain rating and behaviour.
Administer pain medication per the healthcare provider's orders.
The Correct Answer is C
A. While non-pharmacologic strategies are important for pain management, they are typically introduced after initial assessment and understanding of the client's pain experience. In this case, the priority is to clarify the apparent discrepancy between the reported pain level and observed behavior.
B. Respecting the client's privacy and providing time for personal activities like phone calls is important but does not directly address the concern of incongruent pain assessment and behavior.
C. Incongruence between reported pain intensity (10/10) and observed behavior (laughing on the phone) suggests a potential discrepancy that needs to be documented and further investigated. This documentation is crucial for accurate assessment and communication among the healthcare team.
D. Administering pain medication immediately without further assessment may not be appropriate if there is uncertainty about the accuracy of the pain report. It's important to first clarify and validate the client's pain experience before proceeding with medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
No explanation
Correct Answer is ["C","D"]
Explanation
C. Albuterol: Albuterol is a bronchodilator that helps to relieve bronchoconstriction and improve airflow. It is commonly used to treat wheezing and respiratory distress in conditions like croup.
D. Racemic epinephrine: Racemic epinephrine is a vasoconstrictor and bronchodilator that can help reduce upper airway edema and improve breathing. It is often used in the treatment of croup to alleviate stridor.
Incorrect answers:
A. 5% dextrose: Dextrose is a type of sugar solution used for various purposes, including providing energy. However, it is not indicated for the immediate management of inspiratory stridor and respiratory distress.
B. Acetaminophen: Acetaminophen is a fever and pain reducer. While fever control might be important, it doesn't address the child's primary respiratory symptoms.
E. Morphine: Morphine is an opioid analgesic and can depress the respiratory drive. It is not indicated for the treatment of respiratory distress in a child with inspiratory stridor.
F. Aspirin: Aspirin is not recommended for use in children due to the risk of Reye's syndrome, a potentially serious condition. Additionally, aspirin does not address the child's respiratory symptoms.
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