An adolescent hospitalized with sickle cell anemia 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 behavior.
Administer pain medication per the healthcare provider's orders.
The Correct Answer is B
Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.
Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.
Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.
Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Performing a fundal massage is the first priority in this situation to assess and manage uterine tone and prevent postpartum hemorrhage.
Choice B: Drawing blood for hemoglobin and hematocrit can be important but is not the immediate priority when the client has just delivered outside the hospital.
Choice C: Obtaining a complete obstetrical history is important but can be done after addressing the immediate postpartum concerns.
Choice D: Inspecting the perineum for lacerations is also important but should be done after addressing uterine tone and hemorrhage prevention.
Correct Answer is C
Explanation
Choice A: A pureed regular diet may not provide enough nutritional support for a client who has lost 25% of their body weight and is experiencing stomatitis. This diet may not have the necessary nutrients to address the client's nutritional needs.
Choice B: A high protein soft diet may be appropriate for some clients, but it may still be challenging for a client with stomatitis to consume. Additionally, the focus should also be on providing adequate overall nutrition, not just protein.
Choice C: A mechanical soft diet is often recommended for clients with stomatitis because it provides foods that are easier to chew and swallow while still offering a variety of nutrients. It is a suitable option for clients who have difficulty eating due to oral mucositis (stomatitis).
Choice D: A low residue diet may not provide sufficient nutrients for a client who has lost 25% of their body weight and is experiencing difficulty eating due to stomatitis. This diet may be too restrictive for their nutritional needs.
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