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 D
Explanation
Choice A: Hematocrit is a measure of the proportion of blood volume occupied by red blood cells. While it can provide information about anemia or dehydration, it is not typically the first consideration in evaluating numbness and tingling in the extremities.
Choice B: Reviewing albumin and protein levels may be important for assessing overall nutritional status and potential causes of neuropathy but is not the immediate priority when a client reports numbness and tingling in the extremities.
Choice C: White blood cell count (WBC) is important for assessing immune function and the presence of infections. However, it is not typically the primary focus when evaluating numbness and tingling in the extremities.
Choice D: Electrolytes, such as serum sodium and potassium levels, are crucial to review when a client reports numbness and tingling in the extremities. Abnormal electrolyte levels can lead to neurological symptoms, and a review of electrolyte levels can help identify potential causes.
Correct Answer is ["B","D","E"]
Explanation
Choice A: Flavored gelatin can be a choice if the client enjoys it, but it should not be the primary source of nutrition as it lacks protein and other essential nutrients needed for healing.
Choice B: Eggs are a good source of protein, which is essential for tissue repair and healing.
Choice C: Soda crackers are low in protein and do not provide adequate nutrition for postoperative healing.
Choice D: Baked chicken is a lean source of protein and can be a part of a balanced postoperative diet.
Choice E: Salmon is rich in omega-3 fatty acids and protein, which can support the healing process and provide essential nutrients.
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