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: Maintaining protein intake and increasing intake of fruits and vegetables is generally a balanced and healthy approach to nutrition.
Choice B: Decreasing protein intake and eating more whole grains and vegetables may not be necessary unless there are specific dietary restrictions or medical indications.
Choice C: Increasing protein intake with additional dairy products may not be needed and depends on individual dietary preferences and nutritional goals.
Choice D: Maintaining protein intake but substituting fish and nuts for meat and eggs can be a balanced and healthy dietary choice. Fish and nuts can provide protein and healthy fats while reducing saturated fat intake from red meat and eggs.
Correct Answer is B
Explanation
Choice A: Pretzels are a carbohydrate-rich snack with a high glycemic index, which can lead to spikes in blood glucose levels. Choosing pretzels does not indicate a good understanding of the diet teaching to avoid refined sugar and carbohydrates.
Choice B: Avocado is a healthy choice for a client with Type 2 diabetes mellitus (DM) who wants to avoid refined sugar and carbohydrates. Avocado is a source of healthy fats, fiber, and other nutrients and has a low glycemic index.
Choice C: Potatoes are starchy vegetables that are high in carbohydrates, particularly when prepared in ways like mashed potatoes or fries. Choosing potatoes does not align with the goal of avoiding refined sugar and carbohydrates.
Choice D: Grapes are a fruit that contains natural sugars, and consuming them can affect blood glucose levels. Choosing grapes does not demonstrate an understanding of the need to avoid refined sugar and carbohydrates.
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