An older adult admitted for back surgery asks for opioid pain medication. The nurse knows the client asks for pain medication 30 minutes before it is due. Which recommendation should the nurse implement?
Teach the client alternative comfort measures
Tell the client that it is too soon for pain medication
Administer the pain medication as requested by the client
Validate the pain with other assessment data
The Correct Answer is D
Choice A reason: Teaching the client alternative comfort measures is not the best recommendation for the nurse to implement, as it may imply that the client's pain is not taken seriously or that the nurse is reluctant to provide pain relief. The nurse would teach the client alternative comfort measures, such as relaxation techniques, distraction, or massage, as a supplement to the pain medication, not as a substitute.
Choice B reason: Telling the client that it is too soon for pain medication is not a good recommendation for the nurse to implement, as it may make the client feel dismissed, ignored, or judged. The nurse would follow the prescribed pain medication schedule, but also consider the client's individual needs and preferences, and adjust the dosage or frequency as needed, with the doctor's approval.
Choice C reason: Administering the pain medication as requested by the client is not a safe recommendation for the nurse to implement, as it may cause overdose, addiction, or adverse effects. The nurse would administer the pain medication as prescribed by the doctor, and monitor the client's response, side effects, and vital signs.
Choice D reason: Validating the pain with other assessment data is the best recommendation for the nurse to implement, as it shows respect, empathy, and professionalism. The nurse would acknowledge the client's pain, ask about the location, intensity, quality, and duration of the pain, and use a pain scale or a pain assessment tool to measure the pain. The nurse would also check for any physical or behavioral signs of pain, such as grimacing, guarding, or restlessness. The nurse would document the pain assessment and report any changes or concerns to the doctor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Risk for injury is a potential nursing diagnosis for a client who recently experienced a stroke, but it is not the priority. Risk for injury is related to the possible complications of stroke, such as hemiparesis, hemiplegia, dysphagia, or sensory deficits, that may increase the risk of falls, aspiration, or pressure ulcers. However, these complications are secondary to the primary problem of altered cerebral perfusion, which is the cause of stroke.
Choice B reason: Altered cerebral perfusion is the priority nursing diagnosis for a client who recently experienced a stroke, because it is the most urgent and life-threatening problem. Altered cerebral perfusion is defined as a decrease in blood flow to the brain, which can result in ischemia, infarction, or hemorrhage of the brain tissue. This can lead to irreversible neurological damage, disability, or death. Therefore, the nurse should focus on restoring and maintaining adequate cerebral perfusion as the first priority.
Correct Answer is B
Explanation
Choice A reason: Over-the-counter NSAIDs are generally harmless is not a true statement, as NSAIDs can cause serious adverse effects in older adults, such as gastrointestinal bleeding, renal impairment, hypertension, and heart failure. NSAIDs should be used with caution and under medical supervision in older adults.
Choice B reason: Stool softeners and laxatives should be used with opioids is a true statement, as opioids can cause constipation in older adults, which can lead to discomfort, abdominal pain, fecal impaction, and bowel obstruction. Stool softeners and laxatives can help prevent and treat constipation and promote regular bowel movements.
Choice C reason: Opioids are less effective in older clients than in younger clients is not a true statement, as opioids can have the same or even greater analgesic effect in older adults, depending on the dose, route, and duration of administration. However, opioids can also cause more side effects in older adults, such as sedation, confusion, respiratory depression, and falls. Opioids should be used with caution and under medical supervision in older adults.
Choice D reason: The dose limit for acetaminophen is difficult to reach for older adults is not a true statement, as older adults may be more susceptible to acetaminophen toxicity, especially if they have liver disease, malnutrition, or chronic alcohol use. The dose limit for acetaminophen is 4 grams per day for adults, but it may be lower for older adults or those with risk factors. Acetaminophen should be used with caution and under medical supervision in older adults.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.