Exhibits
The nurse is evaluating the effectiveness of pain interventions for Mrs. Thompson who is unconscious and at the end of life. Which of the following methods is the most appropriate for assessing pain management effectiveness in this client?
Requesting feedback from the patient's family about the patient's comfort.
Monitoring changes in vital signs such as blood pressure and heart rate.
Assessing the patient's responsiveness to verbal stimuli.
Observing for non-verbal cues such as facial expressions and body movements.
The Correct Answer is D
A. Requesting feedback from the patient's family about the patient's comfort. While family members can provide insight, they cannot reliably assess pain in an unconscious client. Pain assessment should be based on objective clinical observations rather than second-hand reports.
B. Monitoring changes in vital signs such as blood pressure and heart rate. While pain can cause changes in vital signs, this method is not the most reliable in end-of-life care. Vital signs may fluctuate due to the body’s natural decline rather than pain alone.
C. Assessing the patient's responsiveness to verbal stimuli. Responsiveness to verbal stimuli helps assess consciousness, but it does not directly determine pain levels. An unconscious client may still experience discomfort, requiring alternative assessment methods.
D. Observing for non-verbal cues such as facial expressions and body movements. In unconscious or non-verbal clients, pain is best assessed through behavioral cues like grimacing, restlessness, moaning, muscle tension, or changes in breathing patterns. These signs help determine whether pain interventions are effective or need adjustment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encourage the client to use a walking stick or guide dog when moving around the home. While mobility aids can be beneficial, they are not always necessary for clients with glaucoma, especially in familiar home environments. The primary concern is reducing tripping hazards to prevent falls.
B. Ensure that all electrical cords and wires are secured against walls and out of walkways. This is the priority intervention because unsecured cords pose a major tripping hazard for clients with decreased vision. Keeping pathways clear reduces the risk of falls and promotes safer movement within the home.
C. Place throw rugs and carpets throughout the home to add comfort and warmth. This intervention is unsafe. Throw rugs increase the risk of tripping, particularly for individuals with impaired vision. The nurse should advise the client to remove or secure rugs with non-slip backing.
D. Install bright, overhead lighting in every room and hallway to improve visibility. Good lighting is important for clients with visual impairments, but excessive brightness can sometimes cause glare, worsening vision problems. While lighting adjustments are helpful, eliminating tripping hazards remains the priority.
Correct Answer is A
Explanation
A. Supporting the client's wish to refuse prescribed medications. Autonomy refers to the right of individuals to make their own decisions regarding their healthcare. If a client chooses to refuse medication, the nurse must respect this decision, as long as the client is deemed competent to make informed choices.
B. Explaining unit rules and policies regarding unacceptable behaviors. This action supports a structured therapeutic environment but does not specifically relate to autonomy. It aligns more with beneficence (acting in the client’s best interest) and justice (ensuring fairness in care).
C. Making sure the client understands expectations for client participation. Ensuring understanding of treatment expectations promotes informed participation but does not directly uphold the ethical principle of autonomy, which emphasizes the right to make personal choices.
D. Encouraging client feedback about satisfaction with the facility experience. Seeking client feedback supports patient-centered care but does not specifically demonstrate autonomy, which involves the right to accept or refuse medical interventions.
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