The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

Pain scale.

Skin integrity.

Bowel sounds.

Functional ability

Heart sounds.

Answer and Explanation

Correct Answer : A,B,D

A. Pain scale: Pain is a key symptom of Herpes zoster (shingles), and the effectiveness of treatment is often measured by the relief of pain. The nurse should assess the pain level regularly using a pain scale to evaluate the effectiveness of pain management interventions.

B. Skin integrity: Herpes zoster causes a rash and blisters, and monitoring skin integrity is important to assess for signs of infection, healing, or any new areas of skin breakdown. The healing of the rash and blisters is a key indicator of treatment effectiveness.

C. Bowel sounds: Bowel sounds are not related to the treatment or condition of Herpes zoster. While important in other contexts, they are not a relevant assessment for evaluating the effectiveness of shingles treatment.

D. Functional ability: Functional ability, including the client’s ability to perform activities of daily living, can be impacted by the pain and discomfort associated with shingles. Assessing functional ability helps to gauge the overall impact of the condition and the effectiveness of treatment in improving quality of life.

E. Heart sounds: Heart sounds are not directly related to the treatment of Herpes zoster. This assessment is not necessary for evaluating the effectiveness of shingles treatment unless there are unrelated cardiovascular concerns.

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Correct Answer is C

Explanation

A. Assess for signs of urine retention: While important, urinary retention is a later complication. It does not take priority over assessing for potentially serious effects like respiratory depression or excessive spread of anesthesia.

B. Inspect epidural catheter insertion site: Inspecting the site helps identify infection or dislodgement but is not the first priority. Neurological and respiratory assessments take precedence due to fentanyl’s CNS effects.

C. Monitor the client's dermatome level for sensation: This assesses the spread of the anesthetic, ensuring it hasn’t ascended to high thoracic levels, which could depress respiration. It’s the most urgent check for client safety.

D. Inquire if the client is experiencing breakthrough pain: Pain assessment is critical, but ensuring safe levels of sensory block must come first to rule out excessive anesthetic spread or complications.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale:

Respirations: After administering morphine, it is crucial to monitor the client's respirations because opioids can cause respiratory depression, which may be more pronounced in elderly patients or those who are in pain and immobile.
Deep breathing techniques: The nurse should encourage deep breathing techniques. This helps improve lung expansion and reduces the risk of respiratory complications such as pneumonia and atelectasis, especially in a client with decreased mobility due to pain and injury.

Rationale for Incorrect Options:

Heart rate: While heart rate monitoring is important, it is not the primary concern immediately after morphine administration. The client's respiratory status takes precedence, especially considering the risk of opioid-induced respiratory depression.
Blood pressure: While blood pressure monitoring is essential, morphine administration primarily affects the respiratory system, not the circulatory system. The nurse should prioritize respiratory monitoring over blood pressure unless the patient exhibits signs of hypotension.
Range of motion exercises: Range of motion exercises are important for mobility and rehabilitation, but they are not a priority immediately following the trauma and morphine administration. The client should be assessed and stabilized before beginning exercises.
Joint protection techniques: Joint protection techniques are beneficial in long-term rehabilitation, but in the acute phase, the priority is to manage the fracture, pain, and prevent further complications.

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The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

Correct Answer is C

Explanation

Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. The nurse monitors the client's dropdownafter administering the morphine. The nurse should include dropdownto reduce complications of the client's injury.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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