The nurse is assessing a 7-year-old post-surgery. Despite denying pain, the nurse observes the patient's fists are clenched and forehead is wrinkled. How will the nurse intervene?
Call the healthcare provider.
Wait for the patient to report pain.
Administer intravenous morphine.
Instruct the parent to play relaxing music.
The Correct Answer is C
Choice A reason: Calling the healthcare provider is a valid action if the nurse encounters an unexpected issue or an emergency. However, in this situation, the nurse's immediate observation of physical signs indicating pain suggests that the patient might be experiencing discomfort. The nurse has enough clinical judgment to address the pain directly rather than waiting for a healthcare provider's intervention, which could delay relief.
Choice B reason: Waiting for the patient to report pain is not an ideal choice here because children, especially younger ones, may not always verbalize their pain even when they are in discomfort. The nurse's role involves assessing both verbal and non-verbal cues to provide timely and appropriate care. Physical signs such as clenched fists and a wrinkled forehead strongly indicate pain, necessitating prompt action rather than waiting.
Choice C reason: Administering intravenous morphine is the appropriate intervention given the clear physical signs of pain observed by the nurse. Morphine is a powerful opioid analgesic used to manage moderate to severe pain. In a post-surgical context, controlling pain effectively is crucial for the patient's recovery. Therefore, this action aligns with the need for timely pain management to ensure the child's comfort and facilitate healing.
Choice D reason: Instructing the parent to play relaxing music can be a helpful non-pharmacological intervention to provide a calming environment for the child. However, this action alone is unlikely to address the acute pain suggested by the patient's physical signs. While it can be part of a comprehensive pain management plan, the primary approach should be administering medication to relieve the immediate pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["64"]
Explanation
To calculate the maintenance IV fluid rate for a child, we typically use the Holliday-Segar formula:
- For the first 10 kg of weight: 100 ml/kg/day
- For the next 10 kg of weight: 50 ml/kg/day
- For any additional weight: 20 ml/kg/day
The weight of the child is 48 pounds, which is approximately 21.8 kg (since 1 pound = 0.45 kg).
Using the formula:
- First 10 kg: 100 ml/kg/day = 1000 ml/day
- Next 10 kg: 50 ml/kg/day = 500 ml/day
- Remaining 1.8 kg: 20 ml/kg/day = 36 ml/day
Total = 1000 ml + 500 ml + 36 ml = 1536 ml/day
To find the rate in ml/hr: 1536 ml/day ÷ 24 hours/day = 64 ml/hr
Correct Answer is C
Explanation
Choice A reason: Observing for mental confusion or hallucinations is important, but it is not the priority action following myelography. While these symptoms can occur due to complications, they are less common than changes in muscle tone or motor function.
Choice B reason: Assessing motor function is crucial, but the priority is specifically monitoring for changes in muscle tone, such as a decrease in spasticity. Myelography can affect the spinal cord and nerve roots, potentially leading to changes in muscle tone and motor function.
Choice C reason: Monitoring for a decrease in spasticity is the priority nursing action. Myelography involves injecting contrast material into the spinal canal, which can affect the spinal cord and nerve roots. Monitoring for changes in muscle tone, such as a decrease in spasticity, helps detect potential complications early and allows for timely intervention.
Choice D reason: Performing a follow-up MRI is not the immediate priority nursing action. While follow-up imaging may be necessary to assess the results of the myelography, the immediate focus is on monitoring the patient's neurological status and ensuring their safety.
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