The nurse is caring for a client who has pain due to sickle cell anemia. The patient rates the pain as a 7 out of 10 (O is no pain and 10 is the worst pain possible). The client is moving around easily and smiling. She is asking for pain medication. Which action by the nurse is most appropriate?

Notify the healthcare provider that the client is exaggerating their pain

Wait 30 minutes and see if the client is still requesting pain medication

Administer the pain medication as prescribed

Administer half of the ordered dose of pain medication

Answer and Explanation

The Correct Answer is C

A) Notify the healthcare provider that the client is exaggerating their pain: It is inappropriate for the nurse to assume that the client is exaggerating their pain based solely on their demeanor. Pain perception is subjective and can vary greatly among individuals, especially in conditions like sickle cell anemia.

B) Wait 30 minutes and see if the client is still requesting pain medication: Delaying pain relief can lead to unnecessary suffering. Given that the client rates their pain as a 7 out of 10, which indicates significant discomfort, it is essential to address their pain promptly rather than postponing treatment.

C) Administer the pain medication as prescribed: This is the most appropriate action. Clients with sickle cell anemia often experience severe pain crises, and effective pain management is crucial. Administering the medication as prescribed supports the client's comfort and well-being.

D) Administer half of the ordered dose of pain medication: Modifying the dosage without a provider's order is not appropriate. If the full prescribed dose is warranted based on the pain level, the nurse should administer it as indicated to ensure effective pain management.

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Correct Answer is ["C","E"]

Explanation

A) "I have cut back on fat and switched to a vegetarian diet." This statement suggests a positive change in dietary habits, which can lower the risk of cardiovascular disease. A vegetarian diet, particularly if it includes plenty of fruits, vegetables, and whole grains, is associated with a reduced risk of heart disease. Therefore, this statement does not indicate an increased risk.

B) "I have cut back on my smoking." While reducing smoking is a positive step, smoking itself is a significant risk factor for cardiovascular disease. However, the statement indicates an attempt to decrease risk, which does not inherently suggest an increased risk. It may show improvement rather than risk.

C) "I have been stressed out since my divorce last year." Chronic stress is a recognized risk factor for cardiovascular disease, as it can lead to behaviors such as poor diet, inactivity, and increased blood pressure. This statement highlights a significant concern for the client’s cardiovascular health.

D) "I have an occasional glass of wine." Moderate alcohol consumption is sometimes associated with cardiovascular benefits. While excessive drinking can pose risks, this statement alone does not indicate an increased risk of cardiovascular disease. It reflects moderation rather than concern.

E) "I have gained 25 pounds over the past year." Weight gain, especially if it leads to obesity, is a significant risk factor for developing cardiovascular disease. This statement indicates a change in health status that could negatively impact the client’s cardiovascular risk profile.

A. Impact on ADL's. B. Family medical history. C. Pain intensity rating D. Characteristics of the pain. E. Aggravating factors.

Correct Answer is ["A","C","D","E"]

Explanation

A) Impact on ADLs: Understanding how pain affects a client's activities of daily living (ADLs) is crucial for assessing the overall impact of the pain on their life. It provides insight into the functional limitations caused by the pain and helps guide treatment planning.

B) Family medical history: While family medical history can provide context for certain conditions, it is not an essential component of a focused pain assessment. The immediate concerns are more directly related to the client's current pain experience rather than their family's medical background.

C) Pain intensity rating: Assessing the intensity of pain is a fundamental aspect of pain assessment. Using scales (e.g., 0-10) allows the nurse to quantify the pain, monitor changes over time, and evaluate the effectiveness of interventions.

D) Characteristics of the pain: Understanding the characteristics of the pain—such as its quality (sharp, dull, throbbing) and location—is essential for determining its cause and guiding appropriate treatment strategies.

E) Aggravating factors: Identifying what exacerbates the pain is critical for understanding its nature and developing effective management strategies. Knowing which activities or positions worsen the pain can help in creating a comprehensive care plan tailored to the client's needs.

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The nurse is caring for a client who has pain due to sickle cell anemia. The patient rates the pain as a 7 out of 10 (O is no pain and 10 is the worst pain possible). The client is moving around easily and smiling. She is asking for pain medication. Which action by the nurse is most appropriate?

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