The nurse is evaluating the client’s response to pain management.
Click to highlight the findings that indicate the client is experiencing the therapeutic effects of the medication.
Pain level presently 3 on a 0 to 10 scale. The client reports feeling "sleepy." Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer. New mild cough noted. Repositions in bed with minimal assistance. Attempted to get up to the chair, but experienced dizziness with standing.
Pain level presently 3 on a 0 to 10 scale
The client reports feeling "sleepy."
Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer.
New mild cough noted.
Repositions in bed with minimal assistance.
Attempted to get up to the chair, but experienced dizziness with standing.
The Correct Answer is ["A","C","E"]
Rationale for correct choices:
• Pain level presently 3 on a 0 to 10 scale: A reduction in pain from 8/10 to 3/10 indicates that the morphine is effectively alleviating the client’s pain. Effective analgesia allows for improved comfort, participation in breathing exercises, and reduced stress response.
• Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer: Increased inspiratory volume demonstrates improved lung expansion, indicating that pain control is facilitating better respiratory effort. This is especially important to prevent atelectasis and maintain adequate oxygenation after rib fractures.
• Repositions in bed with minimal assistance: Ability to move with less assistance reflects improved comfort and mobility due to effective pain management. This shows the therapeutic effect of analgesia in enabling functional activity without excessive pain.
Rationale for incorrect choices:
• Client reports feeling "sleepy": Sleepiness is a common side effect of morphine, reflecting central nervous system depression rather than a therapeutic effect of pain relief. While mild sedation can accompany effective analgesia, it does not directly indicate improvement in the underlying condition.
• New mild cough noted: The appearance of a new cough is not a direct indicator of therapeutic pain relief. It may reflect airway irritation, increased secretions, or a response to deeper breathing, but it is not a measure of analgesic effectiveness.
• Attempted to get up to the chair, but experienced dizziness with standing: Dizziness indicates a side effect of the opioid (orthostatic hypotension or sedation), not a therapeutic response. This finding requires monitoring and safety interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Drinking grapefruit juice will reduce the effects of the medication: Grapefruit juice can interact with itraconazole, but it typically increases rather than reduces drug levels. The client’s awareness of potential interactions is important, though clarification may be needed.
B. If I experience any difficulty with breathing I will report it: Respiratory symptoms could indicate an allergic reaction or adverse effect; reporting these promptly is appropriate and demonstrates understanding.
C. Monitoring for changes in stool color is important: Itraconazole can affect liver function, and changes in stool or urine may signal hepatotoxicity. Monitoring these changes is appropriate teaching.
D. I should take the medication with antacids: Antacids reduce gastric acidity, which decreases itraconazole absorption and effectiveness. The client should be instructed to avoid antacids around the time of medication administration.
Correct Answer is B
Explanation
A. Verbal reassurance: While helpful for reducing anxiety, verbal reassurance alone does not significantly shorten the duration of pain associated with multiple injections.
B. Simultaneous injections: Administering multiple vaccines at the same time in different sites reduces the overall number of needle sticks and the total duration of pain the toddler experiences, making this the most effective strategy.
C. Supine positioning: Proper positioning can improve safety and comfort during injections but does not directly decrease the duration of pain from the procedure.
D. Physical soothing: Holding or comforting the toddler helps reduce distress and anxiety, but it does not shorten the actual time the pain stimulus occurs.
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.