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The nurse is performing an admission assessment on a stable patient admitted after a motor vehicle accident.
The patient reports having bad pain.
What will the nurse do first?

Attempt to determine what type of pain the patient has.

Request an order for intravenous opioid analgesic.

Administer acetaminophen (Tylenol).

Ask the patient to rate the pain on a scale of 1-10.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Determining the type of pain is secondary to assessing pain severity.

Choice B rationale

Intravenous opioids are strong and should be considered only after evaluating pain severity.

Choice C rationale

Administering acetaminophen without assessing pain severity first is not appropriate.

Choice D rationale

Asking the patient to rate their pain helps gauge severity, guiding further pain management steps.

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Correct Answer is A

Explanation

Choice A rationale

Acetaminophen is recommended for children because it is effective for pain and fever relief with a low risk of stomach irritation and other side effects.

Choice B rationale

Ibuprofen, though effective, may cause stomach irritation and should be used with caution in children.

Choice C rationale

Aspirin is not recommended for children due to the risk of Reye’s syndrome, a rare but serious condition.

Choice D rationale

Diflunisal is not recommended for children as it is primarily used for more severe pain and conditions like arthritis.

A. Reassure the client that this is nothing to worry about and will diminish over time. B. Tell the patient to stop taking the drug immediately as this is a serious side effect of the drug. C. Schedule an appointment with the provider to discuss changing to an ARB. D. Instruct the patient to go to the emergency room immediately as this is a hypersensitivity reaction.

Correct Answer is C

Explanation

Choice A rationale

Reassuring the client without addressing the persistent cough would not be appropriate as it may signal a need for a different medication. The ACE inhibitor captopril can cause a bothersome, persistent cough in some patients due to increased bradykinin levels.

Choice B rationale

Instructing the patient to stop the medication immediately is not advised without consulting the healthcare provider. While the cough is a known side effect, stopping the medication abruptly may lead to unmanaged hypertension.

Choice C rationale

Scheduling an appointment with the provider to discuss changing to an angiotensin II receptor blocker (ARB) is appropriate. ARBs do not typically cause a persistent cough, making them a suitable alternative for patients who experience this side effect with ACE inhibitors.

Choice D rationale

Instructing the patient to go to the emergency room immediately is unnecessary as the persistent cough is a common side effect of ACE inhibitors and not an emergency situation. Emergency action is warranted for symptoms of angioedema, such as swelling of the face or throat.

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The nurse is performing an admission assessment on a stable patient admitted after a motor vehicle accident.The patient reports having bad pain.What will the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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The nurse is performing an admission assessment on a stable patient admitted after a motor vehicle accident.
The patient reports having bad pain.
What will the nurse do first?