The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.
Encourage Increased fluid intake and measure urinary output every 8 hours.
Assist the client to ambulate as much as possible during waking hours.
Determine client's subjective measure of pain using a numerical pain scale.
Provide comfort measures such as topical warm application and tactile massage.
Implement a 24 hour schedule of routine administration of prescribed analgesic.
Correct Answer : B,C,D,E
A. Encourage increased fluid intake and measure urinary output every 8 hours:
While hydration and monitoring urinary output are important aspects of overall health care, they are not specifically related to managing chronic pain. Therefore, this intervention may not be directly relevant to addressing the client's pain.
B. Assist the client to ambulate as much as possible during waking hours:
Ambulation helps maintain mobility, prevent complications like muscle atrophy and deep vein thrombosis, and can improve overall well-being. For clients with chronic pain, assisting with ambulation can be beneficial in managing pain and improving quality of life. The goal is to balance activity with the client's pain tolerance and capabilities.
C. Determine client's subjective measure of pain using a numerical pain scale:
Using a numerical pain scale helps assess the intensity of pain and monitor changes over time. It provides valuable information for tailoring pain management strategies to the client's needs and allows for evaluating the effectiveness of interventions.
D. Provide comfort measures such as topical warm application and tactile massage:
Comfort measures such as warm applications and massage can help alleviate pain and promote relaxation. These interventions address the client's comfort and well-being, making them appropriate for inclusion in the plan of care for managing chronic pain.
E. Implement a 24-hour schedule of routine administration of prescribed analgesic:
Establishing a regular schedule of analgesic administration helps maintain consistent pain control and prevents breakthrough pain. This intervention is essential for managing chronic pain effectively and promoting the client's comfort and quality of life.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer PRN oral pain medication:
Administering pain medication without further assessment may not be appropriate, as the client's pain needs must be fully evaluated before intervening with medication. Additionally, pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
B. Review the pain medications prescribed:
While it's important to review the client's pain medications, particularly if the client is exhibiting signs of uncontrolled pain, this intervention should be secondary to further assessment of the client's current pain status.
C. Ask the client what is causing the grimacing:
Asking the client directly about the cause of their grimacing can help clarify their discomfort and provide insight into whether their pain response is being underreported. This approach helps bridge the gap between nonverbal cues and verbal reports.
D. Monitor the client's nonverbal behavior:
While monitoring nonverbal behavior is important, it does not directly address the discrepancy between the client’s grimacing and their verbal denial of pain. This action should be complemented by further assessment to understand the cause of the nonverbal signs.
E. Establish a regular time for going to bed and getting up: This intervention is not relevant to the current situation, as the client is experiencing discomfort while moving.
Correct Answer is D
Explanation
A. Withdraw the medication into a syringe and label it with the client's name:
This is not necessary for the remainder of the medication. The medication should not be withdrawn into a syringe for future use or left labeled, as it could lead to errors or contamination.
B. Throw the vial into the trash in the presence of another nurse:
Discarding the vial into the trash is not appropriate, as it does not ensure proper documentation, accountability, or safe storage of the remaining medication. Additionally, the presence of another nurse does not address these concerns.
C. Place the vial with the remainder of the medication into a locked drawer:
While storing the vial in a locked drawer may prevent unauthorized access, it does not address the need for proper documentation and labeling of the remaining medication. Additionally, the vial should not be stored with the medication still in it after withdrawal.
D. Ask another nurse to witness the medication being discarded:
This is the appropriate action. Many facilities require that the disposal of unused or remaining medications, especially controlled substances, be witnessed by another nurse to ensure accountability and compliance with regulations.
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