The nurse is viewing 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.

Provide comfort measures such as topical warm application and tactile massage.

Determine client’s objective measure of pain using a numerical pain scale.

Assist the client to ambulate as much as possible during waking hours.

Implement a 24-hour schedule of routine administration of prescribed analgesics.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale
Encouraging increased fluid intake and measuring urinary output every 8 hours is not directly related to managing chronic pain. This intervention is more relevant for clients with conditions affecting fluid balance or renal function.
Choice B rationale
Providing comfort measures such as topical warm application and tactile massage can help alleviate chronic pain by promoting relaxation and improving blood circulation. These non- pharmacological interventions can be effective in managing pain and enhancing the client’s comfort.
Choice C rationale
Determining the client’s objective measure of pain using a numerical pain scale is essential for assessing the severity of pain and evaluating the effectiveness of pain management interventions. Accurate pain assessment is crucial for developing an appropriate plan of care.
Choice D rationale
Assisting the client to ambulate as much as possible during waking hours may not be feasible for clients with severe chronic pain. While physical activity is important, it should be balanced with the client’s pain levels and overall condition.
Choice E rationale
Implementing a 24-hour schedule of routine administration of prescribed analgesics ensures consistent pain relief and prevents breakthrough pain. Regular administration of analgesics is a key component of effective pain management for clients with chronic pain.

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Correct Answer is B

Explanation

Choice A rationale
Sending the UAP to be fitted for a particulate filter mask is unnecessary for droplet precautions. Particulate filter masks, such as N95 respirators, are required for airborne precautions, not droplet precautions.
Choice B rationale
Instructing the UAP that a standard face mask is sufficient is correct. Droplet precautions require a standard surgical mask to prevent the transmission of infections like bacterial meningitis. This allows the UAP to safely provide care without the need for a particulate filter mask.
Choice C rationale
Determining which staff members have fitted particulate filter masks is unnecessary for droplet precautions. This action is more relevant for airborne precautions, where particulate filter masks are required.
Choice D rationale
Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is incorrect. A standard face mask is sufficient for all aspects of care under droplet precautions.

A. Ask the healthcare provider for a mild sedative for bedtime. B. Take an afternoon nap to make up for missed sleep. C. Drink a mixture of warm water, whiskey, and honey at bedtime. D. Establish a regular time for going to bed and getting up. E. Avoid drinking caffeinated beverages late in the day.

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

Explanation

Choice A rationale
Asking the healthcare provider for a mild sedative for bedtime may not be the best first-line approach for improving sleep. Sedatives can have side effects and may lead to dependency.
Non-pharmacological interventions are generally preferred for managing sleep disturbances in older adults.
Choice B rationale
Taking an afternoon nap to make up for missed sleep can disrupt the sleep-wake cycle and make it harder to fall asleep at night. It is generally recommended to avoid napping during the day to improve nighttime sleep quality.
Choice C rationale
Drinking a mixture of warm water, whiskey, and honey at bedtime is not a recommended practice for improving sleep. Alcohol can disrupt sleep patterns and lead to poor sleep quality. It is better to avoid alcohol before bedtime.
Choice D rationale
Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and improve sleep quality. Consistency in sleep schedules is a key factor in promoting healthy sleep habits.
Choice E rationale
Avoiding caffeinated beverages late in the day is important for improving sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep.

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The nurse is viewing 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

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

Explanation

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The nurse is viewing 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.