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

A. Place the client on contact precautions: There is no indication of an infectious process requiring isolation. A normal glucose result does not suggest the need for precautions.
B. Start a high-fiber diet: The glucose level is within the normal range but on the higher end. Promoting a high-fiber diet can help maintain stable glucose levels and support long-term glucose control, especially if the client is at risk for impaired glucose tolerance.
C. Administer an oral steroid: Steroids can raise blood glucose levels and are not indicated in this context.
D. Make the client NPO: There is no reason to restrict oral intake based on a normal glucose result. NPO status is typically ordered for specific diagnostic procedures or when there is a risk of aspiration.

Correct Answer is []

Explanation

The correct answer is Potential Condition:

A. Secretory diarrhea.

Actions to Take:

A. Collect stool for culture.

D. Make the client NPO.

Parameters to Monitor:

A. Heart rate.

B. Serum potassium.

Potential Condition A rationale:

Secretory diarrhea is characterized by large volumes of watery stool and can be caused by infections, toxins, or certain medications. It is important to identify the underlying cause to provide appropriate treatment. Potential Condition B rationale:

Steatorrhea is characterized by fatty stools and is typically associated with malabsorption syndromes. The client’s symptoms do not suggest this condition. Potential Condition C rationale:

Motility diarrhea is caused by rapid transit of stool through the intestines, often due to conditions like irritable bowel syndrome. The client’s symptoms are more consistent with secretory diarrhea. Potential Condition D rationale:

Osmotic diarrhea occurs when non-absorbable substances draw water into the intestines. The client’s symptoms are more indicative of secretory diarrhea. Action A rationale:

Collecting stool for culture helps identify any infectious agents that may be causing the diarrhea, allowing for targeted treatment. Action B rationale:

Starting a high-fiber diet is not appropriate for a client with acute diarrhea, as it may exacerbate symptoms. Action C rationale:

Administering an oral steroid is not indicated for the treatment of secretory diarrhea and may worsen the condition. Action D rationale:

Making the client NPO (nothing by mouth) helps to rest the gastrointestinal tract and reduce the severity of diarrhea. Parameter A rationale:

Monitoring heart rate is important as dehydration from diarrhea can lead to tachycardia. Parameter B rationale:

Monitoring serum potassium is crucial as diarrhea can lead to significant electrolyte imbalances, including hypokalemia. Parameter C rationale:

Monitoring respiratory rate is not directly related to the management of diarrhea. Parameter D rationale:

Monitoring urine sodium is not directly related to the management of diarrhea.

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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

A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

Correct Answer is B

Explanation

Correct Answer is []

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.