The nurse outlines the four phases of nociceptive pain as: (Select all that apply.).

The correct answer is choice B. "Why do you think your husband needs more medication when he is asleep?"

Choice A rationale:

"Your husband should decide when more medication is needed.” This response is incorrect because it implies that the partner has the authority to decide when the client needs pain medication, which violates the purpose of a PCA pump. A PCA pump is specifically designed for client-controlled pain management, ensuring that the patient, not anyone else, controls when they receive pain medication. Allowing someone else to press the button can lead to overmedication and safety risks.

Choice B rationale:

"Why do you think your husband needs more medication when he is asleep?" This response is correct because it prompts the partner to reflect on their actions and provides an opportunity for the nurse to educate about the proper use of PCA pumps. It addresses the immediate issue without being confrontational and opens the door for further discussion on the importance of client safety and correct PCA use.

Choice C rationale:

"It's a good idea to help make sure your husband can sleep comfortably.” This response is incorrect as it endorses inappropriate and unsafe behavior. It encourages the partner to continue pressing the PCA button, risking the client's safety due to potential overmedication, which can lead to severe complications, such as respiratory depression.

Choice D rationale:

"Next time you think he needs more medication, call me and I'll push the button.” This response is incorrect because it contradicts PCA protocols and removes the control from the client. The nurse is responsible for monitoring the client’s pain and safety, not administering medication upon another person’s request. This approach also increases the risk of dosing errors and undermines the purpose of patient-controlled analgesia.

Choice A rationale:

An elevated blood pressure is not a reliable indicator of a decrease in pain following the administration of an opioid narcotic. Blood pressure can be influenced by various factors, and it may not directly correlate with the relief of pain.

Choice B rationale:

The client being asleep is not a direct indicator of decreased pain following opioid administration. While opioids may cause drowsiness as a side effect, the absence of pain cannot be confirmed solely based on the patient's sleep state.

Choice C rationale:

An increased respiratory rate can be a reliable indicator of decreased pain following the administration of an opioid narcotic. Opioids often cause respiratory depression, so an increased respiratory rate may suggest that the patient's pain is adequately managed, as they are not experiencing excessive respiratory depression.

Choice D rationale:

Diaphoresis (excessive sweating) is not a direct indicator of decreased pain following opioid administration. Diaphoresis can be caused by various factors, including anxiety, and may not specifically reflect pain relief. .