The nurse performing a focused assessment on pain will assess: (Select all that apply.).

Choice A rationale:

This statement is not accurate and may confuse the client. In a Patient-Controlled Analgesia (PCA) system, a predetermined dose is delivered when the patient activates the device. The dose is usually controlled to prevent excessive medication administration.

Choice B rationale:

This statement is correct. The essence of PCA is that the patient has control over administering their pain medication within set limits or time intervals. The patient can self-administer doses when needed, ensuring effective pain management.

Choice C rationale:

Allowing the partner to push the PCA button for the patient is not recommended. PCA systems are designed to be controlled by the patient themselves to prevent potential overdosing. Involving someone else in the administration can lead to safety concerns.

Choice D rationale:

PCA systems do not deliver medication into the muscle. They typically deliver medication intravenously (IV) or subcutaneously. This statement is inaccurate and could lead to misconceptions about how the PCA system works.

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. .