The practical nurse (PN) observes a male client grimacing and holding his head. The PN determines that the client is in pain. To validate this assessment with subjective data, which action should the PN implement?
Ask the client to provide a detailed description about the quality of the pain.
Review the medication record and note when the client last received an analgesic.
Compare the client's current vital signs with vital signs taken earlier in the day.
Consult with the charge nurse about the manifestations that the client is exhibiting.
The Correct Answer is A
A. Ask the client to provide a detailed description about the quality of the pain: Subjective data are obtained directly from the client’s verbal report. Asking the client to describe the pain’s quality, intensity, and location validates the nurse’s observation and provides essential information for accurate pain assessment and management.
B. Review the medication record and note when the client last received an analgesic: This provides objective data about pain management but does not validate the client’s current pain experience, which must come from the client’s own report.
C. Compare the client’s current vital signs with vital signs taken earlier in the day: Changes in vital signs, such as increased pulse or blood pressure, are objective indicators of pain, but they cannot confirm the client’s subjective experience.
D. Consult with the charge nurse about the manifestations that the client is exhibiting: Discussing observations with another nurse may be appropriate later, but validation of pain requires direct communication with the client, not secondary consultation.
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Related Questions
Correct Answer is C
Explanation
A. Withhold the next scheduled dose of levothyroxine: Levothyroxine should not be withheld for constipation, as it is the primary treatment for hypothyroidism. Stopping the medication could worsen metabolic function and is not indicated for mild gastrointestinal symptoms.
B. Obtain the supplies needed for insertion of a nasogastric tube: Inserting a nasogastric tube is invasive and unnecessary for constipation unless there is severe obstruction or other complications. Routine constipation is managed with noninvasive measures first.
C. Assist the client with ambulation in the room and hallway: Physical activity stimulates bowel motility and helps relieve constipation. Assisting the client with safe ambulation supports gastrointestinal function and promotes overall recovery in hypothyroid patients.
D. Remove any food or fluid from the client's bedside and room: Restricting food and fluid would worsen constipation and is inappropriate. Adequate hydration and dietary intake are essential for promoting normal bowel function.
Correct Answer is A
Explanation
A. Give the prescribed antibiotics in addition to using the candles: Cultural accommodation involves supporting safe cultural practices while ensuring that effective medical treatment is not compromised. Allowing the mother to use the candles along with prescribed antibiotics respects her beliefs and promotes adherence to essential medical therapy.
B. Use the prescribed antibiotics and if there is no improvement, use the candles: Delaying antibiotic treatment can allow the infection to worsen, increasing the risk of complications such as hearing loss or mastoiditis. This approach prioritizes culture over timely medical intervention.
C. Provide the prescribed antibiotics instead of using the candles: Completely rejecting the mother’s cultural practice may damage trust and cooperation. Cultural accommodation seeks to balance safety with respect for cultural traditions.
D. Do not use the candles because of the risk of fire and subsequent burns to the child: While safety is important, dismissing the practice without respectful dialogue can appear culturally insensitive. Education on safe antibiotic use should be combined with cultural respect to maintain therapeutic rapport.
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