What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient's pain?
"I've given her some medication; please report to me whether it seems to have relieved her pain within an hour or so."
"Be sure to keep the room temperature high and the TV on at all times."
"Be sure to tell me if you assess an increase in pain, grimacing, or any unusual behavior."
"Let me know at least 30 minutes before you transport her so I can administer her analgesics."
The Correct Answer is C
A. "I've given her some medication; please report to me whether it seems to have relieved her pain within an hour or so.": NAP are not responsible for evaluating the effectiveness of analgesics, as this requires clinical judgment and assessment skills within the nurse’s scope of practice. Subjective impressions may lead to inaccurate conclusions about pain control.
B. "Be sure to keep the room temperature high and the TV on at all times.": Environmental measures alone are not sufficient for pain management and do not address the primary responsibility of NAP in monitoring patient responses. Maintaining comfort is important, but instructions must be clinically relevant to pain assessment and communication.
C. "Be sure to tell me if you assess an increase in pain, grimacing, or any unusual behavior.": NAP can observe and report nonverbal signs of pain or changes in behavior, which are critical for ongoing assessment. Prompt reporting enables the nurse to intervene appropriately, such as administering medication or implementing additional comfort measures.
D. "Let me know at least 30 minutes before you transport her so I can administer her analgesics.": While coordinating analgesic administration with planned activities is important, this instruction focuses on timing rather than the NAP’s role in monitoring or reporting pain. NAP should observe and communicate changes in pain rather than determine when to medicate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask the patient to clench their jaws: Clenching the jaw primarily assesses cranial nerve V (trigeminal nerve), which controls the muscles of mastication. It does not test the function of cranial nerve XI.
B. Ask the patient to raise eyebrows and smile: Raising the eyebrows and smiling evaluates cranial nerve VII (facial nerve), which controls facial expressions. This does not assess the accessory nerve responsible for shoulder and neck movement.
C. Ask the patient to swallow: Swallowing tests cranial nerves IX (glossopharyngeal) and X (vagus), which are involved in pharyngeal and laryngeal function. These actions are unrelated to cranial nerve XI function.
D. Ask the patient to shrug shoulders against resistance: Cranial nerve XI (accessory nerve) innervates the trapezius and sternocleidomastoid muscles, controlling shoulder elevation and head rotation. Asking the patient to shrug their shoulders against resistance is the correct method to assess strength and integrity of this nerve.
Correct Answer is C
Explanation
A. Increases cellular metabolism to enhance healing process: Applying ice actually slows cellular metabolism in the affected area, which helps reduce tissue damage and inflammation immediately after injury. Increased metabolism is not the goal of cold therapy in acute musculoskeletal injuries.
B. Increases perfusion to promote the delivery of essential nutrients: Cold application causes vasoconstriction, which decreases blood flow to the area temporarily, reducing edema and inflammation. It does not increase perfusion; in fact, increased perfusion occurs with heat therapy, not ice.
C. Increases vasoconstriction to decrease pain at the site of injury: Cold therapy induces vasoconstriction, which limits local blood flow and reduces swelling. It also slows nerve conduction, which decreases pain perception. This is the primary mechanism for using an ice pack immediately after an acute injury such as a sprain or contusion.
D. Increases muscle tension to decrease use of the extremity: Ice can cause temporary muscle stiffness, but the purpose is not to increase muscle tension to restrict movement. The main goal is to reduce inflammation and pain, which may incidentally limit movement but not through increased muscle tension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.