When performing pain assessment, what is a vital initial step?
Understanding the patient's self-reported pain severity and character
Beginning immediate pharmacological intervention
Assessing the psychological background of the patient
Implementing selected nonpharmacological treatments
The Correct Answer is A
A. Understanding the patient's self-reported pain: Pain is a subjective, multidimensional experience, and the patient's own description is the most reliable indicator of its presence and intensity. A comprehensive assessment of location, character, and severity must occur before any clinical decisions can be made. This self-report serves as the baseline for all subsequent therapeutic interventions.
B. Beginning immediate pharmacological intervention: Administering medication before a thorough assessment is completed can mask clinical symptoms and lead to inappropriate treatment. The nurse must first identify the type and severity of pain to select the correct analgesic according to the WHO pain ladder. Assessment is always the priority step in the nursing process.
C. Assessing the psychological background: While psychological factors influence the perception of pain, they are secondary to the primary physical assessment of the painful stimulus. Focusing on the background before the actual pain characteristics can lead to clinical bias and undertreatment. The immediate priority is the patient's current, acute sensory experience.
D. Implementing selected nonpharmacological treatments: Nonpharmacological interventions like repositioning or distraction are useful adjuncts but should not be implemented without a preliminary assessment. The nurse must determine if the pain is acute or chronic to choose the most effective modality. Assessment must guide the selection of any nonpharmacological intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. It is always a safer option than anti-depressants:Labeling an herbal supplement as "safer" is scientifically inaccurate as they are not regulated with the same rigor as pharmaceuticals. St. John's Wort carries significant risks and side effects that can be as severe as conventional medications. Natural origin does not equate to absence of pharmacological danger.
B. It can cause dependency and addiction:St. John's Wort is not associated with the neurobiological pathways that lead to physical dependence or addictive behaviors. While it affects neurotransmitter levels, it does not share the addictive profile of substances like opioids or benzodiazepines. This is not a primary safety concern for this supplement.
C. It needs to be taken in large doses to be effective:High doses of St. John's Wort increase the risk of photosensitivity and serotonin syndrome without necessarily improving therapeutic outcomes. Effective dosing must be carefully balanced to avoid toxicity while attempting to achieve a mood-stabilizing effect. Dose escalation should only occur under medical supervision.
D. It can significantly interfere with the metabolism of prescription medications:This herb is a potent inducer of the Cytochrome P450 enzyme system, specifically the CYP3A4 isoenzyme. This increases the clearance of many drugs, including anticoagulants, oral contraceptives, and antiretrovirals, rendering them ineffective. This represents a major clinical safety risk for patients.
Correct Answer is B
Explanation
A. 50 gtt/min: This rate would deliver the 100 mL infusion in only 30 minutes, which is twice as fast as the prescribed rate. Rapid infusion of certain medications can lead to adverse effects or toxicity. Accurate calculation is essential when an electronic pump is not available.
B. 25 gtt/min: The manual drip rate is calculated by multiplying the total volume (100 mL) by the drop factor (15 gtt/mL) and dividing by the time in minutes (60 min). 1500 divided by 60 equals 25. This ensures the 100 mL is delivered precisely over the 1-hour period.
C. 75 gtt/min: This drip rate would result in the entire volume being infused in approximately 20 minutes. Such a high rate is incorrect for a 1-hour schedule and could cause fluid overload or infusion-related reactions. It significantly exceeds the required delivery speed of 1.67 mL per minute.
D. 60 gtt/min: Setting the rate to 60 drops per minute would infuse the medication in about 25 minutes. This does not align with the prescribed 1-hour duration for the 100 mL volume. Proper use of the drip factor formula prevents such timing errors in manual administration.
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