Which action should the nurse take to assess for analgesic tolerance in a client who is unable to communicate?

Observe the client for the presence of pain behaviors before the next analgesic dose is due.

Review the client's laboratory values for a change in the peak and trough levels of the analgesic

Prolong the interval between analgesic medication doses and monitor the client's vital signs.

Ask family members to report behaviors suggesting that the client's pain has returned.

Answer and Explanation

The Correct Answer is A

A. Observe the client for the presence of pain behaviors before the next analgesic dose is due: In a nonverbal client, observing for pain behaviors such as grimacing, restlessness, moaning, or changes in vital signs is crucial. If these behaviors increase before the next scheduled dose, it may suggest that the current analgesic regimen is becoming less effective, indicating tolerance.

B. Review the client's laboratory values for a change in the peak and trough levels of the analgesic: Peak and trough levels are useful for monitoring therapeutic ranges for certain medications but are not reliable indicators of analgesic tolerance. Tolerance is a clinical observation based on pain behavior, not solely on drug concentration measurements.

C. Prolong the interval between analgesic medication doses and monitor the client's vital signs: Extending the interval between doses risks undertreating the client’s pain and causing unnecessary suffering. Tolerance assessment should focus on evaluating pain control, not withholding medication to observe physiological responses.

D. Ask family members to report behaviors suggesting that the client's pain has returned: While family members can provide valuable insight, their observations should supplement, not replace, the nurse's direct clinical assessment. Family members may miss subtle signs of pain or misinterpret behaviors unrelated to pain.

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Correct Answer is D

Explanation

A. Determine if the medication is being taken correctly: While verifying correct usage is always important, the symptoms described dry mouth and sensitivity to bright light are expected side effects of dicyclomine and are not typically caused by improper administration.

B. Schedule an appointment for evaluation by the healthcare provider: Mild anticholinergic side effects like dry mouth and photosensitivity do not usually require urgent medical evaluation unless they become severe or are accompanied by other concerning symptoms.

C. Advise stopping the medication until the unpleasant effects wear off: Abruptly stopping medications, especially those for chronic conditions like IBS, is generally not recommended without consulting the healthcare provider. It can lead to a return of symptoms or other adverse effects. The nurse should focus on managing the side effects so the client can continue the prescribed treatment.

D. Provide instructions in managing these side effects: Dry mouth can be managed by sipping water, using sugar-free gum, or using saliva substitutes. Photosensitivity can be addressed with sunglasses and protective clothing. Educating the client on managing these effects supports continued therapy and improves comfort.

A. Sodium. B. Glucose. C. Total protein D. Hemoglobin.

Correct Answer is D

Explanation

A. Sodium: Monitoring sodium is important in many conditions, but diclofenac, a nonsteroidal anti-inflammatory drug (NSAID), is more commonly associated with gastrointestinal bleeding rather than causing significant electrolyte imbalances like hyponatremia. Sodium levels are not the primary concern in this scenario.

B. Glucose: Blood glucose monitoring is critical for clients with diabetes or corticosteroid use, but diclofenac is not known to directly impact glucose metabolism. Reviewing glucose levels would not immediately address the symptoms of pallor and fatigue.

C. Total protein: Total protein levels reflect nutritional and liver status but are not the best marker for acute blood loss or anemia. Changes in total protein would not directly explain symptoms like pallor and fatigue related to NSAID complications.

D. Hemoglobin: Diclofenac can cause gastrointestinal irritation and occult bleeding, leading to anemia. Pallor and fatigue are classic symptoms of low hemoglobin levels, making it the most important laboratory value to review to evaluate for possible GI bleeding and anemia.

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Which action should the nurse take to assess for analgesic tolerance in a client who is unable to communicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with irritable bowel syndrome starts a new prescription for dicyclomine, an anticholinergic medication. The client reports the onset of sensitivity to bright sunlight and a dry mouth. How should the nurse respond?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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