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Which six factors should the nurse consider when choosing a time frame for reassessing the patient’s pain level after implementing pain management?

Agency policy

Type of intervention

Pain severity

If family members are present in the patient’s room

The patient’s psychosocial condition

Risks for adverse effects

Workload of the nurse

The patient’s physical condition

Answer and Explanation

Correct Answer : B,C,E,F,H

Choice A: Agency policy

While agency policy provides guidelines for reassessment intervals, it is not the primary factor in determining the specific time frame for reassessing a patient’s pain level. Policies serve as a general framework, but individual patient needs and clinical judgment should guide the reassessment timing.

Choice B: Type of intervention

This is a correct answer. The type of pain management intervention used significantly influences the reassessment time frame. For example, after administering intravenous pain medication, reassessment should occur sooner compared to oral medications due to the faster onset of action. Different interventions have varying durations of effectiveness, necessitating tailored reassessment intervals.

Choice C: Pain severity

This is another correct answer. The severity of the patient’s pain is a crucial factor in determining reassessment timing. Patients experiencing severe pain may require more frequent reassessments to ensure that pain management strategies are effective and to make timely adjustments if needed.

Choice D: If family members are present in the patient’s room

The presence of family members in the patient’s room is not a primary factor in determining the reassessment time frame. While family members can provide valuable support and information, the focus should remain on the patient’s clinical needs and the effectiveness of pain management interventions.

Choice E: The patient’s psychosocial condition

This is a correct answer. The patient’s psychosocial condition, including their emotional and mental state, can impact their perception of pain and response to pain management. Patients with anxiety, depression, or other psychosocial issues may require more frequent reassessments to address both physical and emotional aspects of pain.

Choice F: Risks for adverse effects

This is also a correct answer. The potential for adverse effects from pain management interventions necessitates careful monitoring and timely reassessment. For instance, opioids carry risks of respiratory depression and sedation, requiring close observation and frequent reassessment to ensure patient safety.

Choice G: Workload of the nurse

While the nurse’s workload can influence the practical aspects of care delivery, it should not dictate the reassessment time frame. Patient needs and clinical priorities should guide reassessment intervals, with workload management being a secondary consideration.

Choice H: The patient’s physical condition

This is the final correct answer. The patient’s overall physical condition, including comorbidities and current health status, affects their response to pain management and the need for reassessment. Patients with complex medical conditions may require more frequent monitoring to ensure effective pain control and to promptly address any complications.

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Correct Answer is B

Explanation

Choice A Reason: Fluid Volume Overload

Fluid volume overload, also known as hypervolemia, occurs when there is an excess of fluid in the body. This condition is often characterized by symptoms such as swelling (edema), shortness of breath, and high blood pressure. In the context of the patient’s scenario, fluid volume overload would typically present with signs like jugular venous distention, pulmonary congestion, and possibly ascites. The patient’s blood pressure is 109/70, which is not indicative of hypertension typically seen in fluid overload. Additionally, the patient’s lung sounds are clear, which further suggests that there is no pulmonary congestion. The lab results do not show a significant decrease in sodium levels, which might be expected in fluid overload due to dilutional hyponatremia.

Choice B Reason: Fluid Volume Deficit

Fluid volume deficit, or hypovolemia, is a condition where there is a significant loss of body fluids. This can result from severe diarrhea, as seen in the patient’s case. Symptoms of fluid volume deficit include lightheadedness, weakness, and muscle twitching, all of which the patient is experiencing. The patient’s blood pressure is on the lower side (109/70) and he gets lightheaded when standing up, indicating orthostatic hypotension, a common sign of fluid volume deficit. The elevated BUN (30 mg/dL) and creatinine (1.8 mg/dL) levels suggest dehydration and reduced kidney perfusion. The high potassium level (5.6 mEq/L) can be attributed to the body’s attempt to conserve water and sodium, leading to potassium retention. The ECG changes in the T wave and PR interval are consistent with hyperkalemia, which can occur in dehydration and kidney dysfunction.

A. Watery diarrhea for 3 days. B. Chronic kidney disease, which has been managed with diuretics and fluid restrictions. C. Lung sounds are clear. D. No nausea and vomiting. E. History of hypertension. F. Blood urea nitrogen (BUN).

Correct Answer is ["A","B","E","F"]

Explanation

Choice A reason:

Watery diarrhea for 3 days is a significant finding that correlates with fluid and electrolyte imbalances. Diarrhea leads to the loss of fluids and electrolytes, which can result in dehydration and electrolyte disturbances such as hypokalemia or hyperkalemia. In this case, the patient’s potassium level is elevated (5.6 mEq/L), which could be a result of the body’s attempt to compensate for the loss of other electrolytes. Diarrhea also contributes to the patient’s weakness and lightheadedness due to dehydration.

Choice B reason:

Chronic kidney disease, which has been managed with diuretics and fluid restrictions, is another critical factor. Chronic kidney disease (CKD) affects the body’s ability to regulate fluid and electrolytes. The use of diuretics can exacerbate electrolyte imbalances, particularly potassium levels. In this scenario, the patient’s elevated potassium level (5.6 mEq/L) is concerning, as CKD patients are at higher risk for hyperkalemia due to decreased renal excretion of potassium. The combination of CKD and recent diarrhea increases the complexity of managing the patient’s fluid and electrolyte balance.

Choice C reason:

Lung sounds are clear is an important assessment finding but does not directly correlate with the primary nursing problem of fluid and electrolyte imbalance. While clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection, this finding does not address the immediate concerns related to fluid loss and electrolyte disturbances. Therefore, it is not a priority in this context.

Choice D reason:

No nausea and vomiting is a relevant finding but does not directly correlate with the primary nursing problem. The absence of nausea and vomiting is positive, as it indicates that the patient is not losing additional fluids and electrolytes through emesis. However, it does not address the significant fluid loss from diarrhea or the electrolyte imbalances that are the primary concerns in this scenario.

Choice E reason:

History of hypertension is a relevant factor in the patient’s overall health status. Hypertension can complicate the management of fluid and electrolyte imbalances, particularly in patients with CKD. The use of antihypertensive medications and diuretics can affect electrolyte levels and fluid balance. In this case, the patient’s blood pressure is slightly low (109/70), which could be related to dehydration from diarrhea and the effects of antihypertensive medications. This history is important for understanding the patient’s baseline and potential complications.

Choice F reason:

Blood urea nitrogen (BUN) is elevated at 30 mg/dL, which is above the normal range (6-24 mg/dL). An elevated BUN level indicates impaired kidney function and can be a sign of dehydration or renal insufficiency. In the context of CKD and recent diarrhea, an elevated BUN suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions.

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Which six factors should the nurse consider when choosing a time frame for reassessing the patient’s pain level after implementing pain management?

Nursing Test Bank

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Explanation

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Explanation

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