A home health nurse is planning to use nonpharmacological pain relief measures for a client who has severe chronic back pain. Which of the following pain management guidelines should the nurse use?

Discontinue opioids before trying nonpharmacological methods of pain relief.

Pain relief from the use of heat and cold continues for several hours after removal of the stimulus.

Use imagery with clients who have difficulty with focus and concentration.

Distraction changes the client's perception of pain, but it does not affect the cause.

Answer and Explanation

The Correct Answer is D

A. Discontinue opioids before trying nonpharmacological methods of pain relief: Nonpharmacological interventions can be used alongside opioids to enhance pain relief. Abruptly discontinuing opioids can lead to withdrawal symptoms and inadequate pain control.

B. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus: While heat and cold therapy can provide temporary relief, their effects typically last for a short duration, usually around 15 to 30 minutes after removal.

C. Use imagery with clients who have difficulty with focus and concentration: Guided imagery requires cognitive focus and the ability to concentrate. Clients with impaired attention may struggle to benefit from this technique.

D. Distraction changes the client's perception of pain, but it does not affect the cause: Distraction techniques, such as music or conversation, help shift the client's attention away from pain, altering perception but not addressing the underlying pathology.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Myocardial infarction: The rising troponin levels (Troponin T increasing from 0.08 ng/mL to 0.2 ng/mL and Troponin I rising from 0.01 ng/mL to 0.1 ng/mL) indicate myocardial injury. Persistent chest tightness, shortness of breath, diaphoresis, and anxiety suggest ongoing ischemia. The lack of complete pain relief after nitroglycerin further supports myocardial infarction rather than stable angina.
Pulmonary embolism: Shortness of breath is a symptom of pulmonary embolism, but the absence of acute hypoxia, pleuritic chest pain, or significant coagulation abnormalities makes this less likely. The client's symptoms and laboratory findings more strongly support a cardiac etiology.
Bleeding: While thrombolytic therapy increases bleeding risk, the aPTT (32 seconds) and platelet count (350,000/mm³) are within normal limits. There are no reported signs of active bleeding, such as hypotension, bruising, or hematuria, making this a less relevant immediate concern.
Shortness of breath: Often present in myocardial infarction due to decreased cardiac output and pulmonary congestion. The combination of chest pain, diaphoresis, and dyspnea suggests worsening ischemia rather than a primary pulmonary process. However, it is a nonspecific symptom that can also indicate pulmonary embolism or respiratory distress.
aPTT levels: Normal at 32 seconds (reference: 30–40 seconds), which suggests no immediate risk of abnormal clotting or excessive anticoagulation. This finding does not directly indicate myocardial infarction but is important in monitoring bleeding risk with thrombolytic therapy. A significantly elevated aPTT could raise concern for hemorrhagic complications.
Elevated troponin levels: A highly specific marker for myocardial injury. The rise in Troponin T and Troponin I over time confirms myocardial damage, distinguishing acute coronary syndrome from stable angina. This trend is critical in diagnosing myocardial infarction, as troponin elevation correlates with the extent of cardiac muscle injury.

A. Blood glucose level B. Bowel sounds C. Blood pressure D. Pain level E. Electrocardiogram findings F. Lung sounds G. Troponin T level

Correct Answer is ["C","D","E","G"]

Explanation

Pain level: Chest pain rated at 7/10 with radiation to the left arm, along with diaphoresis and nausea, indicates a potential acute coronary syndrome, likely a myocardial infarction. Immediate intervention is necessary to relieve pain and address the underlying cause, as this could prevent further complications and potential cardiac damage.
Electrocardiogram findings: ST-segment elevation and T wave changes suggest an ST-elevation myocardial infarction (STEMI), which requires urgent medical attention. Prompt identification and activation of treatment protocols, such as percutaneous coronary intervention (PCI) or thrombolytic therapy, are critical to restore blood flow and minimize myocardial damage.
Troponin T level: An elevated troponin T level (0.40 ng/mL, with a normal range <0.1 ng/mL) indicates myocardial injury, supporting the diagnosis of an acute myocardial infarction. Immediate management is essential to mitigate further cardiac injury and ensure appropriate treatment is initiated based on the severity of the elevation.
Blood pressure: While the blood pressure reading of 164/80 mm Hg indicates hypertension, it is not critically high and does not require immediate intervention like the other findings. However, elevated blood pressure in the context of a myocardial infarction can increase myocardial oxygen demand, leading to further complications, thus it should be monitored closely.

Blood glucose level: The blood glucose level of 103 mg/dL is within normal limits (74-106 mg/dL) and does not indicate an immediate concern. Although monitoring blood glucose is essential in clients with diabetes, it is not a priority in the context of acute coronary syndrome.
Bowel sounds: The presence of bowel sounds indicates gastrointestinal function and does not require immediate follow-up in this context. While it’s important to assess overall health, bowel sounds are not a priority when addressing acute cardiac symptoms.
Lung sounds: Clear lung sounds indicate that there is no pulmonary congestion or other respiratory complications at this time. While lung assessment is essential for overall patient evaluation, clear lung sounds do not require immediate follow-up in this acute setting.

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A home health nurse is planning to use nonpharmacological pain relief measures for a client who has severe chronic back pain. Which of the following pain management guidelines should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has angina. Complete the following sentence by using the lists of options. The client is at risk for developing ....... due to .......

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

Correct Answer is ["C","D","E","G"]

Explanation

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