A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?
Continue the medication dosages that relieve the client’s pain
Contact the provider about replacing the opioid with an NSAID
Administer the benzodiazepine but withhold the opioid
Withhold the benzodiazepine but continue the opioid
The Correct Answer is A
A. Continue the medication dosages that relieve the client’s pain:
Opioids and benzodiazepines are commonly used for pain and anxiety management in terminally ill patients. Somnolence is an expected side effect and does not necessarily warrant withholding medication unless the client shows signs of respiratory depression.
B. Contact the provider about replacing the opioid with an NSAID: NSAIDs are not sufficient for severe pain in terminal illness. Opioids are the gold standard for palliative pain management, and switching to an NSAID would likely lead to uncontrolled pain and unnecessary suffering.
C. Administer the benzodiazepine but withhold the opioid: This would leave the client in severe pain, which is unethical in hospice care. Pain relief should not be withheld solely due to sedation.
D. Withhold the benzodiazepine but continue the opioid: Benzodiazepines are often used to relieve anxiety, dyspnea, and agitation in end-of-life care. Withholding it could cause increased distress for the client. Instead of discontinuing the medication, the nurse should monitor for respiratory depression and adjust doses only if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Green:
Green triage tags are typically used for "walking wounded" or patients with minor injuries who can wait longer for treatment. These patients are considered to have non-life-threatening injuries and can be managed after more critical patients have been stabilized.
b. Yellow:
Yellow triage tags are used for patients with moderate injuries who require medical attention but are not in immediate danger of death. These patients may have significant injuries that require timely treatment but do not have life-threatening conditions.
c. Black:
The black tag is used for patients who are not expected to survive due to severe injuries or critical conditions. In the case of full-thickness burns covering a large percentage of the body (such as 72%), the patient’s prognosis is poor, and immediate care resources should be allocated to those with a higher chance of survival.The black tag indicates that the patient’s injuries are incompatible with life, and comfort measures may be provided, but resuscitation efforts are not a priority.
d. Red:
Red triage tags are used for patients with life-threatening injuries who require immediate medical attention to survive. These patients have critical conditions that require rapid assessment, stabilization, and treatment to prevent further deterioration and improve outcomes.
Correct Answer is D
Explanation
a. "I am not sure how I will pay for all the therapy I will need":
"I am not sure how I will pay for all the therapy I will need":This statement expresses a concern about financial matters related to medical expenses and therapy costs. It is relevant for social services or a financial counselor, not an occupational therapist.This indicates a need for assistance with financial planning and resources, possibly involving a social worker or a financial advisor, rather than an OT.
b. "I hope I can adjust to using crutches while I am recovering":
"I hope I can adjust to using crutches while I am recovering":This statement reflects a concern with mobility and the use of assistive devices, such as crutches, during recovery. While this is an important aspect of rehabilitation, it is typically within the scope of physical therapy (PT) rather than occupational therapy.Physical therapists specialize in improving mobility, strength, and the proper use of mobility aids. Therefore, this would be more relevant for a PT referral.
c. "I just don’t think I can handle looking at my leg":
This statement indicates emotional distress and difficulty in accepting the physical changes after the amputation. This is an important issue, but it suggests a need for psychological support rather than OT intervention.This would be more appropriate for a referral to a mental health professional or counselor to address emotional and psychological concerns related to body image and adjustment.
d. "I am worried about taking care of my toddler":
This statement highlights a concern about the client's ability to manage daily tasks and care for a dependent (in this case, a toddler) at home after the surgery. Occupational therapists specialize in helping clients adapt to daily living activities and manage home responsibilities effectively despite physical limitations.
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