A nurse enters a client’s room to answer the call light and finds the client on the bathroom floor. What should be the nurse’s initial action?

Choice A rationale:

Recapping needles is a dangerous practice that significantly increases the risk of needlestick injuries.

The act of recapping involves directing the sharp end of the needle towards one's hand, creating a high likelihood of accidental puncture.

Even experienced healthcare professionals are susceptible to needlestick injuries during recapping.

Wastebaskets are not designed for the safe disposal of sharps and can easily be punctured, leading to potential exposure to bloodborne pathogens.

Choice B rationale:

While it is true that needles should not be recapped on ABG specimens, this option does not address the broader issue of safe needle disposal in general.

Focusing solely on ABG specimens could lead to the misconception that recapping is acceptable for other types of needles.

Choice D rationale:

Breaking needles in half is not recommended as a standard practice for needle disposal.

This action can create sharp fragments that are difficult to handle and can still cause injuries.

Sharps disposal containers are designed to safely contain intact needles and should be used as the primary method of disposal.

Choice C rationale:

Placing uncapped needles directly into a puncture-proof container is the safest and most recommended practice for needle disposal.

These containers are specifically designed to prevent needlestick injuries by shielding the sharps from accidental contact. They are typically made of hard plastic or metal and are clearly labeled for biohazard waste.

Using puncture-proof containers consistently for all needle disposal significantly reduces the risk of needlestick injuries among healthcare workers.

Choice A rationale:

Chronic pain can manifest in various behavioral and physical symptoms, including restlessness, pacing, grimacing, and other facial expressions of pain. These behaviors are often unconscious attempts to cope with or distract from the pain.

They may also reflect the emotional distress that often accompanies chronic pain. Patients may feel frustrated, anxious, or even depressed due to the persistent nature of their pain and its impact on their lives.

It's crucial for nurses to recognize these behavioral signs of pain, as patients may not always readily report their pain verbally. By observing these behaviors, nurses can assess the patient's pain level more accurately and provide appropriate interventions.

Choice B rationale:

Chronic pain is defined as pain that persists for longer than three months, often for much longer. It is not limited and short in duration.

This distinguishes it from acute pain, which is typically associated with an injury or illness and resolves within a few days or weeks.

Choice C rationale:

While some patients with chronic pain may have physical signs of tissue injury, this is not always the case. Chronic pain can also be caused by nerve damage, inflammation, or changes in the central nervous system.

In some cases, the underlying cause of chronic pain may be unknown.

Choice D rationale:

Although chronic pain may not always cause a significant change in vital signs, it can still be a very real and debilitating experience for patients.

Vital signs, such as heart rate, blood pressure, and respiratory rate, are often more sensitive to acute pain.

Nurses should not rely solely on vital signs to assess chronic pain. Instead, they should consider the patient's self-report of pain, behavioral cues, and other factors.