A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?
Cheyne-Stokes respirations
Mottled skin
Constricted pupils
Grimacing
The Correct Answer is D
Choice A reason: Cheyne-Stokes respirations, alternating hyperventilation and apnea, indicate neurological dysfunction or end-of-life changes in brain tumor patients, not pain. This reflects brainstem involvement, requiring respiratory management rather than analgesics, as it is a physiological response to disease progression in palliative care.
Choice B reason: Mottled skin signals poor perfusion or impending death, common in palliative care as circulation declines. It is not a pain indicator but a sign of systemic shutdown, requiring comfort measures like warmth, not analgesics, which are irrelevant to this physiological change in terminal illness.
Choice C reason: Constricted pupils may reflect opioid effects or neurological changes in brain tumor patients but do not directly indicate pain. They suggest autonomic or brainstem dysfunction, necessitating neurological assessment, not immediate pain medication, in palliative care where comfort is prioritized based on clear pain cues.
Choice D reason: Grimacing indicates pain in palliative care patients with brain tumors, reflecting physical discomfort. As a facial expression of distress, it signals the need for analgesics to improve comfort and quality of life, aligning with palliative goals to manage pain effectively in end-stage disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Warming blood products prevents hypothermia during transfusion but is not the priority in a trauma patient. Airway management takes precedence, as oxygenation is critical to survival. Administering blood products comes later in the trauma algorithm, after securing the airway and stabilizing breathing, making this action secondary.
Choice B reason: Establishing a patent oral airway is the first priority in trauma care, following the ABCs (Airway, Breathing, Circulation). A clear airway ensures oxygenation, critical for preventing hypoxia in a patient with multiple injuries. Without a patent airway, other interventions are ineffective, as oxygen delivery is essential for survival and organ function.
Choice C reason: Creating a sterile field for wound care is important to prevent infection but is not the first priority in a trauma patient. Airway and breathing take precedence, as immediate life-threatening issues like hypoxia or shock must be addressed before wound care, making this action lower in priority.
Choice D reason: Administering IV fluids to maintain blood pressure is part of the circulation phase in trauma care but follows airway and breathing stabilization. Without a patent airway, fluid administration cannot address hypoxia, a primary cause of mortality in trauma. This action is secondary to ensuring airway patency.
Correct Answer is B
Explanation
Choice A reason: The lactation amenorrhea method is effective only up to 6 months postpartum, and only if exclusive breastfeeding and amenorrhea are maintained. It is not reliable for 12 months, so this statement is inaccurate, making it incorrect for contraception teaching.
Choice B reason: Placing the transdermal contraceptive patch on the upper arm or back ensures proper adhesion and absorption. This aligns with manufacturer guidelines for effective contraception, making it a correct and appropriate instruction for postpartum clients seeking reliable methods.
Choice C reason: A diaphragm used before pregnancy may no longer fit due to pelvic changes post-delivery. It requires refitting 6 weeks postpartum, so continuing use without adjustment is ineffective and risky, making this incorrect.
Choice D reason: Starting oral contraceptives immediately after delivery is not recommended, especially for breastfeeding mothers, due to risks like reduced milk supply or thromboembolism. Initiation typically begins 3-6 weeks postpartum, making this incorrect and unsafe.
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