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","D","E"]
Explanation
Choice A reason: Instructing pregnant visitors to stay 3 feet away is insufficient, as radiation from a sealed implant requires greater distance (typically 6 feet) or complete avoidance. Pregnant individuals should not visit to minimize fetal exposure, making this precaution inadequate and incorrect for safety.
Choice B reason: Wearing a lead apron shields the nurse from radiation exposure during close contact with the sealed implant, adhering to ALARA (As Low As Reasonably Achievable) principles. This protects the nurse while providing care, making it a necessary and correct safety measure.
Choice C reason: Placing the client in a semi-private room is unsafe, as radiation from the implant could expose other patients. A private room is required to minimize radiation risk to others, making this action incorrect and against radiation safety protocols.
Choice D reason: Closing the client’s door reduces radiation exposure to others outside the room, as sealed implants emit continuous radiation. This containment measure, combined with signage, ensures safety for staff and visitors, making it a correct and essential action.
Choice E reason: Limiting visitors to 30 minutes per day minimizes cumulative radiation exposure, protecting visitors from the sealed implant’s emissions. Time restrictions are standard in radiation safety protocols, ensuring minimal risk while allowing controlled visits, making this a correct action.
Correct Answer is C
Explanation
Choice A reason: Applying testosterone gel to the genital region is contraindicated, as it increases irritation and absorption variability. It should be applied to clean, dry skin on the shoulders, upper arms, or abdomen to ensure safety and efficacy, making this action incorrect and unsafe.
Choice B reason: Checking testosterone levels in 1 week is premature, as steady-state levels typically require 2-4 weeks to stabilize. Monitoring too early may yield inaccurate results, leading to improper dose adjustments. This timing is not standard, making it an incorrect instruction.
Choice C reason: Advising the client to wait 1 hour before showering or swimming ensures adequate absorption of testosterone gel through the skin. Premature water exposure can wash off the gel, reducing efficacy. This aligns with manufacturer guidelines, making it the correct action.
Choice D reason: Applying testosterone gel every other day is incorrect, as daily application maintains consistent hormone levels for hypogonadism treatment. Alternate-day dosing disrupts therapeutic levels, reducing effectiveness. Daily use is standard, making this instruction inappropriate for proper administration.
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