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 D
Explanation
Choice A reason: Avoiding reading for 3 months is not a standard instruction post-retinal detachment surgery. Reading may be restricted temporarily (e.g., 1-2 weeks) if specific positioning is required, but 3 months is excessive. Patients are typically advised to avoid straining, not reading, making this instruction incorrect.
Choice B reason: Bending at the waist increases intraocular pressure, which can disrupt retinal repair and lead to re-detachment. Patients should bend at the knees to avoid straining the eye. This instruction is harmful and contraindicated, as it risks complications in the healing retina.
Choice C reason: Lifting objects up to 50 pounds is dangerous post-retinal surgery, as heavy lifting increases intraocular pressure, risking re-detachment. Guidelines typically restrict lifting to 10-20 pounds during recovery (4-6 weeks). This instruction is incorrect, as it poses a significant risk to surgical outcomes.
Choice D reason: Taking a stool softener daily prevents straining during bowel movements, which can increase intraocular pressure and disrupt retinal healing. Constipation is a concern post-surgery due to immobility or pain medications, and stool softeners ensure safe bowel movements, making this the correct instruction.
Correct Answer is A
Explanation
Choice A reason: Encouraging open communication fosters dialogue, allowing nurses to resolve conflicts directly. This reduces tension and improves teamwork by addressing interpersonal issues, aligning with psychological principles of conflict resolution. Effective communication mitigates misunderstandings, enhancing collaboration in high-stress healthcare environments.
Choice B reason: Assigning an external mediator may help but is premature without trying internal resolution. Encouraging team dialogue leverages existing relationships, fostering cohesion. External mediators may not address unit-specific dynamics, making internal communication a more effective first step in resolving nurse conflicts.
Choice C reason: Mandatory team-building exercises may improve morale but do not directly resolve specific conflicts. Forcing participation can increase resentment if issues persist. Communication-based strategies target root causes, making them more effective for conflict resolution in healthcare teams compared to generic team-building.
Choice D reason: Reassigning nurses to different shifts avoids conflict but disrupts workflow and patient care continuity. It fails to address underlying issues, allowing tensions to persist. Communication-focused approaches promote resolution, maintaining team integrity and collaboration in healthcare settings, unlike reassignment.
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