A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
Clenched teeth
Difficulty swallowing
Constipation
Urinary retention
The Correct Answer is A
The correct answer is A.
Clenched teeth are a sign of unrelieved pain and indicate that the client needs more analgesia from the PCA pump. Difficulty swallowing, constipation, and urinary retention are common side effects of opioids and do not necessarily indicate unrelieved pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Among the options listed, cheese is the food that is contraindicated with MAOI use. Cheese is high in tyramine, and consuming it while taking MAOIs can lead to a potentially life-threatening hypertensive crisis.
An MAOI (Monoamine Oxidase Inhibitor) is a type of medication used to treat depression, anxiety, and other psychiatric disorders. When taking MAOIs, it is important to avoid certain foods that contain high levels of tyramine, as it can lead to a dangerous increase in blood pressure known as a hypertensive crisis.
Choice B reason:
Potatoes: Potatoes are not contraindicated with MAOI use. They do not contain significant levels of tyramine.
Choice C reason:
Grapefruit: Grapefruit is not contraindicated with MAOI use. However, it can interact with certain medications, so it's always a good idea to check with the healthcare provider or pharmacist about specific medication interactions.
Choice D reason:
D. Eggs: Eggs are not contraindicated with MAOI use. Like potatoes, they do not contain significant levels of tyramine.
Correct Answer is A
Explanation
The correct answer is A. Anterior fontanel closed. The anterior fontanel is one of two soft spots on an infant's skull that allow for brain growth and development. The anterior fontanel normally closes between 9 and 18 months of age. If it closes earlier than expected, it may indicate a condition called craniosynostosis, which is when the skull bones fuse prematurely and restrict brain growth. This can lead to increased intracranial pressure, developmental delays, and abnormal head shape. Therefore, if a nurse observes that a 4-month-old infant has a closed anterior fontanel, they should notify the provider for further evaluation. The other options are normal developmental milestones for a 4-month-old
infant and do not require notification of the provider.
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