A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc.
Which of the following findings should the nurse identify as an indicator of unrelieved pain?
Urinary retention
Constipation
Difficulty swallowing
Restlessness
The Correct Answer is D
Restlessness can be an indicator of unrelieved pain in a client who is receiving a spinal epidural to treat a herniated disc. Restlessness is often a manifestation of discomfort or agitation, which can be caused by inadequate pain management. When a client's pain is not adequately relieved, they may exhibit restlessness as they try to find a more comfortable position or seek relief from the discomfort.
Urinary retention (option A) is incorrect because it can be a side effect of certain medications used in pain management, such as opioids, but it is not a specific indicator of unrelieved pain. It is important to monitor for urinary retention as a potential complication of spinal epidural anaesthesia, but it is not directly related to pain relief.
Constipation (option B) is incorrect because it is another possible side effect of opioid medications, but it is not a specific indicator of unrelieved pain. It is important to address constipation as a potential adverse effect of pain management, but it is not a direct indicator of pain relief.
Difficulty swallowing (option C) is incorrect because it is not a common indicator of unrelieved pain in the context of a spinal epidural. It may be associated with other conditions or complications but is not specifically related to pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should describe hyperactive bowel sounds as sounds that are loud, high-pitched and increased in frequency and intensity. They are more frequent than normal bowel sounds, with a rapid succession of sounds occurring at a rate greater than 5 to 30 sounds per minute.
Hyperactive bowel sounds can be heard in conditions such as gastroenteritis, diarrhea, and early mechanical bowel obstruction. They indicate increased bowel motility and are often associated with increased peristalsis.
To differentiate hyperactive bowel sounds from normal or hypoactive bowel sounds, the nurse can explain that hypoactive bowel sounds are decreased or absent sounds that occur when the bowel motility is decreased, such as in conditions like paralytic ileus or after abdominal surgery. Normal bowel sounds are typically soft, low-pitched, and occur at a rate of 5 to 30 sounds per minute.
Correct Answer is B
Explanation
Isolate children who have varicella until the vesicles have formed crusts.
Isolating children who have varicella, also known as chickenpox, until the vesicles (blisters) have formed crusts is an important infection control measure. Varicella is highly contagious, and the fluid-filled vesicles can easily spread the virus to others. Keeping the child isolated until the vesicles have crusted over helps prevent the spread of the disease.
Children who have erythema infectious, commonly known as fifth disease in (option A) is incorrect because they, do not require short-term antibiotic therapy. Fifth disease is a viral infection caused by parvovirus B19 and is usually a self-limiting condition that resolves on its own without specific treatment.
Administration of childhood immunizations, such as the MMR (measles, mumps, rubella) vaccine in (option C) is incorrect because it, does not prevent exanthem subitem, also known as roseola infantum. Roseola infantum is usually a mild viral illness that primarily affects infants and young children. It is caused by human herpesvirus 6 (HHV-6) or human herpesvirus 7 (HHV-7) and is characterized by high fever followed by a rash.
Restricting fluids for children who have pertussis (whooping cough) in (option D) is not appropriate. In fact, it is important to encourage adequate fluid intake to prevent dehydration, especially in children who may have difficulty eating or drinking due to persistent coughing spells. Pertussis is a bacterial infection, and treatment typically involves antibiotics and supportive care.
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