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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Correct answer: D

veracity, in (option A) is incorrect because it refers to telling the truth and being honest with the client. While the nurse's action in obtaining a healthy meal for the client is a positive action, it is not directly related to veracity.

countertransference in (option B) is incorrect because it, refers to the nurse's emotional or personal reaction towards the client that may influence their behaviour or response. It is not applicable to the scenario described.

C. Boundary Crossing happens when a professional line is blurred. In this case, the nurse prioritizes the client's well-being, not a personal connection.

D. Promoting trust involves actions that build rapport, establish a therapeutic relationship, and demonstrate caring and empathy towards the client. By interrupting the bath to obtain a healthy meal for the client, the nurse shows responsiveness to the client's needs, which can enhance trust and confidence in the nurse's care

A. "I will use an astringent on my face." B. "I will cleanse my skin using an antibacterial soap." C. "I will dry my skin by patting it with a towel." D. "I will limit my time in the tanning bed to 15 minutes."

Correct Answer is C

Explanation

Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect the skin. Proper skin care is important for individuals with SLE to minimize potential flare-ups or exacerbation of skin symptoms. The recommended approach to skin care in SLE includes gentle cleansing and moisturizing.

"I will use an astringent on my face." Astringents are typically not recommended for individuals with SLE as they can be harsh on the skin and may cause irritation or dryness.

"I will cleanse my skin using an antibacterial soap." While it is important to keep the skin clean, using an antibacterial soap is not specifically required for individuals with SLE. Gentle,

Non-irritating cleansers without antibacterial properties are generally recommended.

"I will limit my time in the tanning bed to 15 minutes." Exposure to ultraviolet (UV) radiation, such as from tanning beds, can be particularly harmful to individuals with SLE. UV radiation can trigger or worsen skin manifestations and may lead to disease flares. Therefore, it is generally advised for individuals with SLE to avoid tanning beds altogether.

In addition to gentle cleansing and moisturizing, individuals with SLE should also practice sun protection, including wearing sunscreen with a high sun protection factor (SPF) and using protective clothing and accessories (such as hats and sunglasses) when exposed to the sun. Regular check-ups with a healthcare provider and following their recommendations are important for managing SLE and its associated skin manifestations.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Correct Answer is D

Explanation

A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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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?