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 C
Explanation
A.If the client is independent, give them privacy to bathe, if they prefer. If leaving a client unattended, check on them every 5 minutes or more frequently as needed. Ensure the client knows how to use safety items such as shower chairs and grab bars.
B.Adding bath oil can make the tub slippery and increase the risk of falls. If used, it should be added before the client gets in, and the client should be made aware so they can be cautious.
C.Draining the tub water before the client gets out helps prevent slips and falls that can occur if the client attempts to exit the tub while the water is still present. This practice enhances safety by reducing the risk of accidents.
D.Tub baths or very warm showers can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of patient discomfort, weakness, or complaints of feeling faint.
Correct Answer is ["A","B","C"]
Explanation
Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma: It is important to ensure that the opening in the skin barrier is slightly larger than the stoma to prevent irritation or pressure on the stoma. This allows for proper fit and helps maintain a secure seal.
Use a mild, non-irritating soap or specifically designed ostomy cleanser to clean the skin around the client's stoma: Harsh soaps or cleansers can irritate the skin around the stoma. Using a moisturizing or gentle cleanser helps maintain the integrity of the skin and reduces the risk of irritation or breakdown.
Empty the client's ostomy pouch before removing the skin barrier: It is important to empty the ostomy pouch to prevent leakage or spillage during the appliance change. This helps maintain cleanliness and prevents potential contamination or soiling of the surrounding area.
The timing of the ostomy appliance change is not specified in the given options. The appropriate timing for changing the ostomy appliance depends on the individual client's needs and preferences. It may be helpful to consider factors such as the client's comfort, schedule, and amount of output in determining the best time for the appliance change. This instruction is not necessary for the teaching session.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today