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
Nitroglycerin is a common medication used to relieve chest pain associated with angina. However, if the client is experiencing ongoing chest pain, it is important to follow the prescribed instructions for nitroglycerin administration, which may involve taking additional doses if needed, as instructed by the healthcare provider. Calling the provider after taking one dose may not address ongoing chest pain adequately.
This action, known as the Valsalva maneuver, is not recommended for managing chest pain associated with stable angina. The Valsalva maneuver involves forcibly exhaling while keeping the mouth and nose closed, which can temporarily decrease blood flow to the heart and may exacerbate chest pain.
Aspirin can be beneficial during angina episodes. However, the recommended dose is usually 162 to 325 milligrams (one tablet). Taking two tablets at once may not be necessary unless specifically advised by a healthcare provider..
I will stop what I am doing and lie down.” Correct: This statement demonstrates an understanding of appropriate action. When experiencing angina, the client should stop any physical activity, sit down, or lie down. Resting helps reduce the heart’s workload and allows blood flow to stabilize.
Correct Answer is D
Explanation
Including the client's physical assessment findings will provide important information to the physical therapist regarding the client's current condition, limitations, and areas that require rehabilitation or therapy.
While family medical history is important for comprehensive healthcare, it may not be specifically relevant to the referral for a physical therapist unless there is a specific genetic or familial condition that could impact the therapy or rehabilitation process.
Medical health insurance claims are primarily related to billing and reimbursement and may not provide pertinent information to the physical therapist unless there are specific coverage limitations or requirements that need to be considered.
While medication history is important for overall healthcare management, it may not be directly relevant to the referral for a physical therapist unless there are specific medications that could affect the therapy or rehabilitation process (e.g., medications that may cause drowsiness or affect balance).
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