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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Opening the dampers of fireplaces: This instruction is not appropriate during an outdoor chemical disaster. Opening the dampers of fireplaces can allow contaminated air from outside to enter the home, increasing exposure to hazardous substances. It is best to avoid introducing outdoor air into the home during such incidents.
B. Turning on ceiling fans and air conditioners: This instruction is also not recommended during an outdoor chemical disaster. Turning on fans and air conditioners can potentially circulate contaminated air within the home, leading to increased exposure. It is best to turn off fans and air conditioners during such incidents and focus on evacuating the area.
C. Covering heat registers with plastic and tape:This would help seal the house and prevent contaminated air from entering through heating vents.
D. While evacuation is essential in some situations (such as fires), it’s not the first step during a chemical disaster.Immediate evacuationmay not be safe if the outdoor environment is hazardous. First, take protective measures within the home.
Correct Answer is C
Explanation
Fontanels are soft spots on an infant's skull where the bones have not yet fused together. The anterior fontanel, located at the front of the head, typically closes between 12 to 18 months of age. The posterior fontanel, located at the back of the head, usually closes by 2 to 3 months of age.
The other findings mentioned are typical developmental milestones for a 4-month-old infant:
1. Rolling from back to abdomen: By 4 months of age, it is expected that infants can roll from their back to their abdomen. This is a normal developmental milestone.
2. Moves objects to mouth: At 4 months, infants begin to develop hand-eye coordination and the ability to reach for objects. Bringing objects to the mouth is a typical behavior at this age as infants explore their environment.
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