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 A
Explanation
Insulin lispro is a rapid-acting insulin, while insulin glargine is a long-acting insulin. It is important to keep them separate to maintain their individual properties and avoid any potential interactions or changes in their effectiveness.
Insulin glargine is a clear solution and should not appear cloudy. Cloudiness in insulin can indicate contamination or improper storage.
The instruction to "take an extra dose of insulin lispro prior to aerobic exercise" is not recommended. The client should consult with their healthcare provider to determine if any adjustments to their insulin regimen are necessary for exercise. Typically, adjustments are made based on the individual's blood glucose levels and anticipated intensity and duration of exercise. Insulin glargine is a long-acting insulin that provides a steady release of insulin over a prolonged period, without distinct peaks or valleys in its action. Its onset of action is gradual and its effect lasts for approximately 24 hours.
It is important for the client to receive accurate and appropriate instructions regarding their insulin regimen. The nurse should clarify any misunderstandings and provide accurate information to promote safe and effective diabetes management.
Correct Answer is A
Explanation
This statement reflects an important recommendation for car seat safety. It is recommended to keep infants and toddlers rear-facing in their car seats until they reach the age of 2 or until they outgrow the height and weight limits specified by the car seat manufacturer. Rear-facing car seats provide better protection for the child's head, neck, and spine in the event of a crash.
"I should position the car seat's retainer clip at the level of my baby's belly button." The correct position for the retainer clip is at the armpit level. It should be positioned across the chest, resting on the bony part of the child's shoulders. Placing the retainer clip at the level of the belly button can be unsafe and may not provide proper protection.
"I should enable the airbag when my baby is in the front seat of the car." It is not recommended to place a rear-facing car seat in the front seat of a vehicle with an active airbag. The force of the airbag deployment can cause serious injuries to the child. The safest place for a rear-facing car seat is in the back seat of the vehicle.
"I should place my baby in the car seat at a 90-degree angle." The angle at which the car seat is installed depends on the specific instructions provided by the car seat manufacturer. It is important to follow the manufacturer's guidelines for proper installation. Some car seats have built-in angle indicators or adjustable recline positions to help achieve the correct angle for optimal safety.
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