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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Related Questions
Correct Answer is C
Explanation
Giving change -of-shift report to a nurse outside the client’s room
Protecting client confidentiality is an essential aspect of providing healthcare. Confidentiality ensures that sensitive client information remains private and is not disclosed to unauthorized individuals.
Giving change-of-shift report to a nurse outside the client's room: This is an appropriate action as long as the nurse ensures that the conversation occurs in a private and secure location where unauthorized individuals cannot overhear the discussion. This protects the client's confidentiality while allowing for effective communication and continuity of care.
Discarding worksheets containing client information in a wastebasket in (option A) is not an appropriate action, as discarding worksheets containing client information in a wastebasket can expose the information to unauthorized individuals. Instead, the nurse should follow proper procedures for the disposal of confidential information, such as shredding or using secure disposal methods.
Writing a client's diagnosis on the message board in the client's room in (option B) is not an appropriate action, as it can compromise the client's privacy. The nurse should avoid posting or displaying any client- specific information in public areas where it can be accessed by unauthorized individuals. Confidential information should be shared only on a need-to-know basis with healthcare professionals involved in the client's care.
Discussing a client's prognosis with assistive personnel who is caring for the client in (option D) is not an appropriate action, as discussing a client's prognosis with unauthorized individuals breaches the client's confidentiality. Prognosis and sensitive medical information should be discussed only among healthcare professionals directly involved in the client's care and on a need-to-know basis.
Correct Answer is C
Explanation
This statement reflects appropriate newborn care as newborns have sensitive skin, and using soap on the face can cause irritation. Washing the baby's face with a warm, wet washcloth is a gentle and effective way to clean the baby's face without the need for soap.
Moist towelettes may not be suitable for cleaning a newborn's head as they may contain chemicals or fragrances that can be harsh on the baby's delicate skin. It is generally recommended to use a soft, damp cloth for cleaning the baby's head.
Bathing a newborn under a faucet of running water can be unsafe as the water temperature may fluctuate and pose a risk of scalding. It is recommended to use a baby bathtub or a basin with warm water for bathing the baby.
Newborns do not need to be bathed daily as frequent bathing can strip their skin of natural oils and cause dryness. It is generally recommended to bathe newborns 2-3 times a week or as needed, focusing on areas that need cleaning such as the diaper area and skin folds.
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