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","C"]
Explanation
A. Assign the client to a negative-pressure airflow room:Varicella zoster (chickenpox) is highly contagious and can be transmitted through airborne droplets.A negative-pressure airflow room helps prevent the spread of the virus to other patients and healthcare workers.
B.Have visitors remain at least 0.91 m (3 feet) away from the client: While maintaining distance is generally advisable, it is not the primary intervention for varicella. The focus should be on preventing transmission through other means.
C.Initiate contact precautions for the client:Correct!Contact precautions are essential for varicella-zoster patients. This includes using gloves and gowns when in direct contact with the client or their environment. Airborne precautions are also recommended because varicella is highly contagious.
D.Administer aspirin if the client develops a fever: Aspirin is generally avoided in children with varicella due to the risk of Reye’s syndrome. Acetaminophen (paracetamol) is a safer choice for fever management.
Correct Answer is D
Explanation
Ensure that the client has given informed consent.
Obtaining informed consent is a critical step before any medical procedure. It ensures that the client understands the nature of the procedure, its risks, benefits, and alternatives, and voluntarily consents to it. It is essential to ensure that the client has given their informed consent before proceeding with the EGD.
The other options do not directly pertain to the EGD procedure:
- Administering an oral contrast solution is typically not part of the preparation for an EGD.
- Informing the client about the duration of the procedure is important for the client's understanding, but it is not the primary action for the nurse to take.
- Ensuring that the client's bladder is full is not a standard preparation for an EGD.
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