A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.

Exhibits

Complete the following sentence by selecting the most appropriate actions based on the client’s current status.

The nurse should first
dropdown
then
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

The nurse should first: Response 1: Notify the primary health care provider immediately.

This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.

Then, the nurse should: Response 2: Start an IV line for potential medication administration.

Starting an IV line ensures that the client can receive any necessary medications quickly.

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Correct Answer is C

Explanation

Choice A rationale

Reminding the client that they must receive the medication as prescribed may increase their anxiety and does not address the fear of needles. It is essential to consider the client's emotional state and explore alternative solutions.

Choice B rationale

Telling the client not to worry because the pain will be temporary does not validate their fear or provide a solution to their anxiety about needles. It is important to address the client's concerns empathetically.

Choice C rationale

Requesting a change in the medication route to PO addresses the client's fear of needles directly and provides an alternative method of administration. This approach considers the client's comfort and preferences while ensuring they receive the necessary medication.

Choice D rationale

Asking one of the client's loved ones to encourage them to receive the IM medication may help, but it does not address the underlying fear of needles. It is essential to find a solution that directly addresses the client's anxiety.

A. "I think about my grandfather's farm to reduce pain.”. B. "I listen to my favorite music to take my mind off the pain.”. C. "I use focused breathing to control my pain.”. D. "I learn to notice the sensation of muscle tension.”.

Correct Answer is A

Explanation

Choice A rationale

Guided imagery involves the use of mental visualization to relieve stress and manage pain. By thinking about a peaceful setting, such as the client’s grandfather's farm, they can divert attention from the pain and enter a state of relaxation. This technique helps reduce pain perception by engaging the mind in positive, soothing imagery, which can lead to decreased stress and muscle tension.

Choice B rationale

Listening to music is a distraction technique rather than guided imagery. While it can help take the mind off pain, it does not involve the mental visualization process that is central to guided imagery. Music can help by shifting attention away from pain and providing a calming effect through auditory stimulation.

Choice C rationale

Focused breathing is a relaxation technique that can help manage pain through controlled breathing patterns. It helps reduce anxiety and physical tension by focusing on slow, deep breaths. However, it does not involve the imaginative visualization that characterizes guided imagery.

Choice D rationale

Noticing the sensation of muscle tension is part of body awareness techniques, which involve paying attention to and understanding bodily sensations. While this can help in managing pain by addressing muscle tension, it is different from the mental visualization process of guided imagery.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder.As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles.”. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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