A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?
Determine the time the last dose of pain medication was administered.
Reposition the client to assist with reduction of pain.
Ask the client to describe the pain and rate it on a scale of 0 to 10.
Check the client’s medical record for type of PRN pain medication.
The Correct Answer is C
Choice A Reason
Determine the time the last dose of pain medication was administered. While it is important to know when the last dose of pain medication was given, assessing the client’s current pain level is a priority. This helps in understanding the severity and nature of the pain, which guides further interventions.
Choice B Reason
Reposition the client to assist with reduction of pain. Repositioning can help alleviate pain, but it should be done after assessing the pain. Without understanding the pain’s characteristics, repositioning might not address the underlying issue effectively.
Choice C Reason
Ask the client to describe the pain and rate it on a scale of 0 to 10. This is the correct first action. Pain assessment is crucial in determining the appropriate intervention. By asking the client to describe and rate their pain, the nurse can tailor the pain management plan to the client’s specific needs.
Choice D Reason
Check the client’s medical record for type of PRN pain medication. Reviewing the medical record for PRN pain medication is important, but it should follow the initial pain assessment. Knowing the pain’s intensity and characteristics will help in deciding whether PRN medication is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason
Diazepam IV is the correct choice for managing repeated tonic-clonic seizures, especially in the context of status epilepticus. Diazepam is a benzodiazepine that acts quickly to stop seizures by enhancing the effect of the neurotransmitter GABA. It is commonly used in emergency settings due to its rapid onset of action when administered intravenously.
Choice B Reason
Lorazepam PO is not the best choice in this scenario. While lorazepam is also a benzodiazepine effective in stopping seizures, the oral route is not suitable for immediate control of seizures. Intravenous administration is preferred for rapid action.
Choice C Reason
Diltiazem IV is incorrect. Diltiazem is a calcium channel blocker used primarily for managing hypertension and certain types of arrhythmias. It is not indicated for the treatment of seizures.
Choice D Reason
Clonazepam PO is not appropriate for immediate seizure control. Although clonazepam is a benzodiazepine used for seizure management, the oral route is not effective for rapid seizure termination. Intravenous administration of a benzodiazepine like diazepam or lorazepam is preferred.
Correct Answer is A
Explanation
Choice A Reason
Expressive aphasia is a common symptom of a left-hemisphere stroke. This condition, also known as Broca’s aphasia, affects the ability to produce language, making it difficult for the patient to speak fluently. The patient may understand speech but struggle to form coherent sentences, often speaking in short, choppy phrases.
Choice B Reason
Poor impulse control is more commonly associated with right-hemisphere strokes. The right hemisphere of the brain is responsible for controlling impulsive behavior and emotional regulation. Therefore, this symptom is less likely to be observed in a patient with a left-hemisphere stroke.
Choice C Reason
Left hemiparesis refers to weakness on the left side of the body. Since the left hemisphere of the brain controls the right side of the body, a left-hemisphere stroke typically results in right-sided weakness or paralysis. Therefore, left hemiparesis is not a typical finding in this scenario.
Choice D Reason
Disorientation to place can occur after a stroke, but it is not specifically associated with left-hemisphere strokes. Disorientation is a general symptom that can result from various types of brain injuries and is not exclusive to strokes affecting the left hemisphere.
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