A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?
Obtain a prescription to adjust the weight amount.
Realign the client's position.
Offer a muscle relaxant to the client.
Administer an opioid analgesic.
The Correct Answer is B
B. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.
A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.
C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.
D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.
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Related Questions
Correct Answer is A
Explanation
A. Muscle spasms can occur in response to the hip fracture as the body attempts to protect the injured area. Spasms may cause pain and muscle rigidity in the affected hip.
B. Pallor refers to paleness of the skin. While hip fractures can result in various signs and symptoms such as pain, swelling, and bruising, hip pallor specifically is not typically associated with a hip fracture.
C. Leg abduction refers to moving the leg away from the midline of the body. In the case of a hip fracture, the affected leg may be held in adduction (closer to the midline) due to pain and muscle guarding.
D. Leg lengthening is not typically associated with a hip fracture. In fact, a hip fracture can often lead to apparent leg shortening due to displacement or angulation of the fractured bone.
Correct Answer is C
Explanation
C. This option is appropriate as the current treatment protocol is not effectively managing the patient's pain. The nurse can collaborate with the healthcare provider to reassess the patient's pain management needs and explore alternative strategies or adjustments to the PCA regimen.
A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.
B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.
D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.
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