A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is a subjective indication that the client needs PRN pain medication?

The client's heart rate is 110/min.

The client is guarding their abdominal incision.

The client exhibits facial grimacing.

The client reports pain.

Answer and Explanation

The Correct Answer is D

The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.

Explanation for the other options:

a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.

b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.

c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.

In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.

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Correct Answer is C

Explanation

c. Hallucination

In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).

In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.

Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.

Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.

Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.

Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.

A. Increased heart rate. B. Increased cardiac output. C. Decreased urinary output. D. Decreased potassium level.

Correct Answer is B

Explanation

The nurse should include increased cardiac output as an expected eﬀect of digoxin when reinforcing teaching with the client. Digoxin is a positive inotropic medication that strengthens the force of contraction of the heart, resulting in increased cardiac output.

Option a, increased heart rate, is not an expected eﬀect of digoxin. Digoxin may actually decrease heart rate by exerting a negative chronotropic eﬀect.

Option c, decreased urinary output, is not an expected eﬀect of digoxin. In fact, digoxin does not directly aﬀect urinary output.

Option d, decreased potassium level, is not an expected eﬀect of digoxin. However, digoxin can increase the risk of hypokalemia, so it is important to monitor the client's potassium levels while on the medication.

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A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is a subjective indication that the client needs PRN pain medication?

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Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat heart failure. Which of the following should the nurse include as an expected eﬀect of this medication?

Correct Answer is B

Explanation

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