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.
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.
Correct Answer is A
Explanation
a ."I will take a stool softener to prevent constipation."
Explanation:
The statement that indicates an understanding of the instructions is "I will take a stool softener to prevent constipation."
Explanation for the other options:
b. "I will ask to work the night shift, so I will not be driving in bright sunlight."
This statement is incorrect. The need to work the night shift to avoid bright sunlight does not relate to the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma. The primary focus of discharge teaching for this condition would be related to eye care, medication administration, and follow-up appointments.
c. "I will need to use my eye drops for 1 year."
This statement is incorrect. While eye drops are commonly prescribed for open-angle glaucoma, the duration of their use can vary based on the individual's condition and the healthcare provider's instructions. The client should follow the specific instructions given by their healthcare provider regarding the frequency and duration of eye drop use.
d. "I will need to follow a low-protein diet."
This statement is incorrect. A low-protein diet is not typically part of the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma. The focus of dietary recommendations for open-angle glaucoma is on maintaining a healthy diet and managing other health conditions that may affect intraocular pressure, such as high blood pressure or diabetes.
In summary, the statement that demonstrates an understanding of the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma is "I will take a stool softener to prevent constipation." This indicates the client's awareness of the importance of preventing constipation, which can be a side effect of some medications prescribed after surgery.
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