A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?
Client is asleep and resting
Client had 150 mL of emesis in last hour
Ondansetron 4 mg IV bolus for nausea and vomiting
Client reports nausea and vomiting 30 minutes following surgery
The Correct Answer is C
A. This statement pertains to the client's current state but does not represent an intervention taken by the nurse. It would be more appropriate for documentation in a narrative or assessment section rather than the intervention component.
B. This entry describes an outcome or finding related to the client’s condition rather than an intervention. While it is important data, it does not reflect an action taken by the nurse and thus would not be included in the intervention section.
C. It clearly describes a specific action taken by the nurse (administering medication) in response to the problem (nausea and vomiting). It directly addresses the client's needs and reflects an intervention aimed at treating the identified problem.
D. This statement indicates the problem or symptom that the client is experiencing but does not describe an intervention. While it is critical information for understanding the client’s condition, it belongs in the problem or assessment section rather than the intervention component.
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Correct Answer is D
Explanation
A. While changes in vital signs, such as increased heart rate and blood pressure, may indicate pain, they are not specific to pain and can be influenced by other factors.
B. The type of surgery can provide some clues about the potential for pain, but it does not accurately reflect the individual's pain experience.
C. Nonverbal cues like grimacing, guarding, or restlessness can suggest pain, but they are not always reliable indicators. Some clients may not exhibit obvious signs of pain, even if they are experiencing significant discomfort.
D. This is the most reliable source of information about a client's pain intensity. Only the client can accurately describe their own pain experience, including its location, severity, and quality.
Correct Answer is C
Explanation
A. Chronic pain is defined as pain that persists for longer than three months or beyond the normal healing time. While dermatitis can be painful, if it is a direct result of radiation therapy, it is typically not classified as chronic pain unless it continues for an extended period beyond the expected recovery.
B. Neuropathic pain arises from damage or dysfunction of the nervous system, often described as burning, tingling, or shooting pain. Dermatitis resulting from radiation therapy is generally not classified as neuropathic pain, as it primarily relates to skin irritation rather than nerve damage.
C. Acute pain is usually of recent onset and often linked to a specific injury or medical intervention, lasting a short duration (typically less than three months). The painful dermatitis from radiation therapy would likely be classified as acute pain since it arises as a direct result of a specific treatment and typically resolves with healing.
D. While the dermatitis is a side effect of radiation therapy, the pain associated with it specifically due to dermatitis may not be fully characterized as "cancer pain," since it's a localized skin issue rather than pain directly related to cancer progression.
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