A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?

Encourage the client to abstain from distracting activities.

Ensure that the client's room is kept at a cool temperature.

Play music in the client's room.

Keep the client's room well lit.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Encouraging the client to abstain from distracting activities is incorrect. Engaging in distracting activities can actually be beneficial in pain management. It can redirect the client's focus away from the pain, potentially reducing its intensity.

Choice B Reason:

Ensuring that the client's room is kept at a cool temperature is incorrect.

While temperature can influence comfort, maintaining a cool room might not directly address or alleviate the client's pain.

Choice C Reason:

Playing music in the client's room is correct. Music therapy is a nonpharmacological intervention that can effectively help in managing pain. Calming or soothing music can distract the client from pain, reduce anxiety, and promote relaxation, potentially reducing the perception of pain.

Choice D Reason:

Keep the client's room well-lit is incorrect. The lighting in the room might not significantly impact pain levels. Some individuals might prefer dim lighting for relaxation, but it might not directly influence pain perception.

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Correct Answer is D

Explanation

Choice A Reason:

Hyperkalemia is incorrect. Vomiting and diarrhea typically lead to a loss of potassium rather than an increase. These conditions often result in depletion of electrolytes, including potassium, due to the loss of fluids.

Choice B Reason:

Hypocalcemia is correct. While prolonged or severe diarrhea could potentially lead to some electrolyte imbalances, hypocalcemia is not typically a primary finding associated with vomiting and diarrhea. Calcium levels may not be significantly affected by these symptoms compared to sodium and potassium.

Choice C Reason:

Hypermagnesemia is incorrect. Similar to calcium, magnesium levels are not usually significantly impacted by vomiting and diarrhea alone. Hypermagnesemia is more commonly associated with excessive intake of magnesium-containing medications or renal dysfunction rather than acute gastrointestinal symptoms.

In a client experiencing vomiting and diarrhea, the loss of fluids and electrolytes due to these symptoms commonly leads to:

Choice D Reason:

Hyponatremia is correct. Vomiting and diarrhea can cause a loss of sodium and water, leading to decreased sodium levels in the blood, which manifests as hyponatremia. This electrolyte imbalance is a typical finding in individuals experiencing gastrointestinal issues with fluid loss.

A. "I'm sure it's nothing serious and their appetite will return soon." B. "Tell me more about what happens at mealtime." C. "Why do you think they're not eating?" D. "They may need a feeding tube."

Correct Answer is B

Explanation

Choice A Reason:

"I'm sure it's nothing serious and their appetite will return soon." Is incorrect. This response dismisses the concern without addressing the underlying issue. It might overlook potential reasons for the lack of appetite and could lead to neglecting a serious problem.

Given the concern about the client not eating, the most appropriate response for the nurse to make would be:

Choice B Reason:

"Tell me more about what happens at mealtime." Is correct. This response encourages the child to share specific details about the mealtime routine, any challenges, or reasons behind the lack of eating. It allows the nurse to gather more information, identify potential issues, and offer appropriate guidance or interventions. Understanding the context surrounding the eating habits can help determine the best approach to address the situation effectively.

Choice C Reason:

"Why do you think they're not eating?" is incorrect. While it encourages discussion, this response puts the responsibility on the child to provide explanations that they might not fully understand or be equipped to articulate. It's essential for the nurse to gather information but in a more supportive and guiding manner.

Choice D Reason:

"They may need a feeding tube." Is incorrect. Jumping to a conclusion about a feeding tube without gathering more information or exploring other possibilities could alarm the child unnecessarily. This response could also create unnecessary worry for the child and the family without assessing the situation comprehensively.

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A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?

Nursing Test Bank

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