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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
The stoma bleeds lightly when touched is incorrect. Some minor bleeding during the initial postoperative period is expected due to surgical trauma. Light bleeding when touched might not be unusual in the immediate days following colostomy placement.
Choice B Reason:
The stoma appears dark in color is correct. A dark-colored stoma could indicate compromised blood supply or ischemia, which is a concerning finding postoperatively. It's crucial to report this change in color promptly to the provider for further evaluation and intervention.
Choice CReason:
The stoma is draining a small amount of liquid stool is incorrect. In the early postoperative period, drainage of liquid stool from the stoma is normal. The digestive system needs time to adapt to the new anatomy created by the colostomy, and initially, the stool consistency might be liquid before it starts to normalize.
Choice DReason:
The stoma protrudes slightly from the abdomen is incorrect. A slightly protruding stoma is a common and expected finding after colostomy surgery. It's often a normal part of the healing process as the stoma settles and adjusts.
Correct Answer is D
Explanation
Choice A Reason:
Adhesive tape is incorrect. Adhesive tape is commonly used for securing dressings or medical devices, but it may not be the primary supply needed for managing a stage 4 pressure injury. Wound care for a stage 4 pressure injury often involves specialized dressings, cleansing solutions, and applicators rather than adhesive tape alone.
Choice B Reason:
Tongue depressor is incorrect. A tongue depressor is typically used for oral examinations or to apply topical treatments to the mouth. It's not a standard supply for managing a stage 4 pressure injury, which requires specific wound care supplies designed for wound cleaning and dressing application.
Choice C Reason:
Syringe is incorrect. While syringes are versatile tools used in various medical procedures, in the context of managing a stage 4 pressure injury, their primary use might be for administering medications or irrigation solutions rather than being the essential supply for wound care in this specific instance.
For a client with a stage 4 pressure injury, the nurse should obtain supplies that are suitable for wound care. Among the options provided, the most appropriate supply is:
Choice D Reason:
Cotton-tipped applicator is correct. A cotton-tipped applicator can be used for wound cleaning and dressing application for a stage 4 pressure injury. It allows for gentle cleaning of the wound and application of topical treatments while minimizing trauma to the wound area.
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