A nurse is reinforcing teaching with a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following statements by the client indicates an understanding of the teaching?
"I'll be careful about pushing the button so I don't get an overdose."
"I should tell the nurse if I can't control my pain with this device."
"I will ask my family to push the dose button when I am asleep."
"I should only use the device when it's absolutely necessary."
The Correct Answer is B
A. While it's important to use the PCA device responsibly, the device is designed to prevent overdose. The client should not be overly concerned about this.
B. This statement demonstrates an understanding of the PCA device's limitations and the importance of seeking additional pain relief if needed. The nurse is responsible for adjusting the medication dosage or providing alternative pain relief methods if the PCA device is not adequately controlling the client's pain.
C. Only the client should administer the medication through the PCA device. Family members or other individuals should not be allowed to use the device.
D. The PCA device is designed to provide pain relief as needed. The client should use it whenever they experience pain, rather than waiting until the pain becomes severe.
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Correct Answer is D
Explanation
A. This action is based on the nurse's responsibility to manage the client's pain effectively, but it does not reflect the client's autonomy. Instead, it focuses on the nurse's duty to provide care.
B. While this demonstrates fairness and equality in care, it does not specifically address the autonomy of the clients. Autonomy involves allowing clients to make choices tailored to their individual preferences and needs, rather than applying the same approach to everyone.
C. This option reflects the nurse's commitment to their responsibilities and maintaining trust with the client. However, it does not exemplify autonomy, as it does not involve the client's choice or decision- making.
D. This is the best example of autonomy. By allowing the client to choose when to take their medication, the nurse respects the client's right to make decisions about their own care, which is a fundamental aspect of autonomy.
Correct Answer is A
Explanation
A. This statement incorporates an inquiry into the client's emotional and psychological state, recognizing that stress may contribute to headache frequency. It reflects a holistic approach by considering factors beyond the physical symptoms, acknowledging the interplay between mental health and physical well- being.
B. This question focuses specifically on the physical symptoms of the headaches. While it’s important to understand the client’s symptoms, this statement does not consider emotional or psychosocial factors, making it less holistic.
C. Checking blood pressure is a vital assessment related to potential physiological causes of headaches. However, this action is primarily focused on physical health and does not encompass a holistic view of the client’s overall experience or emotional state.
D. This question addresses treatment and management of headaches, focusing on the effectiveness of medication. While important, it does not explore other contributing factors such as lifestyle, emotional health, or stress, and therefore lacks a holistic perspective.
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