A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?
Administering hydromorphone as needed
Distracting the patient with activity
Dimming the lights and reducing stimulation
Initiating a patient-controlled analgesia (PCA) of morphine sulfate .
The Correct Answer is C
Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale
While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Respiratory acidosis is characterized by a low pH (less than 7.35), a high PaCO2 (greater than 45 mm Hg), and a normal or high HCO3 (22-26 mEq/L). It occurs when there is a buildup of carbon dioxide in the blood due to impaired ventilation.
The patient's ABGs do not align with respiratory acidosis because the pH is elevated (7.6), and the PaCO2 is within the normal range (40 mm Hg).
Choice B rationale:
Respiratory alkalosis is characterized by a high pH (greater than 7.45), a low PaCO2 (less than 35 mm Hg), and a normal or low HCO3 (22-26 mEq/L). It occurs when there is excessive loss of carbon dioxide through hyperventilation.
The patient's ABGs do not align with respiratory alkalosis because the HCO3 is elevated (32 mEq/L), which is not typical for this condition.
Choice C rationale:
Metabolic acidosis is characterized by a low pH (less than 7.35), a normal or low PaCO2 (less than 40 mm Hg), and a low HCO3 (less than 22 mEq/L). It occurs when there is an excess of acid in the body or a loss of bicarbonate.
The patient's ABGs do not align with metabolic acidosis because the pH is elevated (7.6), and the HCO3 is elevated (32 mEq/L).
Choice D rationale:
Metabolic alkalosis is characterized by a high pH (greater than 7.45), a normal or high PaCO2 (40-45 mm Hg), and an elevated HCO3 (greater than 26 mEq/L). It occurs when there is an excess of bicarbonate in the body or a loss of acid.
The patient's ABGs align with metabolic alkalosis because of the high pH (7.6), normal PaCO2 (40 mm Hg), and elevated HCO3 (32 mEq/L).
Correct Answer is A
Explanation
Choice A rationale
The best way to determine if a patient can safely and effectively self-administer medications is to ask the patient to demonstrate the instillation of the medications. This allows the nurse to directly observe the patient’s technique, identify any errors, and provide immediate feedback and instruction. It also gives the patient an opportunity to ask questions and clarify any misunderstandings. This method is often referred to as the “show-back” or “teach-back” method and is widely used in patient education to confirm understanding and competency.
Choice B rationale
While assessing the patient for any previous inability to self-manage medications can provide useful information, it does not directly assess the patient’s ability to self-administer the new eye medications. Previous difficulties may be due to factors that do not apply to the current situation, such as complex medication regimens, cognitive impairment, or lack of resources.
Choice C rationale
Although the patient accurately describing the directions for administering the medications indicates that the patient understands the instructions, it does not necessarily mean that the patient can perform the task correctly. Physical limitations, dexterity issues, or misunderstanding of the instructions can still result in incorrect administration.
Choice D rationale
Assessing the patient’s functional status can provide valuable information about the patient’s overall ability to perform activities of daily living, including medication management.
However, it does not specifically assess the patient’s ability to self-administer eye medications.
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