An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Introduce non-pharmacologic strategies for pain reduction.

Allow adequate privacy and time for the client's phone call.

Document the concern of incongruent pain rating and behavior.

Administer pain medication per the healthcare provider's orders.

Answer and Explanation

The Correct Answer is B

Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.

Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.

Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.

Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.

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Free Nursing Study Resources

Correct Answer is ["A","C"]

Explanation

Choice A: Cooked cereal can be used as part of a gastrostomy tube feeding regimen for clients who require enteral nutrition.

Choice B: Lettuce is not typically used in gastrostomy tube feedings as it may not be well-tolerated in liquid form.

Choice C: Clear fat-free broth can be used as part of a gastrostomy tube feeding regimen for clients who require enteral nutrition.

Choice D: Brussels sprouts and nuts are not typically used in gastrostomy tube feedings as they may not be well-tolerated in liquid form.

A. Pretzels B. Avocado C. Potatoes D. Grapes

Correct Answer is B

Explanation

Choice A: Pretzels are a carbohydrate-rich snack with a high glycemic index, which can lead to spikes in blood glucose levels. Choosing pretzels does not indicate a good understanding of the diet teaching to avoid refined sugar and carbohydrates.

Choice B: Avocado is a healthy choice for a client with Type 2 diabetes mellitus (DM) who wants to avoid refined sugar and carbohydrates. Avocado is a source of healthy fats, fiber, and other nutrients and has a low glycemic index.

Choice C: Potatoes are starchy vegetables that are high in carbohydrates, particularly when prepared in ways like mashed potatoes or fries. Choosing potatoes does not align with the goal of avoiding refined sugar and carbohydrates.

Choice D: Grapes are a fruit that contains natural sugars, and consuming them can affect blood glucose levels. Choosing grapes does not demonstrate an understanding of the need to avoid refined sugar and carbohydrates.

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An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who is on a gastrostomy tube feeding, which foods should the nurse encourage the client use? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

The nurse instructs a client with Type 2 diabetes mellitus (DM) to avoid refined sugar and carbohydrates. Choosing which food indicates that the client understands the diet teaching?

Correct Answer is B

Explanation

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