An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Ask the client to describe how they are feeling.

Administer a PRN dose of a prescribed analgesic.

Document that the client denies pain in the nurse's notes.

Confront the client about inconsistent behavior and response.

Answer and Explanation

The Correct Answer is A

A.   Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B.   Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C.   While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D.   Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

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Correct Answer is B

Explanation

A. Assessing whether the expected outcomes were realistic involves evaluating if the goals set in the plan of care were achievable given the client’s condition, resources, and constraints. While this is an important consideration, it is not the immediate next step after reviewing the expected outcomes.
B. After reviewing the expected outcomes, the next critical step is to gather and analyze current client data. This includes assessing the client’s current condition, symptoms, and responses to interventions. By comparing this data with the expected outcomes, the nurse can determine if the goals are being met, if they need adjustment, or if different interventions are required.
C. Reviewing professional standards of care involves understanding the accepted norms and guidelines for nursing practice. While important, this action typically precedes the direct evaluation of care and is part of ensuring that the care plan was developed and implemented according to professional guidelines.
D. Modifying nursing interventions is an action that might be required if the evaluation shows that the expected outcomes are not being met. However, this action is taken after evaluating the effectiveness of the current interventions by comparing client data with expected outcomes.

A. Add the second portion of the feeding before the syringe is completely empty. B. Use 25 mL of water between the two portions of the feeding to flush the GT. C. Raise the syringe barrel higher to increase the flow rate of the bolus feeding. D. Flush the tube with 50 mL of water between the two portions of the feeding.

Correct Answer is D

Explanation

A. This instruction is not recommended because adding the second portion of the feeding before the syringe is empty can lead to inconsistent feeding rates and potential complications, such as overloading the stomach with too much formula at once.
B. Flushing the GT with water between portions of feeding is a good practice to prevent clogging and to ensure that all formula is delivered. However, 25 mL of water is generally not enough; standard practice typically involves using 30 to 60 mL of water for effective flushing. This option is close but not as specific as the recommended volume.
C. Raising the syringe barrel can increase the flow rate of the feeding, but this approach should be used with caution. Rapid flow can cause gastrointestinal discomfort or cramping. The primary focus should be on ensuring proper flushing and administration rather than manipulating the flow rate in this way.
D. This option is the best practice because flushing the GT with 50 mL of water between portions of the feeding helps to clear any remaining formula from the tube and prevents clogging. Proper flushing also helps ensure that the entire dose of formula is delivered and maintains tube patency.

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An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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