Exhibits

The nurse is evaluating the effectiveness of pain interventions for Mrs. Thompson who is unconscious and at the end of life. Which of the following methods is the most appropriate for assessing pain management effectiveness in this client?

Requesting feedback from the patient's family about the patient's comfort.

Monitoring changes in vital signs such as blood pressure and heart rate.

Assessing the patient's responsiveness to verbal stimuli.

Observing for non-verbal cues such as facial expressions and body movements.

Answer and Explanation

The Correct Answer is D

A. Requesting feedback from the patient's family about the patient's comfort. While family members can provide insight, they cannot reliably assess pain in an unconscious client. Pain assessment should be based on objective clinical observations rather than second-hand reports.
B. Monitoring changes in vital signs such as blood pressure and heart rate. While pain can cause changes in vital signs, this method is not the most reliable in end-of-life care. Vital signs may fluctuate due to the body’s natural decline rather than pain alone.
C. Assessing the patient's responsiveness to verbal stimuli. Responsiveness to verbal stimuli helps assess consciousness, but it does not directly determine pain levels. An unconscious client may still experience discomfort, requiring alternative assessment methods.
D. Observing for non-verbal cues such as facial expressions and body movements. In unconscious or non-verbal clients, pain is best assessed through behavioral cues like grimacing, restlessness, moaning, muscle tension, or changes in breathing patterns. These signs help determine whether pain interventions are effective or need adjustment.

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Correct Answer is D

Explanation

A. "I promise I won't tell anyone about this." This statement is inappropriate because nurses are legally required to report suspected or confirmed child abuse. Making a promise to keep the abuse confidential could create false trust and prevent necessary intervention.
B. "Let's discuss what happened with your family here." Discussing the abuse in front of the family could put the child at further risk of harm and may make them feel unsafe. The child should be given a private and secure environment to share their experience.
C. "Your family is bad for doing this to you." Labeling the family as "bad" may cause the child to feel guilty, conflicted, or responsible for their family member's actions. A more supportive and nonjudgmental approach helps the child feel safe and reassured.
D. "It is not your fault that this happened." This is the best response because children often blame themselves for abuse. Reassuring them that they are not responsible helps alleviate feelings of guilt and fosters emotional healing while building trust in the nurse.

A. Lay the client's head flat. B. Consider any cultural, religious, or social practices of the client that would impact postmortem care. C. Dim the lights and minimize noise to provide a calm environment. D. Verify the provider has certified and documented death of the client. E. Tell the family to leave the room while you prepare the body.

Correct Answer is ["B","C","D"]

Explanation

A. Lay the client's head flat. Keeping the client’s head slightly elevated, rather than flat, helps prevent discoloration from blood pooling in the face. Positioning the body appropriately is part of postmortem care, but laying the head completely flat is not recommended.
B. Consider any cultural, religious, or social practices of the client that would impact postmortem care. Respecting cultural and religious practices is essential in providing compassionate end-of-life care. Some cultures have specific rituals or beliefs regarding handling the body, and the nurse should accommodate these whenever possible.
C. Dim the lights and minimize noise to provide a calm environment. Creating a peaceful environment is important for both the family and staff. A calm, quiet setting allows the family to grieve and say their final goodbyes in a respectful and dignified manner.
D. Verify the provider has certified and documented death of the client. Before proceeding with postmortem care, the nurse must ensure the provider has officially confirmed and documented the time of death. This is a legal requirement and a crucial step in the process.
E. Tell the family to leave the room while you prepare the body. Forcing the family to leave is inappropriate and insensitive. Many families want to be present during postmortem care or take part in rituals. The nurse should offer them the option to stay or leave based on their preference.

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Exhibits The nurse is evaluating the effectiveness of pain interventions for Mrs. Thompson who is unconscious and at the end of life. Which of the following methods is the most appropriate for assessing pain management effectiveness in this client?

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Exhibits

The nurse is evaluating the effectiveness of pain interventions for Mrs. Thompson who is unconscious and at the end of life. Which of the following methods is the most appropriate for assessing pain management effectiveness in this client?