Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?
Perform a complete mental status exam.
Determine if the client has had a shingles vaccination.
Teach the client about phantom pain symptoms.
Complete an assessment of the client's pain.
The Correct Answer is D
Choice A reason: This is incorrect because performing a complete mental status exam is not a relevant or appropriate action for the nurse to implement. A mental status exam is used to evaluate the client's cognitive, emotional, and behavioral functioning, but it does not address the client's physical pain or its underlying cause.
Choice B reason: This is incorrect because determining if the client has had a shingles vaccination is not a priority or helpful action for the nurse to implement. A shingles vaccination is recommended for people who are 50 years or older to prevent or reduce the severity of shingles, but it does not affect the occurrence or treatment of postherpetic neuralgia, which is a chronic pain condition that can develop after shingles.
Choice C reason: This is incorrect because teaching the client about phantom pain symptoms is not an accurate or useful action for the nurse to implement. Phantom pain is a type of neuropathic pain that occurs when a person feels pain in a body part that has been amputated or removed. However, this is not the case for the client who has pain in the area where the shingles rash occurred.
Choice D reason: This is correct because completing an assessment of the client's pain is the most important action for the nurse to implement. Pain assessment involves collecting information about the location, intensity, quality, duration, frequency, and aggravating or relieving factors of the pain, as well as its impact on the client's daily activities and quality of life. This can help the nurse identify the cause and severity of the pain, as well as plan and evaluate appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
For Potential Conditions:
The correct answer is c) Abdominal compartment syndrome.
Choice A reason: Pneumothorax is a condition where air leaks into the pleural space, causing lung collapse and impaired gas exchange. It can cause respiratory distress, hypoxia, chest pain, and decreased breath sounds on the affected side. However, it does not cause abdominal distension, acidosis, or hyperglycemia.
Choice B reason: Pulmonary embolism is a condition where a blood clot blocks one or more pulmonary arteries, causing impaired gas exchange and reduced blood flow to the lungs. It can cause respiratory distress, hypoxia, chest pain, and tachycardia. However, it does not cause abdominal distension, acidosis, or hyperglycemia.
Choice C reason: Abdominal compartment syndrome is a condition where increased intra-abdominal pressure causes reduced blood flow to the abdominal organs and impaired diaphragm movement. It can cause respiratory distress, hypoxia, abdominal distension, acidosis, decreased urine output, and organ failure. It is a common complication of cirrhosis with ascites.
Choice D reason: Sepsis is a condition where a systemic inflammatory response to an infection causes organ dysfunction and hypoperfusion. It can cause respiratory distress, hypoxia, fever or hypothermia, tachycardia, acidosis, and hyperglycemia. However, it does not cause abdominal distension unless there is an intra-abdominal infection.
The two actions the nurse should take to address abdominal compartment syndrome are:
- Prepare the client for a paracentesis: Paracentesis is a procedure where a needle or catheter is inserted into the peritoneal cavity to drain excess fluid and reduce intra-abdominal pressure.
- Place an intravenous line to start fluid boluses: Fluid boluses are given to maintain adequate blood pressure and perfusion to the vital organs.
The two parameters the nurse should monitor to assess the client’s progress are:
- Oxygen saturation: Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood. It should be maintained above 90% to ensure adequate oxygen delivery to the tissues.
- Urine output: Urine output reflects the function of the kidneys and the perfusion of the renal arteries. It should be maintained above 0.5 mL/kg/hour to prevent acute kidney injury and electrolyte imbalances.
Correct Answer is A
Explanation
Choice A reason: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
Choice B reason: Left-sided facial drooping and dysphagia are common signs of right hemisphere stroke, but they do not require immediate intervention by the nurse. The nurse should monitor the patient's swallowing ability and provide oral care.
Choice C reason: Orientation to person and place only is a sign of impaired cognition, which is also common in right hemisphere stroke. The nurse should assess the patient's memory, judgment, and attention span.
Choice D reason: Unequal bilateral hand grip strengths are a sign of hemiparesis, which is a weakness on one side of the body. The nurse should assist the patient with mobility and prevent contractures.
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