For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?
Continue to observe the client.
Ask the client to describe the discomfort.
Encourage the client to progressively relax all muscle groups.
Administer the prescribed analgesic and document the client’s response.
The Correct Answer is B
Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.
This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.
Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.
Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.
Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.
Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.
Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.
Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.
Correct Answer is B
Explanation
This is because mitt restraints can reduce the patient’s mobility and circulation in the hands, and range of motion exercises can help prevent contractures, stiffness, and edema.
Choice A is wrong because removing the mitts when the client is asleep can increase the risk of self-injury or removal of therapeutic equipment.
Choice C is wrong because tying the restraints securely around the wrists and to the bed can impair the patient’s circulation and cause nerve damage.
Choice D is wrong because placing the restraints loosely to allow increased freedom of movement can cause entanglement or strangulation.
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