For the past six hours, a postoperative male client has refused pain medication because he believed that he could "tough it out." When an opioid analgesic is administered, the client has difficulty obtaining a satisfactory level of comfort. Which action is best for the practical nurse (PN) to use in assisting this client to deal with his pain?
Dim the lights in the room and close the door.
Guide the client through slow, rhythmic breathing.
Turn the television on to the client's favorite show.
Obtain a prescription for a higher dose of pain medication.
The Correct Answer is B
This is the best action for the PN to use in assisting this client to deal with his pain because it provides a non-pharmacological method of pain relief that can enhance the effect of the opioid analgesic. Slow, rhythmic breathing can help the client relax, distract from the pain, and increase oxygenation and blood flow.
A. Dimming the lights in the room and closing the door may not be enough to help the client deal with his pain and may not address his psychological or emotional needs.
C. Turning the television on to the client's favorite show may not be effective in helping the client deal with his pain and may be distracting or irritating for him.
D. Obtaining a prescription for a higher dose of pain medication may not be necessary or appropriate for this client and may increase the risk of side effects or dependence. The PN should assess the client's pain level and response to the current dose before requesting a change in medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A:
"Are you planning to obey the voices?.”. Choice A rationale:
The PN should ask the client if he plans to obey the voices because it helps assess the potential risk of harm to himself or others. If the client indicates an intention to follow the voices' commands to harm someone, it indicates a serious concern for safety and may require immediate intervention to protect the client and others.
Choice B rationale:
While asking if the client believes the voices are real is important for understanding the client's perception of the situation, it may not immediately address the risk of harm that the client or others might be facing.
Choice C rationale:
Asking if the client has taken any hallucinogens is relevant to explore possible substance- induced psychosis, but this question should be asked later in the assessment process. The priority is to assess immediate safety concerns related to the client's compliance with the voices' instructions.
Choice D rationale:
Inquiring about when the voices began is important, but it is not the most urgent question in this situation. Although the onset of the symptoms is relevant, addressing the potential for harmful actions should be prioritized.
Correct Answer is B
Explanation
Choice A rationale:
The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
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