The nurse takes into consideration the Joint Commission on Accreditation of Healthcare Organizations (CAHO) standards for pain assessment and treatment.
Include:.
Pain is assessed only for patients who complain of pain.
Pain treatment ends at discharge.
All patients have the right to appropriate assessment of pain.
Pain treatment is based on objective data collected by the nurse.
The Correct Answer is C
Choice A rationale:
False. Pain should not be assessed only for patients who complain of pain. Pain assessment should be a routine part of patient care, as not all patients may be able to verbalize their pain or may underreport it. Identifying and addressing pain is crucial for patient well-being.
Choice B rationale:
False. Pain treatment does not necessarily end at discharge. The management of pain may continue beyond the hospital setting, and a plan for pain management post-discharge may be needed. This ensures that patients receive appropriate pain relief and support during their recovery.
Choice C rationale:
True. According to the Joint Commission's standards, all patients have the right to appropriate assessment of pain. This means that every patient, regardless of their condition or the presence of pain complaints, should have their pain assessed and managed as necessary.
Choice D rationale:
False. Pain treatment is not solely based on objective data collected by the nurse. Pain is a subjective experience, and it is essential to consider the patient's self-report of pain, in addition to any objective data, when determining the appropriate treatment. Objective data can help, but it should not be the sole basis for pain management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Increasing pain over several hours is not a typical sign of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose symptoms often involve respiratory depression, altered mental status, and other serious issues. While it is possible for a patient to experience increased pain if the fentanyl patch is not providing adequate pain relief, this is not a specific sign of overdose.
Choice B rationale:
An itchy red rash on the skin is not a sign of a fentanyl patch overdose but can be associated with skin irritation or allergies to the adhesive in the patch. It's important to differentiate between a skin reaction and an overdose when evaluating patients using fentanyl patches. Overdose symptoms are more severe and life-threatening.
Choice C rationale:
Confusion and the inability to walk normally are characteristic signs of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose can lead to central nervous system depression, resulting in confusion, altered mental status, and difficulty with coordination and walking. These symptoms are serious and require immediate medical attention.
Choice D rationale:
Headache and nausea are not specific signs of a fentanyl patch overdose. While opioid overdose can cause various symptoms, such as respiratory depression and altered mental status, headache and nausea are not among the primary indicators. However, individual responses to medications can vary, and some patients may experience these symptoms as part of a broader set of overdose signs.
Correct Answer is C
Explanation
Choice A rationale:
Taking a warm bath before trying to go back to sleep is a relaxation technique that may help with sleep but does not address the underlying causes of insomnia. It is more of a short-term coping strategy rather than a method for locating the reasons for the insomnia.
Choice B rationale:
Reviewing times in her life when she had no insomnia is not a practical approach to addressing the current issue of insomnia. It does not help in identifying the specific factors or triggers contributing to the patient's current sleep problems.
Choice C rationale:
Keeping a diary related to sleep and problems encountered is a practical and effective approach to identify the factors contributing to the patient's insomnia. This diary can help track patterns, such as bedtime routines, diet, stressors, and other variables that may be linked to the sleep problem. Identifying these factors can aid in developing a plan to address the specific causes of the insomnia.
Choice D rationale:
Discussing the problem with her friends may provide emotional support but is unlikely to help identify the root causes of the insomnia. Friends may offer advice or share their experiences, but a structured approach like keeping a sleep diary is more likely to yield valuable information.
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