The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Physical soothing.

Verbal reassurance.

Simultaneous injections.

Supine positioning.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- While physical soothing can help comfort the child after the injections, it may not significantly reduce the duration of pain during the injections themselves.
B)   Incorrect- Verbal reassurance is important to provide a calming environment, but it may not directly reduce the duration of pain during the injections.
C)   Correct- Administering vaccines can be distressing for toddlers due to the pain associated with injections. To reduce the duration of pain and minimize the overall discomfort, the nurse should prioritize the strategy of simultaneous injections. This involves administering multiple vaccines at the same time rather than spacing them out. The rationale behind this approach is that the child experiences the discomfort of the injections only once, which can help reduce their overall distress and anxiety.
D)   Incorrect- The positioning of the child may not have a direct impact on the duration of pain during injections. However, choosing an appropriate position for comfort is still important.

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Correct Answer is D

Explanation

A) This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B) Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C) Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D) The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.

A. Arrange for unlicensed assistive personnel to assist the PN during the procedure. B. Acknowledge that the PN has positioned the client safely and correctly. C. Assume care of the client and assign the PN to the care of a different client. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

The correct answer is choice D. Demonstrate to the PN how to position the client more effectively for the procedure.

Choice A rationale:

Arranging for unlicensed assistive personnel to assist the PN during the procedure does not address the incorrect positioning of the client. The priority is to ensure the client is positioned correctly for the sigmoidoscopy, which is typically on the left side with knees drawn toward the chest.

Choice B rationale:

Acknowledging that the PN has positioned the client safely and correctly is not appropriate because the flat prone position is incorrect for a sigmoidoscopy. The correct position is on the left side with knees drawn toward the chest.

Choice C rationale:

Assuming care of the client and assigning the PN to the care of a different client does not address the educational opportunity. It is important to demonstrate the correct positioning to the PN to ensure proper care in future procedures.

Choice D rationale:

Demonstrating to the PN how to position the client more effectively for the procedure is the correct action. This ensures the client is in the proper position for the sigmoidoscopy and provides an educational opportunity for the PN.

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The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Correct Answer is D

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

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