The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Encourage Increased fluid intake and measure urinary output every 8 hours.

Assist the client to ambulate as much as possible during waking hours.

Determine client's subjective measure of pain using a numerical pain scale.

Provide comfort measures such as topical warm application and tactile massage.

Implement a 24 hour schedule of routine administration of prescribed analgesic.

Answer and Explanation

Correct Answer : B,C,D,E

A. Encourage increased fluid intake and measure urinary output every 8 hours:

While hydration and monitoring urinary output are important aspects of overall health care, they are not specifically related to managing chronic pain. Therefore, this intervention may not be directly relevant to addressing the client's pain.

B. Assist the client to ambulate as much as possible during waking hours:

Ambulation helps maintain mobility, prevent complications like muscle atrophy and deep vein thrombosis, and can improve overall well-being. For clients with chronic pain, assisting with ambulation can be beneficial in managing pain and improving quality of life. The goal is to balance activity with the client's pain tolerance and capabilities.

C. Determine client's subjective measure of pain using a numerical pain scale:

Using a numerical pain scale helps assess the intensity of pain and monitor changes over time. It provides valuable information for tailoring pain management strategies to the client's needs and allows for evaluating the effectiveness of interventions.

D. Provide comfort measures such as topical warm application and tactile massage:

Comfort measures such as warm applications and massage can help alleviate pain and promote relaxation. These interventions address the client's comfort and well-being, making them appropriate for inclusion in the plan of care for managing chronic pain.

E. Implement a 24-hour schedule of routine administration of prescribed analgesic:

Establishing a regular schedule of analgesic administration helps maintain consistent pain control and prevents breakthrough pain. This intervention is essential for managing chronic pain effectively and promoting the client's comfort and quality of life.

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Correct Answer is B

Explanation

A. Encourage the use of incontinence briefs:

While incontinence briefs may help contain fecal leakage and protect clothing and bedding, they do not address the underlying issue of fecal incontinence or assist the client in achieving continence. Additionally, relying solely on incontinence briefs may not promote independence or improve the client's quality of life.

B. Assist to a bedside commode 30 minutes after meals:

This is the most appropriate intervention for establishing a bowel training regimen. Timing the use of the bedside commode after meals takes advantage of the gastrocolic reflex, which increases bowel motility after eating. Assisting the client to the commode at specific intervals helps promote regular bowel movements and may decrease the likelihood of fecal incontinence episodes.

C. Administer a glycerin suppository 15 minutes after meals:

While glycerin suppositories can stimulate bowel movements, they are typically used for acute constipation rather than chronic fecal incontinence. Additionally, using suppositories does not address the client's emotional distress or help establish a bowel training regimen focused on promoting continence.

D. Insert a rectal tube at specified intervals:

Rectal tubes are not typically used as a first-line intervention for bowel training in clients with fecal incontinence. They may be indicated in certain situations, such as severe impaction or when other interventions have failed, but they are not appropriate for all clients and may cause discomfort and complications.

A. "I'm sorry, but your child's medical Information is none of your business." B. "I can only give medical Information to your child because they are legally an adult." C. "The healthcare provider will share this information with you." D. "I can give you those results as soon as I get them back from the laboratory." E. None F. None

Correct Answer is B

Explanation

A. "I'm sorry, but your child's medical Information is none of your business."

This response is confrontational and dismissive, and it doesn't effectively address the parents' concerns. It's important to maintain professionalism and respect even in challenging situations.

B. "I can only give medical Information to your child because they are legally an adult."This response respects the minor's emancipated status and acknowledges that, legally, the nurse can only disclose medical information to the emancipated minor themselves. It upholds the principles of patient confidentiality and autonomy while also providing clear and accurate information to the parents about their limitations regarding access to their child's medical information.

C."The healthcare provider will share this information with you," could potentially mislead the parents because it implies that the healthcare provider will provide them with the information directly. However, if the minor is legally emancipated, the healthcare provider would still be bound by confidentiality laws and would only be able to disclose information to the minor themselves unless there are extenuating circumstances or legal exceptions.

D. "I can give you those results as soon as I get them back from the laboratory."

While this response offers to provide information, it doesn't address the issue of confidentiality or the parents' role in receiving the information. It's also not accurate to promise the results directly without involving the healthcare provider, who is responsible for interpreting and discussing the results with the patient and family.

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The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic fecal Incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which Intervention should the nurse Implement?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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