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 C

Explanation

A. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care:

This option might be tempting but is not appropriate because the UAP should be properly equipped with the correct protective gear before any contact with the client. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

B. Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client:

This action is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N95, which is used for airborne precautions. This option indicates a misunderstanding of the type of precautions needed for bacterial meningitis.

C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client:

This is the correct course of action. Bacterial meningitis requires droplet precautions, which only require a standard face mask. The UAP can safely provide care using a standard mask.

D. Before changing assignments, determine which staff members have fitted particulate filter masks:

While it is prudent to know which staff members are fitted for particulate filter masks, this is not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

A. The client will demonstrate ability to change the ostomy bag in two days. B. The client will adhere to the medication regimen after discharge. C. The client's breath sounds will be auscultated by the nurse every 4 hours. D. The client attempts to self administer Insulin but is unable to perform injection.

Correct Answer is B

Explanation

A. The client will demonstrate ability to change the ostomy bag in two days.

This outcome statement focuses on the client's ability to perform a specific task related to ostomy care. While it's important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.

B. The client will adhere to the medication regimen after discharge.

This outcome statement directly addresses the client's need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client's health needs and goals following the surgical procedure and the development of hyperglycemia.

C. The client's breath sounds will be auscultated by the nurse every 4 hours.

This outcome statement focuses on monitoring the client's respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client's primary health concern in this scenario, which is managing hyperglycemia and insulin administration.

D. The client attempts to self-administer insulin but is unable to perform injection.

This outcome statement indicates the client's attempt to self-administer insulin but inability to perform the injection. While it's important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.

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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

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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