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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Regular exercise:
Regular exercise is important for overall cardiovascular health and can help reduce the risk of developing heart disease. However, smoking cessation is more crucial because smoking is a significant risk factor for heart disease and quitting smoking has immediate and long-term benefits for heart health.
B. Smoking cessation:
Smoking is a major risk factor for heart disease as it damages the blood vessels, increases blood pressure, reduces oxygen supply to the heart, and promotes the formation of blood clots. Encouraging smoking cessation is essential for reducing the risk of heart disease and improving overall health.
C. Low-fat diet:
Adopting a low-fat diet can help lower cholesterol levels and reduce the risk of heart disease, but it may not be as critical as smoking cessation for individuals with a family history of cardiac disease.
D. Stress reduction:
While stress reduction techniques such as relaxation exercises, meditation, and mindfulness can be beneficial for heart health, addressing smoking cessation is more urgent for individuals with a family history of cardiac disease, as smoking is a more significant risk factor for heart disease.
Correct Answer is A
Explanation
A. Provide a back rub at bedtime:
This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.
B. Leave the door to the client's room open slightly:
Leaving the door open may not prevent wandering and could potentially lead to safety issues.
C. Apply wrist restraints to prevent wandering:
Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.
D. Administer a PRN sedative prescription:
Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.
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