The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Administer PRN oral pain medication.

Review the pain medications prescribed.

Ask the client what is causing the grimacing.

Monitor the client's nonverbal behavior.

Answer and Explanation

The Correct Answer is C

A. Administer PRN oral pain medication:

Administering pain medication without further assessment may not be appropriate, as the client's pain needs must be fully evaluated before intervening with medication. Additionally, pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

B. Review the pain medications prescribed:

While it's important to review the client's pain medications, particularly if the client is exhibiting signs of uncontrolled pain, this intervention should be secondary to further assessment of the client's current pain status.

C. Ask the client what is causing the grimacing:

Asking the client directly about the cause of their grimacing can help clarify their discomfort and provide insight into whether their pain response is being underreported. This approach helps bridge the gap between nonverbal cues and verbal reports.

D. Monitor the client's nonverbal behavior:

While monitoring nonverbal behavior is important, it does not directly address the discrepancy between the client’s grimacing and their verbal denial of pain. This action should be complemented by further assessment to understand the cause of the nonverbal signs.

E. Establish a regular time for going to bed and getting up: This intervention is not relevant to the current situation, as the client is experiencing discomfort while moving.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Positive external places:

Guided imagery typically involves directing the client to visualize calming and peaceful external environments, such as a beach, forest, or other positive, serene places. This technique helps divert the client's attention away from pain and promotes relaxation.

B. Emotional reflection:

Emotional reflection may be part of the guided imagery process, especially if it helps the client process and cope with their emotions related to chronic pain. However, the primary focus of guided imagery is typically on visualization techniques rather than emotional reflection alone.

C. Motivational phrases:

Motivational phrases can be helpful in some relaxation techniques, but in guided imagery for chronic pain management, the emphasis is usually on visualizing soothing images or scenarios rather than repeating motivational phrases.

D. Tranquil sounds:

Tranquil sounds may be part of a relaxation strategy, but guided imagery specifically involves visualizing calming scenes, not just focusing on sounds.

A. Administering the medication to a client behind a closed curtain. B. Enlisting security personnel to assist with restraining the client. C. Informing a client that the medication being administered is a vitamin. D. Placing a client in restraints without having a healthcare provider's order.

Correct Answer is D

Explanation

A. Administering the medication to a client behind a closed curtain:

Administering medication behind a closed curtain is not necessarily a tort. However, it may be a breach of privacy depending on the circumstances and the client's preferences.

B. Enlisting security personnel to assist with restraining the client:

Enlisting security personnel to assist with restraining an agitated client is not inherently a tort. It may be necessary to ensure the safety of the client and healthcare providers, depending on the situation.

C. Informing a client that the medication being administered is a vitamin:

Misinforming a client about the medication being administered is not a tort, but it is unethical and can lead to potential harm if the client does not receive appropriate treatment.

D. Placing a client in restraints without having a healthcare provider's order:

This action constitutes a tort known as false imprisonment. Restraints should only be applied when ordered by a healthcare provider and when necessary to ensure the safety of the client or others. Placing a client in restraints without proper authorization can lead to physical and psychological harm and is a violation of the client's rights.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Correct Answer is A

Explanation

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Correct Answer is D

Explanation

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?