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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Begin the collection the next day:
This option would delay the start of the 24-hour urine collection unnecessarily. Since the client has already begun voiding, it's appropriate to start the collection process with the next void.
B. Start collecting the specimen with the next void:
Since the client has already provided a urine sample, the nurse should discard this initial void and begin the 24-hour collection process with the next void. This ensures that the entire 24-hour period is captured for accurate measurement of creatinine clearance.
C. Observe the sample for sediment:
While observing the sample for sediment may be part of the assessment process, it is not the priority in this situation. The focus should be on initiating the 24-hour urine collection process correctly.
D. Empty the sample into the 24-hour container:
The initial void should not be emptied into the 24-hour container, as this would inaccurately include urine that was not collected over the entire 24-hour period. It's important to start the collection process fresh with the next void to ensure accurate results for creatinine clearance measurement.
Correct Answer is C
Explanation
A. Turn the head to the right and left:
Turning the head involves rotation of the cervical spine, which primarily consists of pivot joints rather than hinge joints. This action is more relevant to the movement of pivot joints.
B. Extend the arm at the side and rotate in circles:
Extending the arm and rotating it in circles primarily involves the movement of ball-and-socket joints, such as the shoulder joint, rather than hinge joints.
C. Bend the arm by flexing the ulna to the humerus:
This action involves bending the arm at the elbow joint by flexing the ulna (forearm bone) towards the humerus (upper arm bone). The elbow joint is a hinge joint, allowing primarily flexion and extension movements.
D. Tilt the pelvis forwards and backwards:
Tilting the pelvis forwards and backwards primarily involves the movement of ball-and-socket joints in the hip area, rather than hinge joints.
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