The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client's plan of care?
Encourage the client to resume normal activities after medication administration.
Observe the client for involuntary movements of the lips and tongue every day.
Perform a daily whisper test of the client's hearing to detect symptoms of ototoxicity.
Implement ongoing assessments for signs of shallow or slow breathing.
The Correct Answer is D
Tramadol is an opioid analgesic that can depress the respiratory system and potentially cause respiratory depression. Therefore, it is crucial for the PN to closely monitor the client's breathing pattern, depth, and rate. Assessing for signs of shallow or slow breathing is important to detect any potential respiratory depression and take appropriate action promptly.
The other options listed are not directly related to the administration of tramadol:
A. Encouraging the client to resume normal activities after medication administration is not an appropriate intervention for a client experiencing torticollis. The focus should be on pain management, rest, and implementing measures to relieve the torticollis.
B. Observing the client for involuntary movements of the lips and tongue every day is not specifically related to tramadol. This intervention is more relevant to monitoring for tardive dyskinesia, a side effect associated with certain antipsychotic medications.
C. Performing a daily whisper test of the client's hearing to detect symptoms of ototoxicity is not necessary with tramadol. Ototoxicity refers to damage to the inner ear, often caused by specific medications, but tramadol is not known to cause ototoxic effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A thready pulse refers to a pulse that is weak and difficult to palpate. It may disappear or weaken with light pressure. This can be an indication of decreased peripheral perfusion or reduced blood volume. By documenting the finding as "Thready pulse volume," the nurse is accurately describing the quality of the pulse and its response to light pressure.
Incorrect:
A. Missing pulse: A missing pulse would mean that the pulse is not palpable at all, even without applying pressure.
B. Light pressure applied to pulse: This is not a description of the pulse quality, but rather a description of the action taken to assess the pulse.
C. Pulse skips beats: This would mean that the pulse is irregular, with beats being missed or added. In this case, the pulse disappears when light pressure is applied and returns when the pressure is removed, which describes a thready pulse volume.
Correct Answer is ["A","D","E"]
Explanation
During a generalized tonic-clonic seizure, it is important for the practical nurse (PN) to prioritize the safety and well-being of the child. The correct actions to implement immediately are:
A. Observe the progression of the seizure: The PN should closely observe the seizure to gather important information that can be helpful for medical professionals in assessing the seizure's characteristics and duration.
D. Pad the side rails with pillows: Padding the side rails of the bed with pillows helps to prevent the child from injuring themselves by hitting the side rails during the seizure.
E. Loosen clothing around the neck: Loosening any tight clothing around the child's neck helps to ensure adequate breathing and prevent any constriction or discomfort during the seizure.
B. Hold the extremities close to the body: This action is not recommended during a seizure as it may increase the risk of injury to the child or the PN.
C. Insert a tongue blade between the teeth: It is not recommended to insert any object, including a tongue blade, between the teeth of a person experiencing a seizure. This can cause injury to the person's mouth or teeth and is no longer considered an appropriate intervention for seizures.
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