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.

Answer and Explanation

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.

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Correct Answer is ["B","E"]

Explanation

The PN should instruct the UAP to observe and report any ear drainage after removing the device, as this may indicate an infection or irritation of the ear canal. The PN should also instruct the UAP to verify that the device is labeled with client's identification, as this can prevent mix-ups or misplacement of the device. The PN should also instruct the UAP to remove ear wax from the device's surface, as this can improve the sound quality and prevent damage to the device.

The other options are not correct because:

a. Keeping the battery door closed during storage is not a correct instruction, as it can drain the battery and shorten its life span. The PN should instruct the UAP to keep the battery door open during storage, as this can conserve the battery power and prevent corrosion.

c. Storing the device on the window sill to prevent loss is not a correct instruction, as it can expose the device to heat, moisture, or sunlight, which can damage its components or affect its function. The PN should instruct the UAP to store the device in a dry, cool, and safe place, such as a case or a drawer.

A. The client will use self-affirmation statements to decrease fear. B. The client will ambulate with assistance for q4 hours. C. The physical therapist will instruct the client in the use of a walker. D. The PN will place a gait belt on the client prior to ambulation.

Correct Answer is B

Explanation

While all of the options address the issue of impaired mobility related to fear of falling, the desired outcome of ambulating with assistance q4 hours is the most specific and measurable goal. This outcome focuses on promoting mobility and addressing the client's fear of falling by providing the necessary assistance during ambulation. It ensures that the client is engaging in regular activity and working towards regaining mobility.
The other options address different aspects of the nursing problem:

A. "The client will use self-affirmation statements to decrease fear" is a potential intervention that can be used to address the client's fear of falling, but it does not directly address the issue of impaired mobility.
C. "The physical therapist will instruct the client in the use of a walker" is an intervention that can be helpful in improving mobility, but it does not specify the frequency or timing of ambulation.
D. "The PN will place a gait belt on the client prior to ambulation" is a specific intervention that ensures the safety of the client during ambulation, but it does not address the frequency or timing of ambulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

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Correct Answer is B

Explanation

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