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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Administering the medication and alerting the charge nurse is not necessary in this scenario. The heart rate of 120 beats/minute is within the normal range for a 2-month-old infant, which is typically between 80 to 160 beats per minute. Therefore, there is no immediate concern that would require alerting the charge nurse.
Choice B reason:
Holding the medication and documenting the cardiac assessment would be appropriate if the heart rate were outside the normal range or if there were other signs of digoxin toxicity or adverse effects. Since the heart rate is within the normal range, this action is not warranted.
Choice C reason:
Administering the medication and documenting the heart rate is the correct action. The heart rate of 120 beats/minute falls within the normal range for a 2-month-old infant¹². Digoxin is prescribed to manage certain heart conditions, and as long as the heart rate is within the normal range and there are no signs of toxicity, the medication should be given as prescribed.
Choice D reason:
Holding the medication and rechecking the heart rate in 1 hour would be considered if the heart rate were borderline or if there were concerns about the stability of the infant's condition. Since the heart rate is stable and within the normal range, this action is unnecessary.
Correct Answer is A
Explanation
Hoarseness or voice changes after thyroidectomy can be indicative of injury or irritation to the recurrent laryngeal nerve, which is responsible for controlling the vocal cords. This is a potential complication of the surgery and should be reported to the charge nurse or healthcare provider for further evaluation and management.
B. Administer humidified oxygen per nasal cannula: This option is not appropriate for addressing hoarseness in a client following a thyroidectomy. Hoarseness after a thyroidectomy is typically related to vocal cord injury or irritation, and providing humidified oxygen would not directly address this issue. It is important to notify the charge nurse or healthcare provider for further evaluation and management.
C. Obtain a cup of ice chips for the client: Providing ice chips is not the appropriate action for hoarseness following a thyroidectomy. Ice chips are typically used to provide hydration and comfort to clients, but they do not directly address the underlying cause of hoarseness, which in this case may be vocal cord injury or irritation. It is important to notify the charge nurse or healthcare provider for appropriate evaluation and management.
D. Ensure that the drainage device is compressed: While ensuring proper compression of a drainage device is important for preventing complications such as bleeding or infection, it is not directly related to the client's hoarseness. Hoarseness after a thyroidectomy is more likely related to vocal cord injury or irritation, and notifying the charge nurse or healthcare provider is necessary for further assessment and management.
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