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
This is the correct answer because it is the most important and relevant action that the PN should do for a postoperative patient with a PCA machine. A PCA machine is a computerized device that allows the patient to self-administer a preset dose of pain medication, usually an opioid, by pressing a buton. The PCA machine is attached to an intravenous (IV) line that delivers the medication directly into the bloodstream. The PCA machine can provide effective and individualized pain relief for postoperative patients, as well as increase their sense of control and satisfaction¹².
The PN should assess the pain management response of the postoperative patient with a PCA machine by monitoring their pain level, vital signs, oxygen saturation, sedation level, and side effects. The PN should use a valid and reliable pain scale, such as the numeric rating scale (NRS) or the visual analog scale (VAS), to measure the patient's pain intensity and relief. The PN should also check the settings and functioning of the PCA machine, such as the dose, lockout interval, and limit. The PN should document and report the patient's pain management response and any problems or complications with the PCA machine to the health care provider.
Correct Answer is A
Explanation
This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it. The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.
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