Comfort-PrepU

After sedating a patient, the nurse assesses that the patient is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this patient?

3 The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows: 1 = awake and alert; no action necessary, 2 = occasionally drowsy but easy to arouse; requires no action, 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose, 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.

When performing an assessment on a client with chronic pain, the nurse notes that the client frequently shifts conversational topics. The nurse determines that this may be an indicator for which of the following?

Anxiety Explanation: Clients in pain may experience anxiety, and the anxiety may also increase the perception of pain. Signs of anxiety include decreased attention span or ability to follow directions, asking frequent questions, shifting topics of conversation, and avoidance of discussion of feelings

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?

Document the client's choice and re-assess pain in 1 hour. Explanation: A client has the right to choose whether to take medication. The nurse should assess the client's pain regularly and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication. (less)

A client asks about complementary therapies for relief of discomfort related to pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching?

Herbal remedies Explanation: A pregnant woman should avoid all medication unless her physician instructs her to use it. This includes herbal remedies, because their effects on the fetus have not been identified. Meditation, music therapy, and acupuncture have all proven to enhance relaxation without harm to the mother or baby.

Which of the following sedative medications is effective for treating pruritus?

Hydroxyzine (Atarax) Explanation: Atarax is a sedating medication effective in the treatment of pruritus. Benzoyl peroxide, Allegra, and tetracycline are not effective in treating pruritus.

Which phase of pain transmission occurs when the one is made aware of pain?

Perception Explanation: Problems that may develop with opioid and opiate therapy include Risk for Impaired Gas Exchange related to respiratory depression, Constipation related to slowed peristalsis, and Risk for Injury related to drowsiness and unsteady gait.

The parents of a preschool child diagnosed with autism must take their child on a plane flight and are concerned about how they can make the experience less stressful for her and their fellow travelers. The nurse suggests a dry run to the airport in which they simulate going through security and boarding a plane. In addition, the nurse suggests taking items to help the child be calm during the flight. In what order of priority from first to last should the parents employ the items listed below? All options must be used.

a DVD player with headphones and favorite games, cartoons, and child films a favorite non-electronic game a favorite stuffed animal or other soft toy medication that can be given as needed to calm the child Explanation: Electronic games and stories are favorites of most children, but are particularly enjoyed by children on the autism spectrum. The headphones block out some of the noises that might be upsetting to a child on the autism spectrum. If the child cannot be engaged electronically, a favorite non-electronic toy would be the next choice. Stuffed animals or other soft toys can soothe a child who is starting to become upset. Medication should be a last resort as it can have a paradoxical effect if it is an antianxiety medication or may cause too much sedation during the flight

A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to:

assess for and maintain adequate nutrition and hydration. Explanation: Food and fluid intake may be compromised in a client who is severely depressed. The nurse must ensure that the client is adequately hydrated and is receiving proper nutrition. Although the client's psychological needs are important, physiological needs are the priority in this case. Assessing the client's depression level, continuing the client's ordered medication, and maintaining the client's hygiene needs are lower priorities at this time. The nurse should be aware that family involvement may not be indicated in this client's care.

When assessing a client who reports a back injury, it is critical for the nurse to question the client about:

mechanism of injury. Explanation: The mechanism of injury is always the most critical information to obtain from a client with a musculoskeletal injury. In the event of a back injury, the mechanism of injury provides the greatest clue as to the extent of injury and the proper treatment plan. The other questions are important but will not give the critical information needed related to this specific problem and injury. (less)

A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to:

reposition the client off the reddened skin and reassess in a few hours. Explanation: A stage I ulcer presents as an area of intact, nonblanchable redness, usually over a bony prominence, caused by pressure. If a reddened area blanches and refills with fingertip pressure, it indicates that there is still some blood flow to the injured area, and the redness may be reversible. It may be appropriate to complete and document a Braden score or consult a wound nurse specialist, but it is imperative to reposition the client off the reddened skin area first. Since there is no break in the skin, it is not appropriate to apply a moist to moist dressing.