A patient complains of pain and asks the nurse for pain ...

[cnetterville]

A patient complains of pain and asks the nurse for pain medication. The nurse first assesses vital signs and finds them to be as follows: Blood pressure 134/92 mm Hg, pulse 90 beats per minute, and respirations 26 breaths per minute.
 
  Which of the following is the nurse's most appropriate action? a. Assess with a pain scale, and administer the medication.
  b. Ask if the patient is anxious.
  c. Check the patient's dressing for bleeding.
  d. Recheck the patient's vital signs in 30 minutes.

Question 2

The nurse is making rounds and finds her older adult patient sobbing and obviously upset. She states that her doctor told her that she has cancer, and she does not want to die. What's the sense? she says. I might as well die.
 
  I'm going to anyway. I guess that shows how useless I really am. Nobody wants an old lady around. The nurse notices that the patient's respirations have increased, and the tip of her nose and ear lobes are becoming cyanotic. The nurse assesses the patient and finds that the patient's pulse rate is over 150 beats per minute. According to Maslow's hierarchy of needs, the nurse should first a. Call the physician to request a psychiatric consult.
  b. Reassure the patient that she has value as a human being.
  c. Place the patient on oxygen and try to calm her.
  d. Call the patient's family to help her realize that she is wanted.

[huda]

Answer to Question 1

A

Feedback
A The patient's vital signs are consistent with the patient being in pain (increased pulse, shallow breathing, and increased blood pressure). It would be safe and appropriate for the nurse to assess the patient's pain on a pain scale and then administer the pain medication.
B Asking if the patient is anxious is not the most appropriate action.
C The patient is not demonstrating signs of shock (i.e., decreased blood pressure, increased pulse). Therefore, the most appropriate action is not to check the patient's dressing but to administer pain medication.
D Rechecking the patient's vital signs in 30 minutes would not be the most appropriate action. The nurse should medicate the patient for pain.

Answer to Question 2

C
Maslow's hierarchy is useful in setting patient priorities. Basic physiological and safety needs are usually the first priority. These include physiological needs such as air, water, and food. Cyanosis and fast heart rate are indicators of physiological stress and must be dealt with first, or the patient may not survive. The second level includes psychological security. A psychiatric consult would come after physiological stabilization. The third level includes love and belonging needs that would also need to be addressed, and the family may be helpful in dealing with this, once the patient is stabilized. The fourth level involves self-esteem, which would also need to be addressed.