The nurse is providing care to a client who returns to the ...

[sjones]

The nurse is providing care to a client who returns to the medical-surgical unit after herniated disk surgery.
 
  The client's HR is 100, RR 22, BP 130/86 mmHg, temperature 98.8 degrees F, and a pain rating of 7 on a scale of 1 to 10. Which nursing diagnosis is the priority for this client based on the assessment data?
  A) Impaired Physical Mobility
  B) Acute Pain
  C) Activity Intolerance
  D) Chronic Pain

Question 2

A preadolescent client is recovering from spinal fusion surgery for scoliosis. Which interventions would be appropriate related to movement restrictions and pain?
 
  Select all that apply.
  A) Reposition every 2 hours.
  B) Monitor intake and output.
  C) Encourage and assist with ROM exercises every 4 hours while awake.
  D) Administer pain medication around the clock.
  E) Encourage incentive spirometer use every 4 hours while awake.

[Cnarkel]

Answer to Question 1

Answer: B

The client is experiencing acute pain evidenced by a pain rating of 7 on a 1 to 10 scale and elevate vital signs. The priority nursing diagnosis is acute pain. Impaired physical mobility and activity intolerance are appropriate diagnosis for the client's surgical procedure, but are not the current priority. The client was most likely experiencing chronic pain when lead to the need for surgery.

Answer to Question 2

Answer: A, C, D

Interventions appropriate for a preadolescent client recovering from spinal fusion to address Impaired Physical Mobility related to movement restrictions and pain would include repositioning every 2 hours, encouraging and assisting with ROM exercises every 4 hours while awake, and administering pain medication around the clock. The use of an incentive spirometer would be applicable for Impaired Tissue Perfusion. Monitoring intake and output would be applicable for either Fluid Volume Excess or Deficit.

[sjones]

Gracias!

[yeungji]

Excellent