Author Question: The nurse is discussing goals to relieve pain and fatigue with a client newly diagnosed with ... (Read 53 times)

Davideckstein7 · **on:** Jun 25, 2018

The nurse is discussing goals to relieve pain and fatigue with a client newly diagnosed with fibromyalgia. Which goal statement would be realistic for this client to achieve within 30 days?

A) Cook dinner five nights a week.
B) Join an exercise group.
C) Walk her son to school daily.
D) Get a job outside the home.

Question 2

A client is admitted to the emergency department in a sickle cell crisis. The nurse assesses the client and documents the following clinical findings: temperature 102 F, O2 saturation of 89, and complaints of severe abdominal pain.

Based on the assessment findings, which intervention is the greatest priority?
A) Apply oxygen per nasal cannula at 3 L/minute.
B) Assess and document peripheral pulses.
C) Administer morphine sulfate 10 mg IM.
D) Administer Tylenol 650 mg by mouth.

dpost18 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: A

Fibromyalgia saps the client's energy. The client might set as an initial goal to be able to perform daily tasks for the family such as cooking and doing the laundry. Walking her son to school daily is a bit ambitious to start, as are joining an exercise group and getting a job outside the home.

Answer to Question 2

Answer: A

Hypoxia is often the cause of a sickle cell crisis from the clumping of damaged RBCs, which creates an obstruction and hypoxia distal to the clumping. Administering the oxygen will improve the pain and increase the oxygen saturation of body tissues. Therefore, applying the oxygen should be the first action by the nurse. Although the temperature is elevated, and will increase oxygen demands in the body by increased basal metabolic activity, administering Tylenol is not the first action the nurse should take, because a sickle cell crisis is caused by oxygen deprivation in tissues, not by the fever. Morphine sulfate is a narcotic for pain, but it should be given after the oxygen is started, since the symptoms are caused by hypoxia. The morphine will decrease the pain and decrease metabolic oxygen needs by decreasing basal metabolic rates; therefore, supply is increased and demand is increased. Full body assessment, including peripheral pulses, is significant to identify the location of the potential obstruction, but this is secondary to treating the hypoxia that is known to be present from the sickling of the cells during sickle cell crisis.