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

[karen]

A client 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; pulse, 90; and respirations, 26 .
 
  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 client is anxious.
  c. Check the client's dressing for bleeding.
  d. Recheck the client's vital signs in 30 minutes.

Question 2

A client has been hospitalized for an extended time while receiving therapies for lung cancer. The client has become very depressed, refuses to participate in personal grooming, and does not want visitors.
 
  To assist in achieving resolution of the client's problem, what should the nurse do? a. Encourage the client to get washed and dressed independently.
  b. Help the client think positively instead of negatively.
  c. Contact a support group and explore a psychological consultation.
  d. Encourage the client to become more independent and return to prior activities.

[ally]

Answer to Question 1

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

Answer to Question 2

C
Consultation with significant others, mental health clinicians, and community resources can result in a more comprehensive and workable plan. Clients who are experiencing threats to or alterations in self-concept often benefit from collaboration with mental health and community resources to promote increased awareness.
The client's problem of a negative self-concept must be addressed first. As a result, the client may begin to bathe and dress independently.
The client needs to express negative feelings. This would be one step in addressing the self-concept problem. Stating that the client should think positively instead of negatively, at this point, is unrealistic.
A long-term goal may be that the client will become more independent and return to prior activi-ties, but this is not realistic at this time.

[karen]

Both answers were spot on, thank you once again

[ally]

Great! Please up vote