The nurse is preparing to complete the admission assessment for a ...

[jparksx]

The nurse is preparing to complete the admission assessment for a client who is being admitted for pain management due to severe pain.
 
  The nurse is preparing to plan care for this client. Organize the nursing actions in the order in which they should occur.
  Select the correct choice from the list.
 
  Response 1. Contact the healthcare provider.
  Response 2. Discuss the unit routine with the client and family.
  Response 3. Ask the client when the pain first began.
  Response 4. Ask the client what helps to relieve the pain.
  Response 5. Assess the client's past coping methods for pain throughout her life.

Question 2

A young adult male client of Arab descent is admitted to the medical-surgical unit for a ruptured appendix.
 
  The client's parents are at the bedside for most of the day. The nurse who is providing care notes that the client denies pain while on day shift, but request medication every four hours during the night. Which explanation for this client behavior is the most probable?
  1. The night nurse had more time to spend with the client.
  2. The client must be afraid or lonely at night and is trying to get attention.
  3. The client may not report pain in the presence of parents based on their influence or cultural beliefs.
  4. The client was asking for medication at night to facilitate sleep.

[dajones82]

Answer to Question 1

Correct Answer: 3, 4, 5, 2, 1

Determining the duration of the pain is the most important step that must be taken by the nurse. This information will provide a guide for the remaining information that will be sought from the client. The client in pain has likely been employing methods to manage the discomfort at home. Determining the measures being taken away from the acute care facility will help to lead the health care team in managing the current pain. This information can also be used to help indicate the severity of pain being experienced. An individual's methods of coping with pain will help to determine her tolerance and ability to manage current pain. This information is needed but does not take priority over assessing the duration of the pain being experienced or the methods being used to manage the current pain. The client and family need to have information provided concerning unit policies but this is not an immediate task. Management of the client's admission data collection takes precedence. The healthcare provider will need to be contacted about the current condition of the client but this cannot be completed until the client has been assessed. The assessment information will allow the nurse to provide information to the healthcare provider.

Answer to Question 2

Correct Answer: 3

A client may have ethnic or cultural beliefs that influence the response to pain. Some clients may be verbal and open, while some clients may choose to be quiet and suffer with the pain. The presence of family members, especially adult family members in this situation, may influence the reporting of pain. The client may have not wanted to contradict the perceived parental expectations of how an adult Arab male was to respond to pain. There is no information provided to indicate the night nurse spent more time with the client than the day/evening shifts. There is no indication the client is afraid or lonely. Many healthcare providers routinely order hypnotic medications. There is no indication the client is experiencing difficulty sleeping.

[jparksx]

Gracias!

[billybob123]

Excellent