A client with appendicitis in the emergency department is highly ...

[viki]

A client with appendicitis in the emergency department is highly agitated and states that there is a great deal of pain. Which of the following interventions will the nurse plan to assist the client to achieve the outcome of decreased anxiety?
 
  1. Assess pain levels every 2 hours and administer ordered medication
   2. Administer pain medications when the client complains of pain
   3. Distract the client with ambulation
   4. Provide reading material to help distract the client

Question 2

While helping a client with the evening meal, the nurse observes the client close his eyes, bow his head, and murmur words of thanks and praise. Which of the following does this behavior indicate to the nurse?
 
  1. The client is confused.
   2. The client was praying before eating.
   3. The client was asking that the meal be better than the last.
   4. The client did not want the nurse to leave.

[jointhecircus]

Answer to Question 1

1. Assess pain levels every 2 hours and administer ordered medication

Rationale:
The extreme pain experienced by the client with appendicitis is the source of the client's anxiety. Assessing pain levels every 2 hours and administering medications before the pain gets intense is the best intervention for anxiety. Waiting until the client complains of pain makes pain relief more difficult and increases anxiety. Distraction does not work when clients have severe pain but is more appropriate for those with chronic pain.

Answer to Question 2

2. The client was praying before eating.

Rationale:
The client's behavior of bowing the head, closing the eyes, and murmuring words of thanks and praise are indications that the client was praying. The client was not demonstrating confusion. The nurse has no way of knowing if the client was asking that the meal be better than the last. The client was not delaying the nurse so that she did not leave.

[viki]

Thanks

[jointhecircus]

Welcome