The nurse is caring for an adolescent who complains of a ...

[MirandaLo]

The nurse is caring for an adolescent who complains of a headache. The nurse dims the light in the room, administers the ordered pain medication, and provides the adolescent with a caffeinated soda.
 
  Which of the following is the correct method of evaluating the effectiveness of this intervention? 1. Take the client's vital signs.
  2. Ask the parents if the client is feeling better.
  3. Observe the adolescent for signs of pain.
  4. Ask the adolescent to rate the pain in one hour.

Question 2

When the nursing student prepares to administer an injectable medication to a client for the first time, after practicing in the skills lab, the student should do which of the following? Select all that apply.
 
  Standard Text: Select all that apply. 1. Establish a therapeutic relationship with the client and family.
  2. Review the facility policy on medication administration.
  3. Explain the procedure to the client.
  4. Request supervision from the instructor.
  5. Call the physician to verify the order.

[xiazhe]

Answer to Question 1

4
Rationale 1: Pain is a subjective symptom that only the client can describe. Asking the parents to report the client's status and observing for signs of pain would yield secondary data, while asking the client directly provides more valuable information to evaluate outcome.

Answer to Question 2

2,3,4
Rationale 1: Procedures can vary slightly from facility to facility, so it is important for the student to review the facility policy before administering the medication. When a nursing student is performing a skill for the first time, or until competence is determined, the nursing instructor should always supervise the procedure. The client should not be touched without first explaining what will be done and why it is being done. The order does not need to be verified with the physician unless there is a problem with the order. A therapeutic relationship with the client and family is optimal, but it is not required in this situation.

[MirandaLo]

Excellent

[yeungji]

TYSM