HESI Case Study: Pain - Answered with Rationales

HESI Case Study: Pain During the nurse's initial interview, Natalie shares information about her home, career, and family. The nurse evaluates the information to determine psychosocial factors that may impact pain management Pain Assessment (Title) What information obtained by the nurse is most likely to influence Natalie's perception of her pain? - Natalie's younger child is an infant who feeds every 3 hours -Natalie's 4 -year-old enjoys being the "big brother" to his baby sister - Natalie was a firs t grade teacher before having children but now stays home -Natalie's parents live in the same neighborhood and often help with the children Rationale: Feeding an infant every 3 hours interrupts sleep and results in fatigue. Fatigue often heightens the per ception of pain and impairs coping skills To assess the quality of Natalie's pain, the nurse asks which question? - "On a scale of 0 to 10, how would you rate your pain?" - "What word best describes the pain you are experiencing?" - "What actions do you t ake to relieve the pain?" - "What do you fear most about your pain?" Rationale: The quality of pain experienced is typically a descriptive term, such as burning, crushing, aching or stabbing. Which behavior that Natalie exhibits, that the nurse documents as objective signs of acute pain? - States pain level of 5 out of 10 - Complains of shortness of breath - Difficulty concentrating - Frequent grimacing Rationale: Grimacing is an objective indicator of pain. After completing the pain assessment, the nur se develops a plan of care. The nurse identifies pain and anxiety as the priority problems. Nursing Process (Title) To determine the etiology of Natalie's anxiety, what is the priority nursing intervention? - Refer the client to the clinic social worker - Continue the interview with the client - Review the healthcare provider's (HCP's) note -Recognize that pain causes anxiety Rationale: Further assessment by the nurse is needed to determine the cause of the client's anxiety. Which is the best goal for the nurse to include in the plan of care related to the problem statement of, "Acute pain related to strain on muscles with movement?" - Client reports pain of less than 1 on a 0 to 10 scale - Client will verbalize pain control methods - Client will learn alt ernative methods for pain control - Client will learn to live with long -term pain Rationale: The goal is a broad statement that reflects a positive direction for the client's problem, in this case, acute pain. The nurse considers interventions to include in the plan of care. Before implementing any interventions, what action is most important for the nurse to take? - Place a copy of the plan of care in the client's chart - Evaluate the client's response to the interventions - Review interventions in a car e plan manual - Discuss the plan of care with the client Rationale: After considering interventions to implement, the nurse should review the plan of care with the client and seek client input. Non-Steroidal Anti -inflammatory Drugs (NSAIDs) The nurse consults with the clinic director, a pain management physician, who recommends the use of NSAIDs and alternating heat and cold applications, as well as back exercises. The nurse provides client teaching about these treatments. Natalie tells the nurse that she does not know what an NSAID is. Steroidal Anti -inflammatory Drugs (NSAIDs) (Title) Which medication should the nurse suggest as a common NSAID? - Diphenhydramine (Benadryl) - Alprazolam (Xanax) - Calcium carbonate (Tums) - Ibuprofen (Motrin) Rational e: Ibuprofen is an NSAID that has anti -inflammatory properties Natalie decides to purchase buffered aspirin and asks if this medication is also safe to give her 4 -year-old since he occasionally experiences viral infections and becomes feverish. Medication Safety (Title) What information should the nurse include in responding to Natalie? - Aspirin comes in children's doses, which can be given safely to 4 -year-olds