Examkin

Question

Difficulty: MediumBasic Care and Comfort

A client receiving palliative care for metastatic bone cancer is experiencing restlessness and increasing pain. The family asks for interventions to help the client relax without administering additional sedating medications. Which nursing action is most appropriate to promote basic care and comfort?

  1. A
    Position the client flat on their back with legs fully extended to apply natural traction to the skeletal system.
  2. B
    Ask the unlicensed assistive personnel (UAP) to evaluate the client's non-verbal pain behaviors and determine the best physical intervention.
  3. Dim the room lights, play soft ambient music, and guide the client through a progressive relaxation exercise.Answer
  4. D
    Secure soft extremity restraints to the bed frame to prevent the restless client from inadvertently causing a pathologic fracture.

Answer

The most appropriate action is to dim the room lights, play soft ambient music, and guide the client through a progressive relaxation exercise.
Environmental modifications such as dimming the lights and playing soft music reduce sensory overload, while progressive relaxation serves as a cognitive-behavioral distraction technique. Together, these evidence-based non-pharmacological interventions promote basic care and comfort, helping to manage pain and restlessness without the use of additional sedating medications.

Step-by-Step Solution

1
Analyze the client's condition and the family's request.
The client has metastatic bone cancer, is restless, and is experiencing pain. The family wants non-pharmacological interventions to avoid further sedation.
Understanding the clinical context and family preferences is essential for selecting appropriate basic care and comfort measures.
2
Evaluate the safety and appropriateness of the proposed interventions.
Delegating pain assessment to a UAP, applying restraints for restlessness, and enforcing a rigid supine position are unsafe and contraindicated actions.
Nursing actions must prioritize client safety, adhere to the scope of practice, and avoid causing further harm or distress.
3
Select the best evidence-based non-pharmacological comfort measure.
Environmental modification (dimming lights, playing music) and cognitive-behavioral techniques (progressive relaxation) are safe and effective.
These interventions decrease environmental stimuli and promote endogenous relaxation responses, directly addressing the client's pain and restlessness without additional medication.

Key Concept

Non-pharmacological pain management and environmental modification in palliative care
Rate this question

Topics

Basic Care and Comfort

More questions from this topic