The nurse is developing the plan of care for a client who is recovering from abdominal surgery. When planning interventions the nurse recognizes which of the following will best meet the needs of the client experiencing pain?

Question

1. The healthcare provider will prescribe additional analgesics.
2. The client will have reduced pain after administration of analgesics.
3. The client will vocalize reduced levels of pain within 3 hours.
4. Assist the client with guided imagery to manage pain levels.

Answer 1

4
Rationale 1: The prescribing of additional analgesics does not determine the characteristics of the pain and does not offer patient-driven information.
Rationale 2: This is a goal statement, not an intervention.
Rationale 3: This is a goal statement, not an intervention.
Rationale 4: Nursing interventions, such as assisting the client with guided imagery, are geared to assist in meeting client goals. The interventions are derived from the second part of the diagnosis, which is the etiology. The defining characteristics provide the background support for the diagnosis. The diagnostic label is global and requires specification before attempting to determine a goal. The client's stated wishes are an important component of planning, and may be included in the list of interventions as appropriate. The interventions are based upon nursing actions.