A nurse identifies a nursing diagnosis of Acute Pain for a client receiving a vaccine. Which of the following would the nurse include in the client's plan of care to address this problem? Select all that apply
A) Administering acetaminophen every 4 hours
B) Providing for adequate rest periods
C) Ensuring that the environment is stimulating
D) Applying compresses to the injection site
E) Limiting the client's access to fluids
Ans: A, B, D
Feedback:
For the client with acute pain related to the administration of a vaccine, the nurse would administer prescribed acetaminophen; provide for frequent rest periods in a quiet, nonstimulating environment; apply warm or cool compresses to the injection site; and encourage fluid intake.
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