Pain
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks what would happen if i arrive at the emergency department and I had difficulty breathing? Which of the following responses should the nurse make? 1. "We would consult the person appointed by your health care proxy to make decisions." 2. "We would give you oxygen through a tube in your nose." 3. "You would be unable to change your previous wishes about your care." 4. "We would insert a breathing tube while we evaluate your condition."
2. "We would give you oxygen through a tube in your nose." Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? Select all that apply A) Assist the client with a partial bed bath B) Measure the clients blood pressure after the nurse administers an anti-hypertensive medication C) Test client's swallowing ability by providing thickened liquids D) Use a communication board to ask what the client wants for lunch E) Irrigate the client's indwelling urinary catheter
A) Assist the client with a partial bed bath B) Measure the clients blood pressure after the nurse administers an anti-hypertensive medication D) Use a communication board to ask what the client wants for lunch
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? A. "I can take echinacea to improve my immune system." B. "I can take feverfew to reduce my level of anxiety." C. "I can take ginger to improve my memory." D. "I can take ginkgo biloba to relieve nausea."
A. "I can take echinacea to improve my immune system." Echinacea is taken to promote immunity and reduce the risk of infection. Feverfew = promote wound healing and decrease inflammation associated with arthritis Valerian & chamomile = reduce anxiety Ginger = relieve nausea and vomiting & aid in digestion Ginkgo biloba = improve memory and reduce stress
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A. "What could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "Where is my daughter at a time like this?" D. "Will I ever begin to feel in charge of my life again?"
A. "What could I have done to deserve this illness?"The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. B. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. C. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. D. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.
A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.
A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all that apply A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs
A. Bathing B. Ambulating C. Toileting E. Measuring vital signs Determining pain level requires assessment, which is the job of the licensed personnel.
A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states which of the following are clinical manifestations of a systemic infection. Select all. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse & and respiratory rate
A. Fever B. Malaise E. Increase in pulse & respiratory rate Edema and pain and tenderness is localized
A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take? A. Offer to assist the client needing the bedpan. B. Administer the injection prepared by the other nurse C. Prepare another syringe & administer the injection D. Tell the client needing the bedpan she will have to wait for her nurse
A. Offer to assist the client needing the bedpan. The medication is already drawn for legal purposes do not administer it if you were not the one who had drawn the medication!!!!
A nurse is assessing the pain level of a client who has come to the ER reporting severe abd. pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following? A. Presence of associated symptoms B. Location of the pain C. Pain quality D. Aggravating & relieving factors
A. Presence of associated symptoms this is a common symptom people have when experiencing pain
A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? Select all that apply A. Provider B. CNA C. Pharmacist D. RN E. Respiratory therapist
A. Provider C. Pharmacist D. RN
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all that apply A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the prescriber's signature on the prescription within 24hrs D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone
A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the prescriber's signature on the prescription within 24hrs
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions. B. Provide breaths with a manual resuscitation bag. C. Administer oxygen. D. Establish an airway.
A. Start chest compressions. The nurse should perform cardiopulmonary resuscitation, which starts with chest compression, then opening the airway, and breathing for adults and pediatric clients because evidence indicates there is a great survival rate when chest compressions are started before a breath is initiated.
A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level B. Discuss the adverse effects of pain medication with the client C. Obtain vital signs D. Check the client's allergies
A. Use the pain scale to determine the client's pain level This action should be done first, as it is an assessment of the client's current condition.
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply A. Warm the enema prior to instillation B. Position the client on the left side w/the right leg flexed forward C. Lubricate the rectal tube or nozzle D. Slowly insert the rectal tube about 2 inches E. Hang the enema container 24 inches above the client's anus
A. Warm the enema prior to instillation B. Position the client on the left side w/the right leg flexed forward C. Lubricate the rectal tube or nozzle D 2 inches is the appropriate length of insertion for a child, 3-4 for an adult. -24 inches is too high & will cause it to run to fast & possible painful distention of the colon, 18 inches is the recommended height
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink
C. Fastening her bra behind her back Fastening a bra from behind requires internal rotation of the shoulder, so this activity will illicit pain
A nurse is discussing the challenges of assessing pain in children with a group of parents. Which of the following statements should the nurse include? A The presence of the child's parent can make it more difficult to assess a child's pain. B Children may deny pain to avoid IM injection or bad tasting oral medicine. C Children often cannot identify where the pain is located. D Young children do not exhibit pain.
B Children may deny pain to avoid IM injection or bad tasting oral medicine. Children may deny pain when the nurse asks. They fear injections and don't want to take bad tasting medications. They may fear that this will happen due to previous experiences when they were sick or hurting or in the hospital. The child's parent can actually help determine if the child is crying due to pain or because of another reason. Children as young as 3 years of age, such as the child in the video, can accurately point to the pain. Although they may not be able to describe in words the location or type/quality of the pain, they can communicate if asked to point to the pain. Children do have the nerve receptors at birth to be able to experience pain.
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A) The client uses a wool blanket on their bed B) The client identifies the location of a fire extinguisher C) The client stores an extra oxygen tank on its side under the bed D) The client has a weekly inspection checklist for oxygen equipment
B) The client identifies the location of a fire extinguisher The client or caregiver should inspect oxygen equipment daily.
A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94 mmHg. The client denies any history of HTN. Which of the following actions should the nurse take next? A. Request a prescription for an antihypertensive med B. Ask the client if she is having pain C. Request a prescription for an anti-anxiety med D. Return in 30min to recheck the client's BP
B. Ask the client if she is having pain Perform a pain assessment would be the appropriate action to take next
A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all that apply A. Slower light touch sensation B. Some vision & hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation
B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline
A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine (Demerol) 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO
C. Morphine 2 mg IV IV morphine is the best because the onset is rapid and absorption to the blood is immediate, which is adequate for a client with a 10 pain severity
A nurse is caring for a client who is receiving morphine via a PCA infusion device after abd. surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping."
C. "I should tell the nurse if the pain doesn't stop after I use this device." The client should let the nurse know if not receiving adequate pain control, so they can reevaluate the pain control plan
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the question? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?"
C. "What do you think caused the onset of your pain?" With this answer, the nurse is using an open-ended question that allows the client to respond with a range of information by using more than one or two words. All other options are close-ended questions that generally can be answered by one or two words.
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the question? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?"
C. What do you think caused the onset of your pain?" With this answer, the nurse is using an open-ended question that allows the client to respond with a range of information by using more than one or two words. All other options are close-ended questions that generally can be answered by one or two words.
A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by: A. asking what precipitates the pain B. questioning the client about the location of the pain C. offering the client a pain scale to measure his pain D. using open-ended questions to identify the situation
C. offering the client a pain scale to measure his pain pain scale can measure the amount and intensity of the pain
A nurse is teaching a client about taking multiple oral meds at home including time-release capsules, liquid meds, enteric-coated pills, & and narcotics. Which of the following statements by the client indicates an understanding of the teaching? A. "I can open the capsule w/the beads in it & sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding." C. "The pills with the coating on them can be crushed." D. "I will eat 2 crackers w/the pain pills."
D. "I will eat 2 crackers with the pain pills." this will prevent N&V from the narcotic
A nurse is obtaining hx from a client who has pain. The nurse's guiding principle throughout this process should be that: A. some clients exaggerate their level of pain B. pain must have an identifiable source to justify the use of opioids. C. objective data are essential in assessing pain D. pain is whatever the client says it is
D. pain is whatever the client says it is the client is the best source of information in their pain, it is a subjective experience
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurses priority? 1. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. 2. Determine the reasons why the client is refusing to use the incentive spirometer. 3. Document the client's refusal to participate in health restorative activities. 4. Administer a pain medication to the client.
2. Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.
A nurse is assessing four adults. Which of the following physical assessment techniques should the nurse use? 1. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. 2. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. 3. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum 4. Palpate the client's abdomen before auscultating bowel sounds.
2. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.
A nurse is reviewing evidence based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? 1. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. 2. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. 3. Make sure the reservoir bag of a partial rebreathing mask remains deflated. 4. Use petroleum jelly to lubricate the client's nares, face, and lips.
2. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? 1. The client uses a wool blanket on their bed. 2. The client uses nonacetone nail polish remover. 3. The client stores an extra oxygen tank on its side under their bed. 4. The client has a weekly inspection checklist for oxygen equipment.
2. The client uses nonacetone nail polish remover. The client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen.
A client who is postoperative is verbalizing pain as a 2 on a scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? 1. "I think I should take my pain medication more often since it is not controlling my pain." 2. "Breathing faster will help me keep my mind off of the pain." 3. "It might help me to listen to music while I'm lying in bed." 4. "I don't want to walk today because I have some pain."
3. "It might help me to listen to music while I'm lying in bed." Listening to music is an effective nonpharmacological intervention for the management of mild pain.
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? 1. Role ambiguity 2. Sick role 3. Role overload 4. Role conflict
3. Role overload The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? 1. "Is your pain constant or intermittent?" 2. "What would you rate your pain on a scale of 0 to 10?" 3. "Does the pain radiate?" 4. "Is your pain sharp or dull?"
4. "Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should in form the client that this condition is a contraindication for which of the following therapies? 1. Biofeedback 2. Aloe 3. Feverfew 4. Acupuncture
4. Acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.
A nurse is caring for a client who is experiencing pain. Which of the following are influencing factors of pain? (Select all that apply.) A Client risk factors B Client trends C Anxiety D Type of pain medication used E Moral considerations F Socioeconomic status
A Client risk factors B Client trends C Anxiety D Type of pain medication used The nurse should identify that the factors influencing pain include client risk factors, observe client trends, and consider which medications are being prescribed for pain management, along with the client's level of anxiety. Moral considerations and client socioeconomic status are not influencing factors for pain management
In addition to using an age-appropriate pain scale, the nurse should also note and document additional subjective data. Which of the following subjective data should the nurse have assessed and documented for a child? A Withdrawn B Palmar sweating C Crying D Increased heart rate
A Withdrawn Subjective pain is what the child states about the pain and is the most reliable indicator of pain. Physiologic and behavioral indicators are objective data. A child might experience the behavioral indicator of being withdrawn and has changes in facial expression (quiet in the bed, looking down, speaking softly);
