general Survey, vital signs and pain

What is considered normal blood pressure?

Systolic <120; Diastolic <80

What is considered hypertension stage 2 blood pressure?

Systolic > 160; Diastolic > 100

How is chronic pain defined?

- nonassociated pain lasting more than 3-6 months -pain lasting more than 1 month after an acute injury or illness -pain recurring at intervals of months or years

A nurse begins to assess pain in a client admitted to the hospital for new onset of severe nausea and vomiting. What question should the nurse ask the client to assess the pattern of pain? a) "What therapies have you tried to control the pain?" b) "How often do you experience the pain?" c) "When did your pain start?" d) "Where is the pain located?"

"How often do you experience the pain?" Explanation: The nurse uses the mnemonic COLDSPA to elicit information from a client about the pain. "P" stands for pattern & questions should elicit information about what makes the pain better or worse. Asking the client how often the pain occurs will help the nurse understand the course of the pain and if there is any pattern that may help identify the source of the pain. Asking about onset of the pain is essential to determine the severity of the situation. Therapies alert the nurse to the effect of treatment modalities that have or have not been successful in alleviating the pain. Location helps to identify the underlying cause.

A nursing instructor is teaching students how to assess a patient's pain. The instructor emphasizes that there are many misconceptions about pain. The instructor realizes that a student needs further direction when the student states: a) "Nurses are the best authority on pain." b) "Patients with chronic illnessess can have chronic pain." c) "Acute pain can be as intense as chronic pain." d) "Chronic pain can be referred to as persistent pain."

"Nurses are the best authority on pain." Explanation: Pain is what the patient says it is, and it exists whenever the patient says it does. The patient is the best authority on pain, and self-report is the gold standard. Therefore, nurses are not authorities on pain. It is true that patients with chronic illnesses can and often do have chronic pain. It also is true that acute pain can be intense. Chronic pain is sometimes known as persistent pain.

The patient asks the nurse about possible causes of neuropathic pain. Which is the best response by the nurse? a) "Patients with diabetes often develop neuropathic." b) "Sickle cell pain is a type of neuropathic pain." c) "Surgical procedures can cause neuropathic pain." d) "Orthopedic trauma is an example of neuropathic pain."

"Patients with diabetes often develop neuropathic." Correct Explanation: Neuropathic pain results from damage to nerves in the peripheral or central nervous system. Examples include diabetic peripheral neuropathy, post-herpetic neuralgia, and post-mastectomy pain. Examples of acute pain include surgery, trauma, or injury. Examples of chronic pain include low back pain and sickle cell pain.

Which question would be most appropriate to ask a client when the goal is to identify precipitating factors that might have exacerbated the pain?" a) "What were you doing when the pain first stated? b) "Do concurrent symptoms accompany the pain?" c) "When did the pain start?" d) "Is the pain continuous or intermittent?"

"What were you doing when the pain first stated? Correct Explanation: Exacerbation means something that could make the pain more intense or worse than previously experienced. Asking when the client was doing when the pain started might identify that type of factor. Asking about concurrent symptoms provides information about the possible source of the pain. Asking when the pain started provides information about the onset and duration of the pain. Asking if the pain is continuous or intermittent helps to identify the nature of the pain.

What are the main categories of general appearance?

-Apparent state of health -level of consciousness -facial expressions -odors: body and breath -posture, gait, motor activity and speech -signs of distress -skin color and obvious lesions -dress, grooming and personal hygiene.

What steps ensure an accurate blood pressure measurement?

-Arm should be free of clothing and there shouldn't be any obstruction/lymphodema -palpate the brachial artery which is at the heart level -if seated; rest arm above patient's wrist -if standing; support patient's arm at mid chest level.

What are some errors that results in false low blood pressure readings?

-cuff too large (wide) - repeating assessments to quickly -inaccurate level of inflation -pressing stethoscope too tightly against pulse

What are some errors that results in a false high blood pressure readings?

-cuff too small (narrow -cuff too loose or uneven -arm below heart level -arm not supported -inflating or deflating cuff too slowly (high diastolic) -deflating cuff too quickly (low systolic and high diastolic)

How do you intensify Korotkoff sounds?

-raise patients arm before and while inflating the cuff then lower the arm to determine bp -inflate cuff and make the patient make a fit several times

What should you make note of when taking pulse?

-rate: beats per minute -rhythm: the interval between pulses (regular or irregular) -amplitude: the force of the pulse 1+= weak (easy to subdue) 2+= normal 3+ = very strong (difficult to subdue) -elasticity: should be smooth and resilient vs. nodular and stiff

how many breaths per minute does the normal adult take?

12-20 breaths per minute in a quiet, regular state

A client is diagnosed with chronic non-malignant pain. The nurse understands that this client has experienced this pain for at least how many months?

6 Correct Explanation: Chronic non-malignant pain usually is associated with a specific cause or injury and described as a constant pain that persists for more than 6 months.

What is the normal range of heart beats per minute?

60-100 beats per minute

Due to a change in the client's status, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4oF. Which finding would the nurse interpret as within the range of the client's previous temperature?

97.4oF Correct Explanation: An axillary temperature is 1oF lower than the oral temperature. In this case, the axillary temperature that is within the client's oral temperature range would be 97.4o F. Rectal temperature is between 0.7oF and 1oF higher than the normal oral temperature.

The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mm Hg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension?

98/52 mm Hg Correct Explanation: A drop of 20 mm Hg or more form the recorded sitting blood pressure may indicate orthostatic hypotension. Therefore, a change in blood pressure from 122/72 mm Hg to 98/52 mm Hg fits this criteria. The other blood pressure readings, although lower than the sitting blood pressure would not reflect orthostatic hypotension.

A patient is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to decribe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers? a) C fibers b) AC fibers c) A-delta fibers d) P fibers

A-delta fibers Correct Explanation: A-delta fibers are myelinated and conduct impusles rapidly, resulting in pain being described as sharp or stabbing. C fibers are unmyelinated and cause pain that is achy and ongoing. There are no known AC or P fibers related to pain

The patient arrives to the emergency room reporting severe abdominal pain that started 3 hours ago. He rates the pain as an 8 on a scale of 1 to 10. After tests are performed, the patient is diagnosed with appendicitis. This is an example of which of the following types of pain?

Acute Explanation: Acute pain is of short duration and results from tissue damage, either through surgery or injury. Chronic pain lasts beyond the normal healing period of 3 to 6 months. Neuropathic pain results from damage to nerves in the peripheral or central nervous system. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues.

A patient presents to the ED with pain in the upper right quadrant that worsens after eating. She describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?

Acute Correct Explanation: Acute pain results from tissue damage, whether through injury or surgery. Chronic, phantom, and cutaneous pains are not described as sharp and stabbing.

A client presents to the health care clinic with reports of 2 day history of sore throat pain, ear pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?

Acute Pain related to sore throat Explanation: The client describes pain on 2 day duration which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for fluid volume deficit.

A pathophysiology instructor is discussing pain and its treatment across cultures. The instructor points out that patients from racial and ethnic minorities often receive less pain medication compared to Caucasians for what specific conditions? a) Broken limbs b) Acute pain in the ED c) Head injuries d) Chronic pain from fibromyalgia

Acute pain in the ED Correct Explanation: African Americans, Hispanic Americans, and other patients of racial and ethnic minority heritage receive less pain medication compared to Caucasians across a range of conditions, including cancer pain, acute postoperative pain, chest pain, acute pain presenting in the ED, and chronic low back pain. This disparity may be the result of patient variables such as nociceptive differences, communication processes, or pain behaviors.

The nurse is seeing an older client who has not had medical care for many years. Vital signs are T 37.2, HR 78, BP 118/92, RR 14. The client denies pain. The nurse notices that the client has some hypertensive changes in her retinas; a urine test reveals mild proteinuria. The nurse expected the client's BP to be higher. The client is not taking any medications. What do you think is causing this BP reading? a) A cuff size error b) The client's emotional state c) Resolution of the process that caused her retinopathy and kidney problems d) An auscultatory gap

An auscultatory gap Explanation: The blood pressure is unusual in this case because the systolic pressure is normal while the diastolic pressure is elevated. Especially with the retinal and urinary findings, the nurse should consider that the BP may be much higher and that an auscultatory gap was missed. This can be avoided by checking for obliteration of the radial pulse while the cuff is inflated. Although a large cuff can cause a slightly lower BP on a client with a small arm, this does not account for the elevated DBP. Emotional upset usually causes elevation of the BP. Although a process that caused the retinopathy and kidney problems may have resolved, leaving these findings, it is a dangerous assumption that this is the sole cause of the problems seen in this client.

What is the term used to describe a pharmaceutical agent that relieves pain?

Analgesic Correct Explanation: An analgesic is a pharmaceutical agent that relieves pain. Analgesics reduce the perception of pain and alter responses to discomfort.

What is the term used to describe a pharmaceutical agent that relieves pain? a) Antihistamine b) Analgesic c) Antacid d) Antibiotic

Analgesic Correct Explanation: An analgesic is a pharmaceutical agent that relieves pain. Analgesics reduce the perception of pain and alter responses to discomfort.

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; hair disheveled, no makeup, and will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

Anxiety Explanation: The major defining characteristics of depression are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements, Risk for Self related Violence, or Impaired Verbal Communication.

A patient reports pain and rates it as a 9 on a scale of 0 to 10. The nurse administers medication as ordered and returns 20 minutes later to assess the severity of the patient's pain. To assess the severity, the nurse would: a) Ask the patient what makes the pain worse. b) Ask about the location of the pain. c) Ask the patient to rate the pain on a scale of 0 to 10. d) Ask the patient if he or she needs anything.

Ask the patient to rate the pain on a scale of 0 to 10. Correct Explanation: When assessing a patient's pain, the nurse should ask about location, duration, intensity, quality, alleviating/aggrevating factors, management goal, and functional goal. To assess severity or intersity, the nurse should ask the patient to rate the pain on a scale of 0 to 10 or 1 to 10.

patient is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what?

Assess the site and intensity of the pain. Explanation: When a patient reports pain, the nurse must do an immediate pain assessment. Such an assessment is the first step of the nursing process. The complete pain assessment will cover different characteristics of the pain; however, the very first aspect is to ask about the location and intensity of the pain. Checking for the patient's allergies and what medication is ordered will follow after the assessment. The nurse would not call the physician at this point.

During assessment of a client's vital signs, the nurse has palpated the client's radial pulse and noted an irregular rhythm. What action should the nurse take based on this assessment finding?

Auscultate the cardiac apex. Correct Explanation: Irregular heart rhythms detected during radial palpation necessitate auscultation of the cardiac apex. Palpating the opposite arm or carotid pulse or measuring blood pressure does not yield as accurate an assessment of heart rate.

The nurse is auscultating a client's blood pressure, and identifies which of the following as the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds? a) Diastolic value b) Phase V c) Auscultatory gap d) Korotkoff sounds

Auscultatory gap Correct Explanation: The auscultatory gap refers to the break in or loss of sound during the latter part of phase I (the first appearance of faint, clear, repetitive tapping sounds) and during phase II (muffled or swishing sounds that are softer and longer than phase I sounds). Korotkoff's sounds are the sounds created when measuring blood pressure. Phase V reflects the disappearance of all sounds. Diastolic value refers to the last sound heard before a period of continuous silence and marks the onset of Phase V.

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except: a) Apparent age b) Dress, grooming, and personal hygiene c) Signs of distress d) Blood pressure

Blood pressure Correct Explanation: Blood pressure is a vital sign, not part of the general survey. Apparent age, signs of distress, and appearance are all parameters of the general survey.

The nurse is caring for a post-operative patient with an order for morphine sulfate 2 mg IV push every 4 hours. The patient's pain is unrelieved 30 minutes following administration of the morphine sulfate with the pain rating increasing from 7 to 10. Which action should the nurse take? a) Call the prescribing physician see about changing the pain medication. b) Instruct the patient that it is too soon for another dose of morphine. c) Administer another dose of the morphine sulfate immediately. d) Wait and medicate the patient when the next dose of morphine is due.

Call the prescribing physician see about changing the pain medication. Correct Explanation: Untreated or undertreated acute pain may lead to chronic pain syndrome (CRPS). Patients who have had surgery are at increased risk for developing CRPS. The nurse works diligently to find acceptable strategies to address a patient's pain, while observing the rights of medication administration. The nurse may need to contact the physician for adjustments in dosing, frequency of dosing, or acquiring an order for another pain medication to obtain optimal pain management for the patient. The other three options do not address the patient's pain.

A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect? a) Neurological deficit b) Balance disorder c) Metabolic disorder d) Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease Correct Explanation: Leaning forward and bracing assists with greater lung expansion and easier breathing in clients with chronic obstructive pulmonary disease. Other deficits or disorders would present with other types of positioning.

Which technique demonstrates the proper position of the arm by a nurse when measuring a blood pressure? a) Client standing with arm outstretched and at the level of the heart b) Client's arm bent at the elbow and resting on the thigh c) Client sitting with arm outstretched and even with the heart d) Client's arm above the level of the heart and resting on a bedside table

Client sitting with arm outstretched and even with the heart Correct Explanation: Ideally, the blood pressure should be taken with the client in a comfortable position for 5-10 minutes. The blood pressure cuff should be placed against the client's skin with the bladder over the arterial pulsation. The client's arm should be slightly flexed and supported with the nurse's arm. The arm should be at the level of the heart with the palm up.

The information gathered during a general survey provides the nurse primarily with which of the following?

Clues about the overall health of the client Correct Explanation: The general survey provides clues about the overall health of the client by assessing the client's appearance and behavior along with vital signs and body weight, height, and nutritional status. During the general survey, the nurse may pick up on clues that suggest anxiety and normal and abnormal variations, but these are only partial aspects of the overall survey. In addition, the general survey may provide clues to the client's underlying problem, but not necessarily a direct link to the client's illness. An in-depth physical examination will help to provide links to the client's illness.

Assessing a patient's cognition is part of the general assessment. The strongest indicator of a cognitive disorder in a patient is what? a) Impaired long-term memory b) Ability to perform selected ADLs c) Inappropriate affect d) Overattentiveness

Correct response: Inappropriate affect Explanation: Inappropriate affect, inattentiveness, impaired memory, and inability to perform ADLs may indicate dementia (eg, Alzheimer's disease) or another cognitive disorder. Therefore, the other options are incorrect and do not indicate dementia.

which of the following? a) Visceral b) Deep somatic c) Radiating d) Cutaneous

Deep somatic Explanation: Deep somatic pain is pain associated with ligaments, tendons, bones, blood vessels, and nerves. Cutaneous pain involves the skin or subcutaneous tissue. Visceral pain involves the abdominal cavity, thorax, and cranium. Radiating pain is perceived at the source and extending to other tissue.

Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?

Evaluating orthostatic hypotension Explanation: For a client taking antihypertensive agents, the nurse should assess for possible orthostatic hypotension, which could increase the client's risk for falls. The blood pressure would fall with a change in position from lying to sitting or standing. A widening pulse pressure may be seen with aging.

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

Explanation: A drop in both the systolic and diastolic readings of 20mm and more indicates orthostatic hypotension. A drop of less than 20mmHg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.

A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta fibers transmit pain that is felt as which of the following? a) Burning b) Throbbing c) Sharp d) Aching

Explanation: A-delta fibers transmit fast pain to the spinal cord that is felt as a pricking, sharp, or electric-quality sensation. C-fibers transmit slow pain felt as burning, throbbing, or aching.

The patient comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the patient is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Explanation: Referred pain originates from a specific site, but the person feels the pain at another site site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigeston. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints.

A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. Which scale should the nurse use to assess the client's pain?

FACES scale Explanation: The nurse should use the Wong-Baker FACES scale, which is best for children and clients who are culturally diverse or mentally challenged. Nurses generally use a numeric scale, a word scale, or a linear scale to quantify the pain intensity of adult clients who can express their pain intensity in words, numbers, or linear fashion with the help of the respective scales.

A nurse is caring for a 4-year-old patient who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the patient to point to the one that best represents the pain he is experiencing. This is an example of which of the following:

FACES scale Correct Explanation: The FACES scale is used for children who are 3 years or older. This tool allows the patient to point to the picture of the face that best represents the pain he or she is feeling. The FLACC scale uses face, legs, activity, cry, and consolability to assess the pain. The visual analog scale uses a 100-mm line with "no pain" at one end and "worst pain" at the other. The numeric scale is the most commonly used scale--an example is an 11-point Likert scale with 0 meaning no pain and 10 meaning the worst pain ever.

When documenting assessment data for a patient experiencing a loss of muscle power, it is acceptable to state, "Patient is experiencing muscle fatigue." a) True b) False

False

A patient on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the patient says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action?

Give the prn morphine Correct Explanation: Pain is what the patient says it is, and it exists whenever the patient says it does. It would not be appropriate to hold the medication for 30 minutes, call the physician to check the order, or just document the patient's pain.

Why must a blood pressure cuff fit properly?

If cuff is too small, blood pressure will read high. If cuff is too larger (wide), blood pressure will read low on a small arm and high on a large arm.

Which of the following would be most important for the nurse to do when assessing a client's blood pressure?

Inflate the cuff 30 mm Hg above where the radial pulse disappears. Correct Explanation: The nurse should inflate the cuff by pumping the bulb to about 30 mm Hg above the point at which the radial pulse disappears. Doing so will help to avoid missing an auscultatory gap. The nurse would palpate the pulsations of the brachial artery, hold the client's arm slightly flexed with the palm up, and deflect the cuff about 2 mm Hg per second.

During general inspection, the examiner: a) Inquires about the client's occupational environment b) Assesses for pain and functional ability c) Integrates visual, auditory, and olfactory data d) Ensures the client moves from standing to lying positions

Integrates visual, auditory, and olfactory data Correct Explanation: The general inspection integrates sights, smells, and sounds to form a preliminary sense of the client's status. Pain assessment and work environment are not part of the scope, and it is not necessary to position the client in a lying position at this stage.

What questions should you ask yourself with assess heart rhythm?

Is the rhythm regular or irregular? If irregular, is there a pattern? Do early beats appear more regular? Does irregularity vary with respiration? Is the rhythm totally irregular?

A nurse obtains a blood pressure on an elderly client of 160/70mmHg. The nurse knows that the term for this condition is what? a) Isolated systolic hypertension b) Stage I hypertension c) Orthostatic hypotension d) Normal for the elderly

Isolated systolic hypertension Correct Explanation: The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage I hypertension is a blood pressure reading of 140-159/90-99mmHg. Hypertension is not normal for any client.

A nurse obtains a blood pressure on an elderly client of 160/70mmHg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension Explanation: The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage I hypertension is a blood pressure reading of 140-159/90-99mmHg. Hypertension is not normal for any client.

Before assessing a client's blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on which rationale? a) It provides identifiable data about the client. b) It indicates client involvement in his health care. c) It shows the client's ability to recall facts. d) It verifies the client's memory.

It indicates client involvement in his health care. Correct Explanation: When a client knows his or her usual blood pressure, it shows that the client has been involved in health care through check-ups. Although it may reveal information about a client's memory or ability to recall facts, the information provides the nurse with valuable information about the client's involvement in health promotion and maintenance activities.

Before assessing a client's blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on which rationale? a) It shows the client's ability to recall facts. b) It verifies the client's memory. c) It indicates client involvement in his health care. d) It provides identifiable data about the client.

It indicates client involvement in his health care. Correct Explanation: When a client knows his or her usual blood pressure, it shows that the client has been involved in health care through check-ups. Although it may reveal information about a client's memory or ability to recall facts, the information provides the nurse with valuable information about the client's involvement in health promotion and maintenance activities.

When patients report pain, it is important to find the source. When patients describe pain as "burning, painful numbness, or tingling," the source is more than likely: a) Visceral b) Somatic c) Neuropathic d) Referred

Neuropathic Correct Explanation: Visceral pain originates from abdominal organs and is often described as crampy or gnawing. Somatic pain originates from the skin, muscles, bones, and joints. Referred pain originates from a specific site, but the patient experiencing the pain feels it at another site along the innervating spinal nerve. Neuropathic pain is described as burning, painful numbness, or tingling.

Identify the steps in nociception.

Noxious stimuli cause a nerve impulse perceived by free nerve endings.The neuronal signal moves from the periphery to the spinal cord and up to the brain. The impulses being transmitted to the higher areas of the brain are identified as pain. Inhibitory and facilitating input from the brain influences the sensory transmission at the level of the spinal cord.

During assessment, the nurse is using a pain scale with the patient, who tells the nurse that his pain is at 7 on a scale of 1 to 10. This type of one-dimensional pain scale is also called: a) Combined thermometer scale b) Verbal descriptor scale c) Visual analog scale d) Numeric pain intensity scale

Numeric pain intensity scale Correct Explanation: When rating the intensity of the pain, the nurse can use a one-dimensional scale called the NPI or numeric pain intensity scale. The visual analog scale uses a 100-mm line with "no pain" at one end and "worse possible pain" at the other. The verbal descriptor scale uses words such as "mild, moderate, and severe" to measure pain. The combined thermometer scale combines elements of other rating scales.

When attempting to assess a client's pain, which of the following would the nurse obtain first? a) Observe behaviors in the client b) Ask family members about the client's pain c) Obtain a client self-report d) Search for possible causes of pain

Obtain a client self-report Explanation: The nurse should always try to get a self-report, but note if unable and go on to the other items such as searching for potential causes of pain, observing client behaviors, and obtaining information from surrogates such as family members, parents, and caregivers.

What is the average temperature when taking it orally? Rectally? Axillary?

Oral= 37 C or 98.6 F (early morning it runs low, later in the day runs high) rectal= higher than oral by 0.4-0.5 C or 0.7-0.9 F Axillary= lower than oral by 1 F degree

What is the 5th vital sign? What is it considered the 5th?

Pain, it's subjected.

What information are you specifically observing when checking respiration?

Rate, depth, rhythm, effort of breathing

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

Reading is erroneously high. Correct Explanation: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.

What is considered prehypertension blood pressure?

Systolic 120-139; Diastolic 80-89

What is considered hypertension stage 1 blood pressure?

Systolic 140-159; Diastolic 90-99

The nurse is taking routine vital signs toward the end of shift. A patient's BP reads 204/148. His baseline BP has been in the 130s systolic. What should the nurse do first?

Retake the blood pressure Explanation: When encountering an abnormal value, obtain the vital sign(s) again to assess accuracy. It would be inappropriate to notify the physician immediately, give PRN blood pressure medications, or document the findings before rechecking the reading.

The nurse is assessing the client's perception of pain and its intensity and quality. Which dimension is the nurse evaluating? a) Physical b) Sensory c) Cognitive d) Behavioral

Sensory Correct Explanation: The sensory dimension concerns the quality of the pain and how severe the pain is perceived to be. This dimension includes the patient's perception of the pain's location, intensity, and quality. The physical dimension refers to the physiologic effects just described. This dimension includes the patient's perception of the pain and the body's reaction to the stimulus. The behavioral dimension refers to the verbal and nonverbal behaviors that the patient demonstrates in response to the pain. The cognitive dimension concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management."

The nurse is assessing the pain of an 86-year-old man who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient's pain? a. family history b. genetic history c. sleep patterns d. elimination patterns

Sleep patterns Explanation: When assessing pain in older adults, the nurse should be sure to also review the effects of pain on diet, sleep, and mood. Unrelieved pain may lead to insomnia or depression and seriously affect the patient's quality of life. It would not be necessary to assess the family history, genetic history, or elimination pattern to gain insight into the patient's pain level.

The nurse is preparing to assess vital signs. Which vital sign would the nurse assess first?

Temperature Explanation: The client's temperature is measured first. Doing so puts the client at ease and causes him or her to remain still for several minutes. This is important because pulse, respiration, and blood pressure are influenced by activity and anxiety

What vital sign would a nurse assess first?

Temperature.

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure? a) The last sound before there is complete and continuous silence b) The first sound that is audible after the auscultatory gap c) The first appearance of faint but distinctive tapping sounds d) The transition from tapping sounds to muffled sounds

The first appearance of faint but distinctive tapping sounds Correct Explanation: The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity.

The nurse recognizes that a barrier to successful pain management for the patient with opioid tolerance is: a) The patient has the normal physiologic response to painful stimuli. b) Appropriate pain assessment tools are unavailable for this type of patient. c) The repeated use of opioids causes their bodies to become less sensitive to pain. d) The patient does not experience pain relief with usual doses of opioid

The patient does not experience pain relief with usual doses of opioids. Correct Explanation: A barrier to successful pain management for the patient with opioid tolerance is that the patient does not experience pain relief with usual doses of opioids. The patient with opioid tolerance has an altered physiologic response to painful stimuli, and repeated use of opioids causes their bodies to become more sensitive to pain. Pain assessment tools appropriate for use with the patient with opioid tolerance exist.

A patient reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?

The release of endorphins Explanation: Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that certain measures such as skin stimulation and relaxation techniques release endorphins.

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

There is an auscultatory gap Explanation: An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique.

Recently, lung cancer has metastasized to the bones of a 68-year-old client, precipitating a sudden increase in his pain. The client's wife and daughter are concerned about the consequent increase in the amount of hydromorphone the client requires, citing the risk of addiction. How can the nurse best respond to the family's concern?

There's a very minimal risk of addiction, and controlling his pain is our first concern." Correct Explanation: Concerns about addiction are normally unfounded. Nonetheless, it is inaccurate to characterize the possibility of addiction as a myth, on one hand, or a very real risk, on the other. Tolerance would not necessitate discontinuation.

A patient with a subdural hematoma may have an odor of alcohol. a) True b) False

True

What are the correct guideline for choosing the correct blood pressure cuff?

Width of the bladder should be approx. 40% of the limb. (upper arm circumference is 12-14cm on the average adult) Length of bladder should be approx. 80% of upper arm circumference. The standard cuff size is 12x23cm so this can be used if the patients circumference is less than 28cm.

A nurse assesses a non-English-speaking client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?

Wong-Baker Faces Correct Explanation: The nurse should use the Wong-Baker Faces Scale (FACES) to rate the pain felt by the client. FACES scales show different facial expressions, where the client is asked to choose the face that best describes the intensity or level of pain being experienced. This tool is best-suited for children and clients who are unable to communicate in the same language as the nurse. A Verbal Descriptor Scale (VDS) ranges pain on a scale between mild, moderate, and severe. The Numeric Rating Scale (NRS) rates pain on a scale from 0 to 10, where 0 reflects no pain and 10 reflects pain at its worst. The Visual Analog Scale (VAS) rates pain on a 10 cm continuum numbered from 0 to 10, where 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.

What is orthostatic (postural) hypotension?

a drop in systolic blood pressure of more than 20 mmHg or drop in diastolic blood pressure of than 10 mmHg within 3 minutes of standing if patient exhibits this, take bp when supine/sitting after resting 10 minutes then within 3 minutes after standing up if

Prior to assessing vital signs, what should you do?

ask the patient a list of medications

What are the four vital signs?

blood pressure, heart rate, respiration, temperature

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? a) Pressure on the cuff would be painful. b) Reading is erroneously high. c) Reading is erroneously low. d) It will be difficult to pump up the bladder.

eading is erroneously high. Explanation: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.

A patient asks to have her temperature taken because she feels hot and is sweating. The previous oral temperature 3 hours ago was 101.6°F. The nurse would expect the new temperature reading to be a) within a subnormal range b) lower than previous c) within an afebrile range d) higher than previous

lower than previous

What should you take note of when checking respiration?

rhythm; interval between breaths (regular or irregular) depth: shallow, moderate or deep effort: using diaphragm and intercostal muscles (which is normal) vs. accessory muscles noise: eupnea (normal; relaxed smooth and effortless vs. noisy) ask about exercise, pain, anxiety and smoking

What is white coat hypertension?

when blood pressue is higher at work than at home or in a relaxed setting- usually > 140/90

What is isolated systolic hypertension?

when systolic blood pressure is greater than or equal to 140 mmHg and diastolic blood pressure is less than 90 mmHg

Pain affects patients in different ways, with no boundaries. Which of the following are possible causes of pain? (Check all that apply.)

• Surgery • Chronic illnesses • Injury • No identifiable cause Correct Explanation: Pain is one of the most common reasons patients seek medical care. It can affect everything about the patient, inculding quality of life and sense of well-being. Pain has many causes such as the result of injury, surgery, and chronic illnesses. In some cases, pain has no identifiable cause. Gender does not cause pain.