NUR 3065 - PrepU Chapter 7

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

Acute

The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level? 2030 2000 1730 1630

1630 Explanation: Pain should be assessed every 4 hours; reassessments after interventions should be done in 30 minutes after intervention.

A nursing instructor is teaching students how to assess a client'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: "Chronic pain can be referred to as persistent pain." "Patients with chronic illnesses can have chronic pain." "Acute pain can be as intense as chronic pain." "Nurses are the best authority on pain."

"Nurses are the best authority on pain." Explanation: Pain is what the client says it is, and it exists whenever the client says it does. The client is the best authority on pain, and self-report is the gold standard. Therefore, nurses are not authorities on pain. It is true that clients 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.

Below are the four physiological processes involved in pain perception. Put them in the correct order. 1Perception 2Transduction 3Modulation 4Transmission

1. Transduction 2. Transmission 3. Perception 4. Modulation Explanation: The correct order of the four physiological processes involved in pain perception is as follows: 1) transduction, 2) transmission, 3) perception, and 4) modulation.

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? 140/55 mmHg 160/85 mmHg 120/55 mmHg 130/65 mmHg

120/55 mmHg

A client presents to the health care clinic with reports of two-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? Risk for Fluid Volume Deficit related to fever Impaired Mobility related stiff neck Anxiety related to prolonged pain Acute Pain related to sore throat

Acute Pain related to sore throat

When can the general inspection be started? As soon as the examiner first sees the client When the client is completely exposed After height and weight have been taken During the examiner's preparation to meet the client

As soon as the examiner first sees the client Explanation: The first moments of interaction between client and examiner should constitute the beginning of the general inspection. This should not wait until after height and weight have been measured or until the client is completely exposed. It is not possible to begin a general inspection prior to seeing (or smelling or hearing) the client.

The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding? Ashen gray skin color Light to medium dark brown skin Lack of visible pores Evenly distributed color

Ashen gray skin color Explanation: In dark-skinned individuals, loss of red tones and ashen gray color (suggesting cyanosis) would be considered abnormal. Normally, skin color is evenly distributed; pores may or may not be clearly visible. Color typically ranges from light tan to dark brown or olive in dark-skinned clients.

The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding? Auscultate the client's apical pulse. Administer a dose of nitroglycerin. Reposition the client in a side-lying position. Palpate the client's ulnar pulse.

Auscultate the client's apical pulse. Explanation: The nurse should perform auscultation of the apical pulse if the client exhibits irregular intervals between beats. The ulnar pulse is not normally palpated, and the administration of nitroglycerin is not warranted. Repositioning the client is not a relevant or an appropriate response.

A nurse takes a client's vital signs. Which of the following is considered a vital sign? Urinary output Mental status Visual acuity Blood pressure

Blood pressure Explanation: Vital signs are a person's temperature, pulse, respiration, and blood pressure. Mental status, visual acuity, and urinary output are not considered vital signs, even though they are frequently assessed.

A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading? Client is seated quietly for 10 minutes prior to measurement. Blood pressure is measured on a bare arm. Blood pressure cuff is tightly fitted. Client's arm is resting, supported by the nurse's arm at the client's mid-chest level.

Blood pressure cuff is tightly fitted. Explanation: A blood pressure cuff that is too tightly fitted can result in a false high reading. Resting prior to assessment, measuring on a bare arm, and supporting the client's arm at mid-chest level all foster accurate BP measurement.

The nurse is caring for a post-operative client with an order for morphine sulfate 2 mg IV push every 4 hours. The client'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? Wait and medicate the client when the next dose of morphine is due. Call the prescribing physician see about changing the pain medication. Instruct the client that it is too soon for another dose of morphine. Administer another dose of the morphine sulfate immediately.

Call the prescribing physician see about changing the pain medication.

A nurse documents periods of deep breathing followed by periods of apnea. The appropriate term for this type of breathing is hypopnea ataxic obstructive Cheyne-Stokes

Cheyne-Stokes

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? Balance disorder Neurological deficit Metabolic disorder Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease

A male client with a history of a back injury 2 months ago has been taking daily doses of narcotic pain medication. He is currently hospitalized with a leg fracture after falling down the stairs. He complains of 10/10 pain in his back and leg after taking pain medication one hour ago. What is the nurse's best action? Tell the client to take his own prescription medication. Inform the client that the next dose of medication is due in one more hour. Request a psychiatric evaluation for drug seeking behavior. Consult with the healthcare provider about increasing the dose of medication.

Consult with the healthcare provider about increasing the dose of medication. Explanation: Clients with a history of opioid tolerance pose difficult challenges for pain assessment (D'Arcy, 2014). They have an altered physiologic response to the pain stimulus, and the repeated use of opioids causes their bodies to become more sensitive to pain. This sensitivity is called opioid hyperalgesia and can occur as soon as 1 month after opioid use begins. Not only are clients with opioid tolerance more sensitive to pain, they face a high level of bias from health care providers. Because these clients are more sensitive to pain, they often report high levels of pain with little relief from usual doses of opioids. They are often labeled as drug seeking.

Which of the following is not released during the stress response? Dopamine Epinephrine Cortisol Norepinephrine

Dopamine Explanation: The stress response causes the release of epinephrine, norepinephrine, and cortisol.

The nurse is assessing a client's pain. Which of the following would lead the nurse to suspect that the client is experiencing pain? Sitting upright, hands on lap Facial grimacing, leaning forward Regular, unlabored breathing Alert, talkative demeanor

Facial grimacing, leaning forward

The nurse explains to the client that smoking has what effect on the body? Select all that apply. Vasodilation Hypertension Vasoconstriction Hypotension Peripheral vascular disease

Hypertension Vasoconstriction Peripheral vascular disease Explanation: Smoking can cause vasoconstriction, hypertension and peripheral vascular disease, not vasodilation and hypotension.

After describing the pathophysiology of pain, an instructor determines that the students have understood the teaching when they identify which of the following as being responsible for transmitting the sensations to the central nervous system? Nociceptors Cytokines Transduction Modulation

Nociceptors

A nurse is creating a concept map of the pathophysiology of pain. The nurse should identify which of the following as being responsible for transmitting pain sensations to the central nervous system? Modulation Transduction Nociceptors Cytokines

Nociceptors Explanation: The source of pain stimulates peripheral nerve endings or nociceptors, which transmit the sensations to the central nervous system. Transduction begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage, stimulating the nociceptors. Modulation inhibits the pain message and involves the body's own endogenous neurotransmitters in the course of processing the pain stimuli. Cytokines are released due to an inflammatory process resulting from the painful stimulus.

The nurse is admitting an elderly client with a diagnosis of congestive heart failure. Admission vital signs are respirations 38; pulse 172; blood pressure 86/72. How should the nurse best respond? Notify the rapid response team Reassess client in one hour Infuse IV fluids Administer diuretics

Notify the rapid response team Explanation: The client is in distress. The most appropriate action of the nurse is to notify the rapid response team. The nurse cannot administer IV fluids or medications without an order Reassessing in one hour is not an appropriate action due to the client's condition.

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

Reading is erroneously high.

The nurse is reviewing the following vital signs of a client who is lying in bed. Which of the following would the nurse identify as being abnormal? Oral temperature 36.6 Blood pressure 116/68 mm Hg Respirations 28 breaths/minute Radial pulse 78 beats/minute

Respirations 28 breaths/minute

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement? Normal Stage 2 hypertension Stage 1 hypertension Prehypertension

Stage 2 hypertension Explanation: The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg.

The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first? Pulse Respiration Temperature Blood pressure

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.

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them? Pulse, temperature, respirations, and blood pressure Temperature, pulse, respirations, and blood pressure Respirations, blood pressure, pulse, and temperature Blood pressure, temperature, pulse, and respirations

Temperature, pulse, respirations, and blood pressure Explanation: When assessing the vital signs of the client, the nurse should begin by measuring the clients temperature, to put the client at ease and to quiet the client for better assessment of the remaining vital signs. Pulse, respirations, and blood pressure can be altered by anxiety and activity.

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

The client does not experience pain relief with usual doses of opioids. Explanation: A barrier to successful pain management for the client with opioid tolerance is that the client does not experience pain relief with usual doses of opioids. The client 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 client with opioid tolerance exist.

The nurse is applying the blood pressure cuff on a client's arm. Which action would be most appropriate? The cuff starts to be wrapped at the end of the bladder. The cuff is placed about 1 inch above the antecubital area. The bladder inside the cuff encircles 50% of the arm circumference. The cuff is wrapped loosely around the arm.

The cuff is placed about 1 inch above the antecubital area.

Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action? To overhear the client's conversation with a family member To determine whether you recognize the client from a previous visit To see the client before the client assumes a social face or behavior To check the client for skin lesions the client may not be aware of

To see the client before the client assumes a social face or behavior Explanation: If possible, try to observe the client and environment quickly before interacting with the client. This gives you the opportunity to see the client before the client assumes a social face or behavior and allows you to glimpse any distress, sadness, or pain before the client, knowingly or unknowingly, may mask it. An initial observation of the client from a distance would not be effective for assessing for skin lesions. Trying to overhear the client conversation with a family member would be inappropriate. You may determine whether you recognize the client from a previous visit by a quick observation, but this is not the primary rationale for this action.

The nurse is conducting a general survey of a client new to the clinic. In what part of the survey would the nurse assess the hair distribution on the client's body? When assessing the body structure and development When assessing the skin When assessing the posture When assessing the range of motion

When assessing the skin Explanation: Observe for even skin tones and symmetry. Note any areas of increased redness, pallor, cyanosis, or jaundice. Observe for any lesions or variations in pigmentation. Note the amount, texture, quality, and distribution of hair.

Which of the following is an average normal temperature in centigrade for a healthy adult? tympanic: 34.4°C oral: 37.0°C axillary: 37.5°C rectal: 36.5°C

oral: 37.0°C Explanation: The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C, an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C.