Nursing Final
Match the behaviors with its stage of separation anxiety the child may exhibit. A. Protest B. Despair C. Denial 1. Withdrawal or compliant behavior 2. Appearance of being happy and content with everyone 3. Clinging to parents 4. Lack of protest when parents leave 5. Screaming and crying 6. Sadness
A: 3, 5; B: 1, 6; C: 2, 4
preventive approach: reducing the amount of time patients are in pain. low levels of pain are easier to reduce or control than intense levels of pain
better pain control
developed for preterm and full-term neonates
CRIES scale
You are frequently assessing an 84-year-old woman's pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a patient of this age, what principle should you best apply? A) Monitor for signs of drug toxicity due to a decrease in metabolism. B) Monitor for an increase in absorption of the drug due to age-related changes. C) Monitor for a paradoxical increase in pain with opioid administration. D) Administer analgesics every 4 to 6 hours as ordered to control pain.
a. monitor for signs of drug toxicity due to a decrease in metabolism
the nurse is caring for a pt with metastatic bone caner. the pt asks the nurse why he has had to keep getting larger doses of his pain medication, although they do not seem to affect him. what is the nurse's best response? a. over time you become more tolerant of the drug b. you may have become immune to the effects of the drug c. you may be developing a mild addiction to the drug d. your body absorbs less of the drug due to the cancer
a. over time you become more tolerant of the drug
The home health nurse is developing a plan of care for a patient who will be managing his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the patient teaching? A) Self-care and safety B) Autonomy and need C) Health promotion and exercise D) Dependence and health
a. self-care and safety
the nurse caring for a 79-year-old man who has just returned to the medical-surgical unit following surgery for a total knee replacement received report from the PACU. part of the report had been passed on from the preoperative assessment where it was noted that he has been agitated in the past following opioid administration. what principle should guide the nurse's management of the patient's pain? a. the elderly may require lower doses of medication and are easily confused with new medications. b. the elderly may have altered absorption and metabolism, which prohibits the use of opioids c. the elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication d. the elderly may require a higher initial dose of pain medication followed by a tapered dose
a. the elderly may require lower doses of medication and are easily confused with new medications
RR: 12-20. HR: 55-105. Systolic BP: 110-120. weight in kilos: >50. weight in lbs: >110
adolescent age group (13+ years)
You are the emergency department (ED) nurse caring for an adult patient who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain are you addressing when you provide care for this patient? A) Chronic B) Acute C) Intermittent D) Osteopenic
b. acute
your pt is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patient's orders specify an initial bolus dose. what is your priority assessment? a. assessment for decreased level of consciousness (LOC) b. assessment for respiratory depression c. assessment for fluid overload d. assessment for paradoxical increase in pain
b. assessment for respiratory depression - pt who receives opioids by any route must be assessed frequently for changes in respiratory status
The nurse is assessing a patient's pain while the patient awaits a cholecystectomy. The patient is tearful, hesitant to move, and grimacing. When asked, the patient rates his pain as a 2 at this time using a 0-to-10 pain scale. How should the nurse best respond to this assessment finding? A) Remind the patient that he is indeed experiencing pain. B) Reinforce teaching about the pain scale number system. C) Reassess the patient's pain in 30 minutes. D) Administer an analgesic and then reassess.
b. reinforce teaching about the pain scale number system
you are the nurse in a pain clinic caring for an 88-year-old man who is suffering from long-term, intractable pain. at this point, the pain team feels that first-line pharmacological and nonpharmacological methods of pain relief have been ineffective. what recommendation should guide this patient's subsequent care? a. the patient may want to investigate new alternative pain management options that are outside the United States b. the patient may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options c. the pt may want to increase his exercise and activities significantly to create distractions d. the pt may want to relocate to long-term care in order to have his ADL needs met
b. the patient may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options
used w/ children ages 3 and older, not limited to children. choose which face best illustrates the pain they are experiencing.
FACES pain scale
used for 2 months - 7 years of age or individuals that are unable to communicate their pain. scale is used in observing vocalization, verbalization, facial expression, motor response, body posture, activity and/or appearance. rated at 0-10 when added together.
Face, Leg, Activity, Cry, Consolability (FLACC) scale
RR: 20-30. HR: 80-140. Systolic BP: 70-100. Weight in Kilos: 4-10. Weight in lbs: 9-22
Infant age group (1-12 months)
Used w/ children ages 4-8 years old. 6 pictures of a child whose expressions suggest various intensities of pain.
Oucher Pain Scale
used in children 3-5 years old. involves the use of 4 red poker chips; with these chips, the child is asked to pick the number of poker chips that best indicate the intensity of pain (4 indicated most intense pain).
Poker-chip tool
The nurse in the pediatric clinic observes a parental lack of warmth and interest toward the child. Which parental style will the nurse most likely document in this situation? 1. Authoritarian 2. Authoritative 3. Indifferent 4. Permissive
3. Indifferent
RR: 20-30. HR: 70-110. systolic BP: 80-102. weight in kilos: 20-42. weight in lbs: 41-92
school age age group (6-12 years)
the more experience a person has had w/ pain =
the more frightened he/she may be about subsequent painful events
used to help meet the emotional needs of children who have an illness or surgery that requires hospitalization. used to help children understand and cope w/ illness, surgery, hospitalization, treatments and procedures
therapeutic play
RR: 20-30. HR: 80-130. Systolic BP: 80-110. Weight in kilos: 10-14. weight in lbs: 22-31
toddler age group (1-3 years)
no particular expression or smile; normal position or relaxes; lying quietly, normal position, moves easily; no cry (awake or asleep); content, relaxed
0 on FLACC pain assessment scale
occasional grimace or frown; withdrawn, disinterested; uneasy, restless, tense; squirming, shifting back and forth, tense; moans or whimpers, occasional complaint; reassured by occasional touching, hugging, or being talked to; distractable
1 on FLACC pain assessment scale
The nurse is working with a school-age child who is hospitalized. Which action by the nurse will promote a sense of industry in this child? 1. Allow the child to assist with her care. 2. Encourage parents to participate in the child's care. 3. Give the child a detailed scientific explanation of the illness. 4. Speak to the child in a high-pitched voice.
1. Allow the child to assist with her care.
The nurse is assigned to a child in a spica cast for a fractured femur suffered in an automobile accident. The child's teenage brother was driving the car, which was totaled. The nurse learns that the father lost his job three weeks ago and the mother has just accepted a temporary waitress job. Which nursing diagnosis will the nurse use when planning care for this child and family? 1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors 2. Impaired Social Interaction (Parent and Child) Related to the Lack of Family or Respite Support 3. Interrupted Family Processes Related to Child with Significant Disability Requiring Alteration in Family Functioning 4. Risk for Caregiver Role Strain Related to Child with a Newly Acquired Disability and the Associated Financial Burden
1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors
The nurse is providing care to a preschool-age client who was admitted to the medical surgical unit after an acute asthma attack. Which interventions foster a family-centered focus to client care? Select all that apply. 1. Discussing rooming in with the parents of the client 2. Allowing the client to "cry it out" after the parents leave for the evening 3. Providing comfort items from home, such as a blanket 4. Maintaining strict visitation for the family 5. Discussing what to expect during the hospital stay
1. Discussing rooming in with the parents of the client 3. Providing comfort items from home, such as a blanket 5. Discussing what to expect during the hospital stay
A nurse is working with a pediatric client. When obtaining an accurate family assessment, which initial step is the most appropriate? 1. Establish a trusting relationship with the family. 2. Select the most relevant family-assessment tool. 3. Focus primarily upon the mother, while learning her greatest concern. 4. Observe the family in the home setting, since this step always proves indispensable.
1. Establish a trusting relationship with the family.
a young school-age client is hospitalized with a fractured femur. which assessment tools are appropriate for this client? Select all that apply. 1. FACES pain scale 2. Oucher scale 3. visual analog scale 4. CRIES scale 5. poker-chip scale
1. FACES pain scale 2. Oucher scale 5. poker-chip scale
the nurse is caring for a toddler client in the postoperative period. which pain assessment tool is most appropriate for this client? 1. FLACC behavioral pain assessment scale 2. FACES pain scale 3. Oucher scale 4. poker-chip tool
1. FLACC behavioral pain assessment scale
The nurse is assessing a family's effective coping strategies and ineffective defensive strategies. Which family-social-system theory is the nurse using in this assessment of the family? 1. Family-stress theory 2. Family-development theory 3. Family-systems theory 4. Family life-cycle theory
1. Family-stress theory
The nurse is working with an adolescent client who will be admitted to the hospital in two days. Which nursing approach is most appropriate to prepare this client for hospitalization? 1. Have teens who have had similar experiences talk to the adolescent about hospitalization. 2. Provide an opportunity for the child to talk with an adult who has had a similar experience. 3. Teach parents what to expect so the information can be shared with the adolescent. 4. Provide an opportunity for the teen to try on surgical attire.
1. Have teens who have had similar experiences talk to the adolescent about hospitalization.
The nurse is working with a hospitalized preschool-age child. The nurse is planning activities to reduce anxiety in this child. Which action by the nurse is the most appropriate? 1. Provide the child with a doll and safe medical equipment. 2. Read a story to the child. 3. Use an anatomically correct doll to teach the child about the illness. 4. Talk to the child about the hospitalization.
1. Provide the child with a doll and safe medical equipment.
Several children arrived at the emergency department accompanied by their fathers. Which father may legally sign emergency medical consent for treatment? 1. The divorced one from the binuclear family 2. The stepfather from the blended or reconstituted family 3. The divorced one when the single-parent mother has custody 4. The nonbiologic one from the heterosexual cohabitating family
1. The divorced one from the binuclear family
A child is being discharged from the hospital after a 3-week stay following a motor vehicle accident. The mother expresses concern about caring for the child's wounds at home. She has demonstrated appropriate technique with medication administration and wound care. Which nursing diagnosis is the priority in this situation? 1. Knowledge Deficit of Home Care 2. Altered Family Processes Related to Hospitalization 3. Parental Anxiety Related to Care of the Child at Home 4. Risk for Infection Related to Presence of Healing Wounds
3. Parental Anxiety Related to Care of the Child at Home
the nurse is admitting a school-age Vietnamese client who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. the child is stoic and denies pain. which nursing actions are most appropriate in this situation? Select all that apply. 1. Use the FLACC scale to determine the child's pain level 2. tell the child to ring the call bell if the leg starts hurting 3. administer pain medication now and continue on a regular basis 4. ask the child's parents to notify the nurse if the child complains of pain 5. use the NIPS scale to determine the child's pain level
1. Use the FLACC scale to determine the child's pain level 3. administer pain medication now and continue on a regular basis 4. ask the child's parents to notify the nurse if the child complains of pain
during the nurse's initial assessment of a school-age child, the child reports a pain level of 6 out of 10. the child is lying quietly in bed watching tv. which action by the nurse is most appropriate? 1. administer prescribed analgesic 2. ask the child's parents if they think the child is hurting 3. reassess the child in 15 minutes to see if the pain rating has changes 4. do nothing, since the child appears to be resting
1. administer prescribed analgesic
the adolescent is 6-hours post-appendectomy and refuses pain medications. the nurse would like to walk the child in the hall but is concerned that the child has unrelieved pain. the nurse knows that unrelieved pain causes physiologic consequences such as (select all that apply). 1. atelectasis 2. pneumonia 3. ileus 4. lethargy 5. hypoactive bowel sounds
1. atelectasis 2. pneumonia 3. ileus
a school-age client is being discharged from the outpatient surgical center. which statement by the parent would indicate the need for further teaching? 1. i can expect my child to have some pain for the next few days 2. i will plan to give my child pain medicine around the clock for the next day or so 3. since my child just had surgery today, i can expect the pain level to be higher tomorrow 4. i will call the office tomorrow if the pain medicine is not relieving the pain
1. i can expect my child to have some pain for the next few days
the nurse is working with a preschool-age client in Bryant traction for a fractured femur. why is the Oucher Scale useful to the nurse caring for this child? 1. it provides continuity and consistency in assessing and monitoring the child's pain 2. it decreases anxiety in the child 3. it increases the child's comfort level 4. it reduces the child's fear of painful procedures
1. it provides continuity and consistency in assessing and monitoring the child's pain - the nurse can reduce anxiety or fear and increase the child's comfort level by implementing appropriate nursing interventions based on assessment scale data
a toddler is hospitalized with a fractured femur. in addition to pain medication, which will best provide pain relief for this child? 1. parents presence at the bedside 2. age-appropriate toys 3. deep-breathing exercises 4. videos for the child to watch
1. parents presence at the bedside
the preschool-age child has been back from surgery for removal of a Wilm's tumor for 6 hours, the nurse anticipates the preschooler will need pain medication very soon. the nurse is aware that the preschool-age child may not complain of pain because - 1. the preschooler cannot give a description of his pain 2. the preschooler may assume the nurse knows he has pain 3. the preschooler may be afraid it may hurt more to have the pain treated 4. the preschooler believes he must be brave 5. the preschooler uses sleeping to deal with pain
1. the preschooler cannot give a description of his pain 2. the preschooler may assume the nurse knows he has pain 3. the preschooler may be afraid it may hurt more to have the pain treated 4. the preschooler believes he must be brave
frequent to constant frown, clenched jaw, quivering chin; kicking or legs drawn up; arched, rigid, or jerking; crying steadily, screams or sobs; frequent complaints; difficult to console or comfort
2 on FLACC pain assessment scale
The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that which hospitalized child at highest risk to experience separation anxiety when parents cannot stay? 1. 6-month-old 2. 18-month-old 3. 3-year-old 4. 4-year-old
2. 18-month-old
The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is the most appropriate? 1. Escort the parents to the waiting room and assure them that they can see their child soon. 2. Allow the parents to stay with the child. 3. Ask the physician if the parents can stay with the child. 4. Tell the parents that they do not need to stay with the child.
2. Allow the parents to stay with the child.
The child was just transferred to the postanesthesia unit (PACU) and report given. The nurse has performed baseline vital signs, the child is stable and pain is under control. What should the nurse do next? 1. Document 2. Allow the parents to visit the child 3. Discharge the child 4. Look for signs of infection 5. Offer clear liquids
2. Allow the parents to visit the child
The nurse is planning care for an adolescent client who will be hospitalized for several weeks following a traumatic brain injury. Which interventions will enhance family-centered care for this client and family? Select all that apply. 1. Making all ADL decisions for the adolescent and family 2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescent's friends to visit during visiting hours 5. Leaving all questions for the healthcare provider
2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescent's friends to visit during visiting hours
The nurse is working on parenting skills with a group of mothers. Which mother would need the fewest discipline-related suggestions? 1. Authoritarian 2. Authoritative 3. Indifferent 4. Permissive
2. Authoritative
a parent asks the nurse if there is anything that can be done to reduce the pain that his 3-year-old experiences each morning when blood is drawn for lab studies. which intervention would the nurse implement based on the parent's concern? 1. intravenous sedation 15 minutes prior to the procedure 2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure 3. use of guided imagery during the procedure 4. use of muscle-relaxation techniques
2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure
The nurse is planning care for a school-age client and family who have expressed wanting to use complementary and alternative modalities (CAM) in the treatment plan. Which interventions can the nurse safely implement into the plan of care? Select all that apply. 1. Substituting an herbal remedy for a prescribed medication 2. Encouraging the parents to share which modalities they would like to implement 3. Educating on the benefits and risks for each modality 4. Using essential oils to decrease nausea 5. Discouraging the use of faith-based therapies
2. Encouraging the parents to share which modalities they would like to implement 3. Educating on the benefits and risks for each modality 4. Using essential oils to decrease nausea
3) A school-age client tells you that "Grandpa, Mommy, Daddy, and my brother live at my house." Which type of family will the nurse identify in the medical record based on this description? 1. Binuclear family 2. Extended family 3. Gay or lesbian family 4. Traditional nuclear family
2. Extended family
There are several tools that help with obtaining a cultural assessment of a client and his family. Which tool would be appropriate to gather 12 major concepts of cultural assessment? 1. Sunrise enabler 2. Model for cultural competence 3. Transcultural assessment model 4. Health traditions model
2. Model for cultural competence
The nurse is counseling the parents of a 13-year-old regarding the behaviors they may encounter after telling the child about their plans to divorce. Which behaviors could the child demonstrate? Select all that apply. 1. Sorrow 2. Skipping school 3. Risk-taking 4. Withdraw from friends and activities 5. Temper tantrums
2. Skipping school 3. Risk-taking
A nurse and the family of an 8-year-old with acute renal failure are reviewing family strengths helpful in managing stressors. Which family strengths should the nurse recommend this family utilize? Select all that apply. 1. Meeting member needs 2. Support by extended family 3. Effective communication 4. Receiving and giving love 5. Prior life experiences
2. Support by extended family 3. Effective communication 5. Prior life experiences
a hospitalized toddler-age client needs ot have an IV restarted. the child begins to cry when carried into the treatment room by the mother. which nursing diagnosis is most appropriate? 1. ineffective individual coping related to an invasive procedure 2. anxiety related to anticipated painful procedure 3. fear related to the unfamiliar environment 4. knowledge deficit of the procedure
2. anxiety related to anticipated painful procedure
as an advocate for the child undergoing bone-marrow aspiration, which intervention would the nurse suggest to decrease the pain experienced due to the procedure? 1. general anesthesia 2. conscious sedation 3. intravenous narcotics ten minutes before the procedure 4. oral pain medication for discomfort after the procedure
2. conscious sedation
the nurse is preparing to perform a heel stick on a neonate. which complementary therapy is appropriate for the nurse to use to decrease pain during this quick but painful procedure? 1. swaddling 2. sucrose pacifier 3. massage 4. holding the infant
2. sucrose pacifier
The nurse is caring for a client in the pediatric intensive-care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing intervention is most appropriate based on the situation? 1. Ask the physician to talk with the family. 2. Explain to the parents that their anger is affecting their child so they will not be allowed to visit the child until they calm down. 3. Acknowledge the parents' concerns and collaborate with them regarding the care of their child. 4. Call the chaplain to sit with the family.
3. Acknowledge the parents' concerns and collaborate with them regarding the care of their child.
The nurse is providing care to a school-age client who is admitted to the hospital after a motor vehicle accident. Which interventions are appropriate to prepare this client and family for their hospital stay? Select all that apply. 1. A hospital tour 2. A health fair brochure 3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation
3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation
The nurse is working on parenting skills with a mother of three children. The nurse demonstrates a strategy that uses reward to increase positive behavior. Which strategy will the nurse document in the medical record based on this description? 1. Time out 2. Reasoning 3. Behavior modification 4. Experiencing consequences of misbehavior
3. Behavior modification
The nurse is assessing a group of children attending summer camp. The nurse will expect which children to most likely have problems perceiving a sense of belonging? 1. Children whose parents divorced recently 2. Children who gained a stepparent recently 3. Children recently placed into foster care 4. Children adopted as infants
3. Children recently placed into foster care
Cultures have many different childrearing practices. Which culture is known to value the male child more than the female child, and often teaches children to avoid displaying emotion? 1. Mexican 2. Amish 3. Chinese 4. Navajo
3. Chinese
The nurse needs to administer a medication to a preschool-age child. The medication is only available in tablet form. Which action by the nurse is the most appropriate? 1. Place the tablet on the child's tongue and give the child a drink of water. 2. Break the tablet in small pieces and ask the child to swallow the pieces one by one. 3. Crush the tablet and mix it in a teaspoon of applesauce. 4. Crush the table and mix it in a cup of juice.
3. Crush the tablet and mix it in a teaspoon of applesauce.
A toddler recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant. Which action by the mother best demonstrates understanding of how to give the medication? 1. Verbalizing how to give the medication 2. Acknowledging understanding of written instructions 3. Drawing up the medication correctly in an oral syringe and administering it to the child 4. Observing the nurse draw up the medication and administering it to the child.
3. Drawing up the medication correctly in an oral syringe and administering it to the child
The community health nurse is assessing several families for various strengths and needs in regard to after-school and backup childcare arrangements. Which family type will benefit the most from this assessment and subsequent interventions? 1. The binuclear family 2. The extended family 3. The single-parent family 4. The traditional nuclear family
3. The single-parent family
A preschool-age client is seen in the clinic for a sore throat. In this child's mind, what is the most likely causative agent for the sore throat? 1. Was exposed to someone else with a sore throat. 2. Did not eat the right foods. 3. Yelled at his brother. 4. Did not take his vitamins.
3. Yelled at his brother.
the nurse is caring for a child who has been sedated for a painful procedure. which nursing activity is the priority for this child? 1. allow parents to stay with the child 2. monitor pulse oximetry 3. assess the child's respiratory effort 4. place the child on a cardiac monitor
3. assess the child's respiratory effort
a preschool-age client is hospitalized following surgery for a ruptured appendix. during assessment of the child, the nurse notes that the child is sleeping. vital signs are as follows: temp: 97.8°F axillary, pulse 90, respirations 12, and BP 100/60. which conclusion by the nurse is appropriate based on assessment findings? 1. the client is comfortable and the pain is controlled 2. the client is in shock secondary to blood loss during surgery 3. the client is experiencing respiratory depression secondary to opioid administration for postoperative pain 4. the client is sleeping to avoid pain associated with surgery
3. the client is experiencing respiratory depression secondary to opioid administration for postoperative pain - respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. a RR of 12 is well below normal for a preschool-age client. the other vital signs are within normal limits for a sleeping preschool-age client
the nurse is working in a pediatric surgical unit. in discussing patient-controlled analgesia (PCA) in a preoperative prenatal meeting, which client would be a candidate for PCA? 1. developmentally delayed 16-year-old, postoperative bone surgery 2. a 5-year-old, postoperative tonsillectomy 3. 10-year-old who has a fractured femur and concussion from a bike accident 4. 12-year-old, postoperative spinal fusion for scoliosis
4. 12-year-old, postoperative spinal fusion for scoliosis
The nurse must perform a procedure on a toddler. Which technique is the most appropriate when performing the procedure? 1. Ask the mother to restrain the child during the procedure. 2. Ask the child if it is okay to start the procedure. 3. Perform the procedure in the child's hospital bed. 4. Allow the child to cry or scream.
4. Allow the child to cry or scream.
A young school-age client is in the playroom when the respiratory therapist arrives on the pediatric unit to give the child a scheduled breathing treatment. Which action by the nurse is the most appropriate? 1. Reschedule the treatment for a later time. 2. Show the respiratory therapist to the playroom so the treatment may be performed. 3. Escort the child to his room and ask the child-life specialist to bring toys to the bedside. 4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed.
4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed.
An infant has been NPO for surgery for 4 hours and does not have an intravenous line. The nurse receives a call from the operating room with the information that the surgery has been postponed due to an emergency. Which action by the nurse is the most appropriate? 1. Feed the infant 4 ounces of formula. 2. Reassure the parents that it will not be much longer before surgery. 3. Allow the parents to feed the infant an ounce of oral rehydration solution. 4. Call the physician to see if the infant needs to have an intravenous line started.
4. Call the physician to see if the infant needs to have an intravenous line started.
The nurse is performing an assessment of a child's biologic family history. Which situation would necessitate the nurse's asking the mother for information should use the term "child's father" instead of "your husband"? 1. Traditional nuclear family 2. Traditional extended family 3. Two-income nuclear family 4. Cohabitating informal stepfamily
4. Cohabitating informal stepfamily
A new pediatric hospital will open soon. While planning nursing care, the hospital administration is considering two models of providing healthcare: family-focused care and family-centered care. Which action best demonstrates family-centered care? 1. Telling the family what must be done for the family's health 2. Assuming the role of an expert professional to direct the healthcare 3. Intervening for the child and family as a unit 4. Conferring with the family in deciding which healthcare option will be chosen
4. Conferring with the family in deciding which healthcare option will be chosen
The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for the toddler-age client? 1. Assign the same nurse to the toddler as much as possible. 2. Let the child listen to an audiotape of the mother's voice. 3. Place a picture of the family at the bedside. 4. Encourage a parent to stay with the child.
4. Encourage a parent to stay with the child.
A group of children on one hospital unit are all suffering separation anxiety. Which child is experiencing the despair stage of separation anxiety? 1. Does not cry if parents return and leave again 2. Screams and cries when parents leave 3. Appears to be happy and content with staff 4. Lies quietly in bed
4. Lies quietly in bed
a school-age client has been receiving morphine every 2 hours for postoperative pain as ordered. the medication relieves the pain for approximately 90 minutes, and then the pain returns. which action by the nurse is the most appropriate? 1. tell the child that pain medication cannot be administered more frequently than every 2 hours 2. reposition the child and quietly leave the room 3. inform the parents that the child is dependent on the medication 4. call the healthcare provider to see if the child's orders for pain medication can be changed
4. call the healthcare provider to see if the child's orders for pain medication can be changed
the nurse is caring for a child who has a long leg cast. the child complains of increasing pain in the toes of the casted foot. which initial action by the nurse is most appropriate? 1. call the healthcare provider to report increasing pain 2. administer pain medication 3. reposition the child in bed 4. check to see if the cast is too tight
4. check to see if the cast is too tight
The nurse who is a member of the palliative care team is assessing a patient. The patient indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this patient? A) Medication should be taken when pain levels are low so the pain is easier to reduce. B) Pain medication can be increased when the pain becomes intense. C) It is difficult to control chronic pain, so this is an inevitable part of the disease process. D) The patient will likely benefit more from distraction than pharmacologic interventions.
A) medication should be taken when pain levels are low so the pain is easier to reduce
Two patients on your unit have recently returned to the postsurgical unit after knee arthroplasty. One patient is reporting pain of 8-9 on a 0-10 pain scale, whereas the other patient is reporting a pain level of 3-4 on the same pain scale. what is the nurse's most plausible rationale for understanding the patients' different perceptions of pain? a. endorphin levels may vary between patients, affecting the perception of pain b. one of the patients is exaggerating his or her sense of pain c. the patients are likely experiencing a variance in vasoconstriction d. once of the patients may be experiencing opioid tolerance
a. endorphin levels may vary between patients, affecting the perception of pain
alkalosis, decreased O2 saturation, atelectasis, retention of secretions, pneumonia, tachycardia, increased blood pressure, increased intracranial pressure, change in sleep patterns, irritability, fluid and electrolyte losses, altered nutritional intake, hypoglycemia, increased risk of infection, delayed would healing, impaired GI functioning, poor nutritional intake, ileus (painful obstruction of the ileum or other part of the intestine), hyperalgesia, decreased pain threshold, and exaggerated memory of painful experiences
physiologic consequences of unrelieved pain
RR: 20-30. HR: 80-120. Systolic BP: 80-110. weight in kilos: 14-18. weight in lbs: 31-40
preschool age group (3-5 years)
screaming, crying; clinging to parents; may resist attempts by other adults to comfort them
protest stage of separation anxiety
young children cannot give a description of their pain because of a limited vocabulary or few pain experiences; some children believe they need to be brave and not worry their parents; preschoolers may assume the nurse knows they have pain, and some children are afraid that it will hurt more to have the pain treated
reasons children may not complain of pain
your patient is 12-hours post ORIF right ankle. the patient is asking for a breakthrough dose of analgesia. the pain medication orders are written as a combination of an opioid analgesic and a non-steroidal anti-inflammatory drug (NSAID) given together. what is the primary rationale for administering pain medication in this manner? ORIF: open reduction and internal fixation a. prevent respiratory depression from the opioid b. eliminate the need for additional medication during the night c. achieve better pain control than with one medication alone d. eliminate the potentially adverse effects of the opioid
c. achieve better pain control than with one medication alone - a multimodal regimen combines drugs w/ different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects
a 52-year-old female patient is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. when addressing the patient's pain in her plan of nursing care, the nurse should consider what characteristic of cancer pain? a. cancer pain is often related to the stress of the patient knowing she has cancer and requires relatively low doses of pain medications along with a high dose of anti-anxiety medications b. cancer pain is always chronic and challenging to treat, so distraction is often the best intervention c. cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications d. cancer pain is often misreported by pts because of confusion related to their disease process
c. cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications
you have just received report on a 27-year-old woman who is coming to your unit from the emergency department w/ a torn meniscus. you review her PRN medications and see that she has an NSAID (ibuprofen) ordered every 6 hours. if you wanted to implement preventive pain measures when the patient arrives to your unit, what would you do? a. use a pain scale to assess the pt's pain, and let the pt know ibuprofen is available every 6 hours if she needs it b. do a complete assessment, and give pain medication based on the pts report of pain c. check for allergies, use a pain scale to assess the pt's pain, and offer the ibuprofen every 6 hours until the pt is discharged d. provide medication as per pt request and offer relaxation techniques to promote comfort
c. check for allergies, use a pain scale to assess the pt's pain, and offer the ibuprofen every 6 hours until the pt is discharged
the nurse is caring for a 51-year-old female patient whose medical history includes chronic fatigue and poorly controlled back pain. these medical diagnoses should alert the nurse to the possibility of what consequent health problem? a. anxiety b. skin breakdown c. depression d. hallucinations
c. depression - depression is associated w/ chronic pain and can be exacerbated by the effects of chronic fatigue
you are the home health nurse caring for a homebound pt who is terminally ill. you are delivering a patient-controlled analgesia (PCA) pump to the pt at your visit today. the family members will be taking care of the pt. what would your priority nursing interventions be for this visit? a. teach the family the theory of pain management and the use of alternative therapies b. provide psychosocial family support during this emotional experience c. provide pt and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication d. provide family teaching regarding use of morphine, recognizing morphine overdose, and offering spiritual guidance
c. provide pt and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication
your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). the patient is complaining of pain, and you are preparing to administer the patient's first scheduled dose of hydromorphone (Dlaudid). Prior to administering the drug, you would prioritize which of the following assessments? a. the pt's electrolyte levels b. the pt's blood pressure c. the patient's allergy status d. the patient's hydration status
c. the pt's allergy status - prior to administering medications such as narcotics for the first time, the nurse should assess for any previous allergic reactions
An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0 - 10-point scale. The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurse's best response? A) Pain often comes and goes with postsurgical patients. Please ask her about pain again in about 30 minutes. B) We need to provide pain medications because it is the law, and we must always follow the law. C) Unless there is strong evidence to the contrary, we should take the patients report at face value. D) It's not unusual for patients to misreport pain to get our attention when we are busy.
c. unless there is strong evidence to the contrary, we should take the patients report at face value.
a 60-year-old pt who has diabetes had a below-knee amputation 1 week ago. the pt asks "why does it still feel like my leg is attached, and why does it still hurt?" the nurse explains neuropathic pain in terms that are accessible to the pt. the nurse should describe what pathophysiologic process? a. the proliferation of nociceptors during times of stress b. age-related deterioration of the central nervous system c. psychosocial dependence on pain medications d. abnormal reorganization of the nervous system
d. abnormal reorganization of the nervous system - hyperexcitable nerve endings in the periphery can become damaged, leading to abnormal reorganization of the nervous system called neuroplasticity, an underlying mechanism of some neuropathic pain states
you are the case manager for a 35-year-old man being seen at a primary care clinic for chronic low back pain. when you meet with the pt, he says that he is having problems at work; in the past year he has been absent from work about once every 2 weeks, is short-tempered with other workers, feels tired all the time, and is worried about losing his job. you are developing this pt's plan of care. on what should the goals for the plan of care focus? a. increase the pts pain tolerance in order to achieve psychosocial benefits b. decrease the pts need to work and increase his sleep to 8 hours per night c. evaluate other work options to decrease the risk of depression and ineffective coping d. decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety
d. decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety
the mother of a cancer pt comes to the nurse concerned w/ her daughter's safety. she states that her daughter's morphine dose that she needs to control her pain is getting higher and higher. as a result, the mother is afraid that her daughter will overdose. the nurse educates the mother about what aspect of her pain management? a. the dose range is high with cancer pts, and the medical team will be very careful to prevent addiction b. frequently, female pts and younger pts need higher doses of opioids ot be comfortable c. the increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment d. there is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.
d. there is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.
You are creating a nursing care plan for a patient with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of patients who live with chronic pain should inform your care planning? A) They are typically more comfortable with underlying pain than patients without chronic pain. B) They often have a lower pain threshold than patients without chronic pain. C) They often have an increased tolerance of pain. D) They can experience acute pain in addition to chronic pain.
d. they can experience acute pain in addition to chronic pain
lack of protest when parents leave; appearance of being happy and content with everyone; show interest in surroundings; close relationships not established
denial (detachment) stage of separation anxiety
sadness; quiet, appear to have "settled in"; withdrawal or compliant behavior; crying when parents return
despair stage of separation anxiety
True or False: chronic pain and acute pain are mutually exclusive
false. they are not mutually exclusive
RR: 30-50. HR: 120-160. Systolic BP: 50-70. Weight in Kilos: 2-3. Weight in lbs: 4.5-7
newborn age group
most appropriate in children 5 years and over. the child must be able to press the button and understand that she will receive pain medicine by pushing the button. Generally prescribed for pts who will be hospitalized for at least 48 hours
patient-controlled analgesia (PCA)
