Week One: Vital Signs
Which information about a patient's pain is accurate? It is a subjective experience. A high score on the rating scale indicates little pain. The nurse is the expert on the patient's pain. A measurement of 0 to 10 mm Hg is expected.
It is a subjective experience.
Which statement by the new nurse indicates understanding of the nurse's role in pain management? "I will be sure to educate the patient about pain treatment options." "I will remember to assess for pain as a part of my initial assessment." "I will perform a cardiac assessment to complete proper pain management procedures." "I must advocate for adequate pain relief for my patient if current therapies seem ineffective." "I must evaluate the patient's response to interventions to deliver focused patient care."
"I will be sure to educate the patient about pain treatment options." "I will remember to assess for pain as a part of my initial assessment." "I must advocate for adequate pain relief for my patient if current therapies seem ineffective." "I must evaluate the patient's response to interventions to deliver focused patient care."
Which response indicates a nurse has a correct understanding about the components of a vital sign assessment? "Oxygen saturation is the measurable intake of oxygen and release of carbon dioxide." "Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart." "Respiration is the measurable amount of oxygen available to the tissues." "Blood pressure is the measurable pressure of blood within the systemic veins."
"Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart."
Which vital sign measurements of adult patients would require the nurse to immediately notify the health care provider? 158 pulse rate 8 respirations 99.5°F (37.5°C) temperature 98% oxygen saturation 50/30 blood pressure
158 pulse rate 8 respirations 50/30 blood pressure
A patient is 2 days post-knee surgery. The pain management plan includes pharmacologic treatment, but the patient also requests nonpharmacologic methods, so the nurse brings the patient an ice pack. Which statement by the nurse indicates an understanding of the use of cold therapy to treat pain? "Thermotherapy provides local analgesia." "Ice packs should be applied for up to 1 hour." "Rest periods from cold therapy should be provided to prevent tissue injury." "Cryotherapy is effective for pain management because it speeds nerve conduction."
"Rest periods from cold therapy should be provided to prevent tissue injury."
The nurse assesses the patient's pain using the SOCRATES acronym. Which additional question would be relevant to the pain assessment? "Where is the pain located?" "Is the pain stabbing, burning, or aching?" "Does anything make the pain worse or lessen it?" "What are your past pain experiences?"
"What are your past pain experiences?"
Which questions would the nurse ask when conducting a pain assessment for a trauma patient? "Where is the pain located?" "Where did the trauma occur?" "What makes the pain worse or better?" "Does the pain radiate anywhere?" "On a scale from 1 to 50, how would you rate your pain?"
"Where is the pain located?" "What makes the pain worse or better?" "Does the pain radiate anywhere?"
Which pain assessment tools utilize verbal reports from the patient? 0-10 Pain Scale Neonatal Infant Pain Scale Universal Pain Tool Wong-Baker Scale Pain Assessment in Advanced Dementia Scale
0-10 Pain Scale Universal Pain Tool Wong-Baker Scale
Which vital sign measurements are unexpected? 99.5°F (37.5°C) temperature for a newborn 60 pulse rate for a 1-year-old 35 respirations for a 6-year-old SpO2 90% for a 15-year-old 110/68 blood pressure for an older adult
60 pulse rate for a 1-year-old 35 respirations for a 6-year-old SpO2 90% for a 15-year-old
What is the expected pulse range for an adult patient?
60-100
Exacerbation of pain even though background pain is controlled Acute Chronic Idiopathic Breakthrough
Breakthrough
Which characteristics are associated with chronic pain? Quick onset Intermittent pain Short-lived Identifiable cause Associated with acute injury Potentially causes disability
Intermittent pain Potentially causes disability
Transient pain with fast onset, short duration, and identifiable cause Acute Chronic Idiopathic Breakthrough
Acute
A patient presents to the emergency department immediately following an arm injury that occurred during a football game. The patient rates the pain in the left arm and shoulder an 8 on a 0-10 pain scale. The patient grimaces, guards the arm and shoulder, and clenches the teeth during the assessment. Which hypothesis would the nurse identify? Acute Pain Chronic Pain Difficulty Coping Inadequate Pain Control
Acute pain
Which solution involves the collaboration of a primary health care provider, nurse, and pharmacist when caring for a patient with pain from an injury to an extremity? Ordering a music therapist consult Providing assistance with ambulation Elevating the extremity and applying an ice pack Administering acetaminophen/oxycodone
Administering acetaminophen/oxycodone`
Which scenario describes when a nurse would perform a focused pain assessment on a patient? Anytime a patient is at high risk for pain Before taking vital signs and the patient reports the pain is mild After taking vital signs and the patient reports the pain is mild After taking vital signs and the patient reports the pain is severe
After taking vital signs and the patient reports the pain is severe
Which cues reflect psychological responses to pain? Anger Anxiety Grimacing Irritability Hopelessness
Anger Anxiety Irritability Hopelessness
Which actions are strictly a nurse's responsibility? Assess patients to determine if medically stable. Interpret vital sign measurements. Report significant vital sign findings to the health care provider. Reassess any unexpected vital sign values. Measure vital signs for stable patients.
Assess patients to determine if medically stable. Interpret vital sign measurements. Report significant vital sign findings to the health care provider. Reassess any unexpected vital sign values.
The nurse provides literature to a patient about side effects and activities to avoid while taking a prescribed medication. Which nursing action is demonstrated when the nurse asks the patient to repeat back the information? Analyzing Assessing Evaluating Understanding
Assessing
Which actions support the nurse's role in pain management? Assessing the patient's pain level Educating the patient about pain relief options Evaluating patient response to pain interventions Using medication as the primary treatment for pain management Advocating with the health care provider for pain relief for the patient
Assessing the patient's pain level Educating the patient about pain relief options Evaluating patient response to pain interventions Advocating with the health care provider for pain relief for the patient
Increases oxygen demand Cardiovascular Respiratory Endocrine Muscular
Cardiovascular
Persistent pain that can affect quality of life or cause disability Acute Chronic Idiopathic Breakthrough
Chronic
Which strategy can the nurse use to care for an athlete who experiences occasional stress and muscle pain before or after sports? Collaborate with a massage therapist Request a prescription for pain medication Gather objective data through the health history Provide education regarding breakthrough pain
Collaborate with a massage therapist
Which action would the nurse take before notifying the health care provider about a patient's vital signs? Compare the findings to the patient's baseline Follow only the expected ranges for the patient Observe for slight changes in results Review for just increases in measurements
Compare the findings to the patient's baseline
Place the steps in the order that the nurse implements them when caring for a patient experiencing pain. Prioritize hypotheses related to pain and pain management. Identify hypotheses related to pain and pain management. Organize and link patient cues related to pain. Determine patient goals/outcomes related to pain management. Complete a pain assessment.
Complete a pain assessment. Organize and link patient cues related to pain. Identify hypotheses related to pain and pain management. Prioritize hypotheses related to pain and pain management. Determine patient goals/outcomes related to pain management.
Which patient cues are indicative of chronic pain? Dilated pupils Constricted pupils Increased heart rate Decreased heart rate Increased systolic blood pressure Decreased systolic blood pressure
Constricted pupils Decreased heart rate Decreased systolic blood pressure
Which cues reflect verbal responses to pain? Anger Crying Moaning Screaming Clenching teeth
Crying Moaning Screaming
Acknowledgment of pain as a weakness for men Cultural Social Psychological Physiologic
Cultural
The nurse collaborates with unlicensed assistive personnel (UAP) to implement care for patients experiencing pain. Which action can the nurse delegate to UAP? Administering morphine sulfate for pain Darkening the room to create a peaceful environment Performing massage and range-of-motion exercises Asking the health care provider to prescribe lorazepam for anxiety
Darkening the room to create a peaceful environment
Which cue reflects that the patient is experiencing pain? Hypoglycemia Decreased urine output Reduced respiratory rate Loose bowel movements
Decreased urine output
Which statement reflects how the gastrointestinal system responds to pain? Releases extra gas Speeds metabolism Increases gastric emptying Decreases intestinal motility
Decreases intestinal motility
Which cues are relevant to the adult patient's acute pain experience? Dilated pupils Heart rate of 120 Respiratory rate of 12 Blood pressure of 118/62 Pain rated 7 on 0-10 pain scale
Dilated pupils Heart rate of 120 Pain rated 7 on 0-10 pain scale
Which actions are required for proper documentation of vital signs? Recording duplicate entries Documenting in a standardized format Documenting at the end of the day Recording on a specified form Recording just expected values
Documenting in a standardized format Recording on a specified form
Which statement describes characteristics of an individual's pain experience? Factors affecting pain can be changed. Each person's pain experience is unique. Spiritual aspects have little impact on response to pain. Pain perception for similar injuries is consistent for most people.
Each person's pain experience is unique.
The nurse tells a patient that oxycodone can cause itchiness and sleepiness and that it must be taken only as prescribed. The nurse also recommends taking a stool softener with this medication as it may cause constipation. Which action is the nurse demonstrating? Education Evaluation Assessment Intervention
Education
Releases hormones Cardiovascular Respiratory Endocrine Muscular
Endocrine
Which actions are responsibilities of the nurse when assigning vital signs to the unlicensed assistive personnel (UAP)? Ensure that the UAP uses the proper technique for measuring vital signs. Validate that the UAP knows what values need to be reported immediately for each patient. Determine that the UAP knows to report unexpected values to the health care provider. Ensure that the UAP is competent to perform vital sign assessments. Validate that the UAP uses appropriate equipment.
Ensure that the UAP uses the proper technique for measuring vital signs. Validate that the UAP knows what values need to be reported immediately for each patient. Ensure that the UAP is competent to perform vital sign assessments. Validate that the UAP uses appropriate equipment.
How frequently would the nurse take vital sign measurements for a stable hospitalized patient? Every 5 minutes Every 15 to 60 minutes Every hour Every 4 to 8 hours
Every 4 to 8 hours
How frequently would the nurse assess vital signs for a patient with a head injury who suddenly reports a severe headache and whose blood pressure rises from 118/62 to 170/94? Every 5 minutes Every 30 minutes Every 4 hours Every 8 hours
Every 5 minutes
Which phrases describe potential hypotheses related to pain management? Nursing interventions Expected patient outcomes Factors that alleviate pain Issues the patient is at risk for developing Actual problems the patient faces
Factors that alleviate pain Issues the patient is at risk for developing Actual problems the patient faces
Decreases motility and emptying Immune Urinary Gastrointestinal
Gastrointestinal
Which cues reflect behavioral responses to pain? Anger Anxiety Grimaces Irritability Clenched Teeth
Grimaces Clenched Teeth
Which statement describes the process nurses use to organize and link cues for a patient experiencing pain? Group collected cues according to type/category of pain, cause, or meaning. Collect objective cues through the health history, including pain experience. Apply critical thinking skills to cluster patient cues, linking them to the disease process. Gather subjective cues through physical assessment and observation of manifestations of pain.
Group collected cues according to type/category of pain, cause, or meaning.
Immune cells release which neurotransmitter during the inflammatory response? Serotonin Histamine Bradykinin Substance P
Histamine
Pain that continues to occur after an injury has healed Acute Chronic Idiopathic Breakthrough
Idiopathic
Releases inflammatory mediators Immune Urinary Gastrointestinal
Immune
The health care provider prescribes an oral analgesic every 4 hours as needed for pain. At hour 3, the patient still complains of severe pain rated 8 on a 0-10 scale and verbalizes feelings of frustration as a result of lack of pain relief. Which action is most effective for the nurse to take while awaiting a prescription for an increase in pain medication? Telling the patient to try to relax and rest Turning on the TV to provide a distraction for the patient Implementing massage and positioning techniques Conversing with the patient to draw attention away from the pain
Implementing massage and positioning techniques
Which situations require vital sign assessment? After discharge In ongoing care During an inpatient stay Before and after surgery As part of a physical assessment
In ongoing care During an inpatient stay Before and after surgery As part of a physical assessment
A patient is restless and moaning, and rates pain a 10 on a 0-10 pain scale 1 hour following administration of prescribed pain medication. Which hypothesis would the nurse identify? Anxiety Acute Pain Inadequate Pain Control Pain Management Satisfaction
Inadequate Pain Control
A patient is prescribed a nonsteroidal antiinflammatory drug (NSAID) for arthritis. The nurse would educate the patient about which potential side effects? Inflammation Hepatotoxicity Increased bleeding Decreased heart rate Gastrointestinal upset Cardiac complications
Increased bleeding Gastrointestinal upset Cardiac complications
A patient with diabetes presents at the emergency department with a broken arm and pain rated 8 on a 0-10 pain scale. Which effect on the patient's blood glucose would be anticipated? Increased blood glucose level Decreased blood glucose level Fluctuating blood glucose level No effect on blood glucose level
Increased blood glucose level
Which cue would the nurse anticipate when assessing a patient experiencing pain? Diarrhea Indigestion Weight gain Increased bowel sounds
Indigestion
Which technology innovations can the nurse use to accurately assess or manage pain? Informatics Pharmacogenomics Neuroimaging biomarkers Noncognitive assessment tools Magnetic resonance imaging
Informatics Pharmacogenomics Neuroimaging biomarkers Magnetic resonance imaging
Which cues are behavioral indications of pain? Fear Moaning Agitation Depression Clenching teeth
Moaning Agitation Clenching teeth
The brain releases analgesic neurotransmitters, or endogenous opioids. Perception Modulation Transmission Transduction
Modulation
Develops spasms, tensions, and fatigue Cardiovascular Respiratory Endocrine Muscular
Muscular
The provider prescribed pain and anxiety medications for a postoperative patient. The lowest pain rating the patient reports during the shift is 7 on a 0-10 pain scale. Which interprofessional team members would the nurse collaborate with to determine nonpharmacologic solutions for the patient? Music therapist Physical Therapist Massage Therapist Health care provider pain management specialist
Music therapist Physical Therapist Massage Therapist pain management specialist
Which theory of pain was based on studies of phantom limb pain in amputees and proposes that pain cannot be explained solely by physical factors? Pattern Theory Melzack Theory Gate Control Theory Neuromatrix Theory
Neuromatrix Theory
A patient complains of shooting pains in a leg following amputation of the leg. Which type of pain is the patient experiencing? Somatic pain Visceral pain Neuropathic pain Psychogenic pain
Neuropathic pain
Which statement provides an accurate description of pain? Pain is objective. Pain is subjective. Pain is a simple perception. Pain is similar among individuals.
Pain is subjective.
Which actions are considered nonpharmacologic pain management interventions the nurse can perform without a prescription from a health care provider? Patient repositioning Using distraction techniques Educating about opioid dependence Postoperative splinting Using progressive relaxation techniques
Patient repositioning Using distraction techniques Postoperative splinting Using progressive relaxation techniques
Which factors influence the interpretation of a patient's vital signs? Patient status Length of time the nurse is on duty Consideration of patient's baseline vital signs Standard range for vital sign values Patient's unique medical condition
Patient status Consideration of patient's baseline vital signs Standard range for vital sign values Patient's unique medical condition
The nurse is caring for a patient who reports pain of 9 on a 0-10 scale. The nurse administers the prescribed pain medication. Which statement reflects a patient goal developed in accordance with the SMART acronym? Patient will state better pain management within 1 hour of starting prescribed pain medication. Patient will verbalize an improvement in pain after taking prescribed dose of analgesia medication. Patient will report a pain level of less than 3 on a 0-10 scale within 1 hour of starting prescribed dose of analgesia. Patient will describe satisfactory pain control at a level less than 4 on a rating scale of 0-10.
Patient will report a pain level of less than 3 on a 0-10 scale within 1 hour of starting prescribed dose of analgesia.
The nurse is caring for a patient who was involved in a mountain bike accident and is experiencing severe pain. The nurse determines that Acute Pain is the priority hypothesis. Which statement reflects a short-term outcome for the patient experiencing pain? Patient will report a pain level of less than 3 on a 0-10 scale within 5 postoperative days. Patient will report a pain level of less than 3 on a 0-10 scale within 1 hour of starting prescribed dose of analgesia. Patient will perform activities of daily living, reporting a pain level of 3 or less within 1 day of beginning new pain medication. Patient will perform activities of daily living, reporting a pain level of 3 or less within 1 week of beginning new pain medication.
Patient will report a pain level of less than 3 on a 0-10 scale within 1 hour of starting prescribed dose of analgesia.
Which finding takes precedence when interpreting a patient's vital sign values? Expected result Normal result Patient's averaged result Patient's baseline result
Patient's baseline result
Which statement describes a benefit of patient-controlled analgesia (PCA)? Patients can self-administer and manage their pain medication. Patients' families can administer medication whenever desired. Patients can give themselves as much medication as they desire. The nurse does not have to perform a check before administration.
Patients can self-administer and manage their pain medication.
The brain interprets the pain signals. q Modulation Transmission Transduction
Perception
Which step of nociception involves translation of nerve signals? Perception Modulation Transduction Transmission
Perception
Which pain management activities can the nurse delegate to unlicensed assistive personnel? Performing oral hygiene Providing back rubs Repositioning the patient Administering pain medication Calling the health care provider to request pain medication
Performing oral hygiene Providing back rubs Repositioning the patient
Which collaborative team members may be involved in providing care to a patient with pain? Art therapist Physical therapist Massage therapist Pain management specialist Muscle manipulation specialist
Physical therapist Massage therapist Pain management specialist Muscle manipulation specialist
Influence of genetics on pain tolerance Cultural Social Psychological Physiologic
Physiologic
Which factors influence legal and ethical aspects of generating solutions for pain management? Patient perception of pain Professional standards of practice Organizational policies and procedures Regulatory pain management standards Pain management position statements
Professional standards of practice Organizational policies and procedures Regulatory pain management standards Pain management position statements
Which statements reflect The Joint Commission's (TJC's) pain assessment standards? Document the comprehensive pain assessment. Provide nonpharmacologic pain treatment modalities. Address pain assessment and management with new staff. Develop an evidence-based and standardized pain treatment plan. Monitor patients at high risk for adverse outcomes related to opioid treatment.
Provide nonpharmacologic pain treatment modalities. Address pain assessment and management with new staff. Monitor patients at high risk for adverse outcomes related to opioid treatment.
Ability to cope with pain and perceived loss of control Cultural Social Psychological Physiologic
Psychological
Which measurements are included as cardinal vital signs? Pain Pulse Respirations Blood pressure Oxygen saturation
Pulse Respirations Blood pressure Oxygen saturation
Which cultural factors influence meanings and attitudes associated with pain? Race Anxiety Genetics Education Previous pain experience
Race Education
Which action would the nurse take when the unlicensed assistive personnel (UAP) reports the patient's pulse increased from 74 beats/min to 100 beats/min and the temperature increased from 99° to 101.8°F (37.2° to 38.8°C)? Advise the UAP to wait 1 hour and repeat vital signs. Compare the findings to the expected values. Reassess the patient. Tell the UAP to give fluids to the patient.
Reassess the patient.
In ongoing care During an inpatient stay Before and after surgery As part of a physical assessment Interpret vital sign data collected. Record vital signs for any patient. Report vital signs for a stable patient. Measure vital signs for a stable patient. Measure vital signs before the nurse has assessed the patient.
Report vital signs for a stable patient. Measure vital signs for a stable patient.
A patient who is in labor reports intense, painful contractions and feels very nauseous. The patient wants to proceed without the use of medication. Which nonpharmacologic interventions can the nurse implement for this patient? Repositioning the patient Massaging the patient's back Assisting with deep breathing exercises Consulting with the patient's birthing doula Keeping the patient hydrated with clear liquids
Repositioning the patient Massaging the patient's back Assisting with deep breathing exercises
Which finding is unexpected for a 15-year-old patient? Pain level 0 Pulse rate 88 Respirations 30 O2 sat 97%
Respirations 30
Decreases air exchange Cardiovascular Respiratory Endocrine Muscular
Respiratory
Which vital sign finding indicates the adult patient is improving? Blood pressure changes from 120/78 to 80/60. Pulse rate increases from 85 to 110. Oxygen saturation changes from 90% to 85%. Respiratory rate decreases from 36 to 20.
Respiratory rate decreases from 36 to 20.
A patient has suffered burn injuries related to a house fire and is in the burn center for pain control and dressing changes. Which function does pain serve when it is associated with a thermal injury? Warning Response Protection Modulation
Response
Following a back injury that occurred while gardening, a patient states that the pain level increases when walking or bending but is relieved when lying down. Which hypothesis would the nurse identify? Anxiety Chronic Pain Difficulty Coping Risk for Activity Intolerance
Risk for Activity Intolerance
Which characteristic of non-opioid analgesic medications describes why nurses administer them more often than opioid analgesics? Easier to dispense Safer for the patient Cheaper to dispense Prescription not required
Safer for the patient
The nurse asks a patient experiencing painful kidney stones to rate the pain on a scale from 0 to 10. The patient rates the pain as a 7. Which phrase describes the patient's level of pain indicated by the rating? Mild pain severe pain average pain moderate pain
Severe pain
Presence of parent to provide support for child experiencing pain Cultural Social Psychological Physiologic
Social
An individual's attendance at a chronic pain support group reflects which type of influencing factor? Social factor Cultural factor Physiologic factor Psychological factor
Social factor
Which action would the nurse take for a stable patient who is scheduled for a transfer to the rehabilitation unit later in the afternoon? Take vital signs before the transfer. Require every 2-hour monitoring until the transfer. Monitor the pulse rate once a day after the transfer. Delay vital signs monitoring since the patient is being transferred.
Take vital signs before the transfer.
Which action allows the nurse to begin collecting cues about a burn patient's pain experience? Perfomring comfort measures Taking the patient's vital signs Recording the patient's meal order Removing the dressings to assess the wound
Taking the patient's vital signs
Which action allows the nurse to begin collecting cues about a burn patient's pain experience? Performing comfort measures Taking the patient's vital signs Recording the patient's meal order Removing the dressings to assess the wound
Taking the patient's vital signs
A patient has a broken femur and is in excruciating pain. The health care provider prescribes an intravenous opioid and acetaminophen combination for pain relief. Which statement explains why the two medications are prescribed for pain? The mixture of medications produces fewer side effects. Multimodal analgesia requires lower doses for effective pain relief. The health care provider wants to avoid an unhappy patient call later complaining of unrelieved pain. The combination of medications is more effective than just the opioid alone. The choices of medications allow the nurse to select the best option based on patient preference.
The mixture of medications produces fewer side effects. Multimodal analgesia requires lower doses for effective pain relief. The combination of medications is more effective than just the opioid alone.
The nurse is providing care for a patient with Alzheimer disease. Which factors would the nurse consider when conducting a pain assessment on a patient with a cognitive disorder? The patient is able to experience pain. The patient is unable to perceive pain. The patient is able to report pain status. The patient is able to perform behaviors to alleviate pain. The patient may not be able to express the location of pain.
The patient is able to experience pain. The patient may not be able to express the location of pain.
After assessing a patient with a fractured wrist, the nurse selects a hypothesis of Difficulty Coping. Which cues would lead the nurse to select this hypothesis? The patient is grimacing. The patient appears restless. The patient has an elevated blood pressure and pulse. The patient reports pain of 5 on a 0-10 pain scale. The patient has decreased sensation in the fingers of the affected wrist.
The patient is grimacing. The patient appears restless.
Which aspects would the nurse consider when conducting a pain assessment for a patient in a non-life-threatening situation? Health literacy does not influence the assessment. The nurse should complete the assessment as quickly as possible. The patient's values and beliefs about pain affect the assessment. The nurse's values and beliefs about pain may influence the assessment. A calm and supportive manner promotes effective communication.
The patient's values and beliefs about pain affect the assessment. The nurse's values and beliefs about pain may influence the assessment. A calm and supportive manner promotes effective communication.
Which statement regarding nociception is accurate? Nociceptors transmit electrical impulses throughout the body. Pain is conducted from the central nervous system to the periphery. The process begins with conversion of a stimulus to an electrical impulse. Nociception involves conduction of "threat" stimuli to the peripheral nervous system.
The process begins with conversion of a stimulus to an electrical impulse.
Which statement describes the role played by neurotransmitters when an individual experiences pain? Neurotransmitters send pain signals to randomized neurons. The release of neurotransmitters is part of the inflammatory response. Neurotransmitters play a minimal role in the cause of generalized pain. Emotional responses to pain cause the release of neurotransmitters.
The release of neurotransmitters is part of the inflammatory response.
Which entries would the nurse include when documenting vital signs? Date of assessment Time of assessment Names of visitors in the room Numeric results of the assessment Expected values for vital signs
Time of assessment Numeric results of the assessment
Injury occurs, and injured tissues release neurotransmitters. Perception Modulation Transmission Transduction
Transduction
Which step of nociception involves recognition of a painful stimulus and conversion of the stimulus to an electrical impulse? Perception Modulation Transduction Transmission
Transduction
Pain impulses travel to the spinal cord and brain. Perception Modulation Transmission Transduction
Transmission
Which statement describes multimodal analgesia? Two or more medications are used to relieve pain. More than one intervention is used to control pain. Pain medication is used in anticipation of a painful event. Pharmacologic and nonpharmacologic strategies are combined.
Two or more medications are used to relieve pain
Which aspects reflect key considerations for the nurse to effectively recognize cues related to pain? Culture Urgency Relevance Physiology Importance
Urgency Relevance Importance
Increases blood pressure through release of hormones Immune Urinary Gastrointestinal
Urinary
Which questions would the nurse ask to assist in prioritizing hypotheses for patients experiencing pain? Which hypotheses are most likely to occur? Which hypotheses might affect the patient's airway? Which hypotheses influence activities of daily living? Which hypotheses can increase the risk for complications? Which hypotheses are most likely to be life-threatening?
Which hypotheses are most likely to occur? Which hypotheses might affect the patient's airway? Which hypotheses can increase the risk for complications? Which hypotheses are most likely to be life-threatening?
The nurse is caring for a patient who was involved in a mountain bike accident and is experiencing severe pain. Which question would allow the nurse to prioritize hypotheses according to risk? Which hypotheses are most likely to occur? Which hypotheses are most likely to affect breathing? Which hypotheses have the potential for complications? Which hypotheses are most likely to be life-threatening as a result of injury?
Which hypotheses have the potential for complications?
A patient who presents to the emergency department with mild leg strain requests nonpharmacologic pain treatment. Which alternative therapies would the nurse suggest? Yoga Aspirin Exercise Meditation Biofeedback
Yoga Meditation Biofeedback
which vital sign can be altered because of a decrease in sweat gland reactivity in older adults? pulse rate blood pressure respiratory rate body temperature
body temperature
Based on the density of nociceptors throughout the body, which condition would the nurse expect to require the most analgesia? burn osteoarthritis low back strain blunt abdominal injury
burn
while assessing the apical pulse in a patient, the nurse places the diaphragm of the stethoscope in her palm for 10 seconds. which rationale would direct this action? ensures the diaphragm is warm reduce anxiety in the patient prevents the transmission of germs increases the sensitivity
ensures the diaphragm is warm
how would the nurse determine the ventilatory rhythm in a patient? observing the pattern of breathing watching the degree of excursion in the chest wall examining full inspiration when counting ventilation noting full inspiration when counting ventilation
ensuring exposure to blood vessels
the nurse is measuring the rectal temperature of an adult patient. the nurse inserts the thermometer probe into the anus of the patient up to 3 cm in the direction of the umbilicus. which rationale would direct this nursing intervention? helping to relax the anal sphincter minimizing trauma to rectal mucosa preventing the dislodgement of the probe ensuring exposure to blood vessels
ensuring exposure to blood vessels
the nurse has difficulty hearing the sounds of a patient who is 80 years old. which factor explains the muffled heart sounds? increased heart rate decreased vessel elasticity increased air space in the lungs ossification of costal cartilage
increased air space in the lungs
Lowest density of nociceptors, respond only to painful stimuli skin joints and tissues internal organs
internal organs
Lower density of nociceptors, less sensitive to pain skin joints and tissues internal organs
joints and tissues
how would the nurse determine the ventilatory rhythm in a patient? observing the pattern of breathing watching the degree of excursion in the chest wall examining full expiration when counting ventilation noting full inspiration when counting ventilation
observing the pattern of breathing
The nurse working in an urgent care office assesses a patient who presents with a possible broken ankle that is edematous. The patient rates the pain a 9 on a 0-10 scale. The nurse obtains vital signs and notices that the patient grimaces every time the affected foot moves. Which cue reflects subjective data? Vital signs edematous ankle weak pulse in the foot pain rating 9 on a 0-10 scale
pain rating 9 on a 0-10 scale
after measuring the temperature of the temporal artery, the nurse cleans the sensory with the alcohol swab. which rationale would direct the nurse's action? ensuring accurate readings protecting the sensor tip from damage preventing transmission of microorganisms maintaining battery charge of thermometer unit
preventing transmission of microorganisms
before assessing the rectal temperature of a patient, the nurse slides a plastic disposable probe cover over the thermometer probe stem. which rationale would direct this intervention? lubricating rectal mucosa during insertion maintaining standard precautions when exposed ensuring adequate exposure against blood vessels preventing transmission of microorganisms between patients
preventing transmission of microorganisms between patients
the nurse is assessing the rectal temperature of a patient with an electronic thermometer. which patient position would promote comfort? side-lying position sitting position supine position high-fowler's position
side-lying position
Highest density of nociceptors; extremely sensitive to pain skin joints and tissues internal organs
skin
while assessing the axillary temperature, for which response would the nurse raise the patient's arm away from the torso? to ensure accurate readings to provide comfort to the patient to inspect for the presence of lesions to prevent the transmission of microorganisms
to inspect for the presence of lesions
While assessing the oral temperature of a patient using an electronic thermometer, for which reason would the nurse ask the patient to close the lips? to ensure proper measurement to provide comfort to the patient to reduce transmission of organisms to maintain proper position of the problem
to maintain proper position of the problem
when assessing the patient's respiration, for which reason would the nurse elevate the bed to 60 degrees in a sitting position? to reveal a specific disease state to determine respiratory cycle to promote ventilatory movement to minimize discomfort because of shortness of breath
to promote ventilatory movement