1012 Pain
A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage the mother to do? Apply cool packs to her breasts to reduce the discomfort Take the analgesic medication prescribed to limit the discomfort Remove the infant from the breast for a few days to rest the nipples Never expose the nipples to air, only wear a tight fitting brassiere Assume a different position when breastfeeding to adjust the infant's sucking
**Apply cool packs to her breasts to reduce the discomfort **Take the analgesic medication prescribed to limit the discomfort **Assume a different position when breastfeeding to adjust the infant's sucking Applying cool packs to the breasts to reduce the discomfort may provide relief after a feeding. Analgesics may eventually be necessary. Altering the breastfeeding position may ensure that the entire nipple and as much of the areola as possible are in the . When the infant is latched on the nipple correctly and a finger is used to release suction at the end of a feeding, trauma to the nipple is reduced. Soreness is common; it usually occurs at the beginning of a feeding and is temporary, lasting till the nipples become accustomed to the infant's sucking. Nursing mothers should be encouraged to expose their nipples to air several times a day. Discontinuing feeding for several days will result in engorgement, which will increase the discomfort.
What is a nurse's responsibility when administering prescribed opioid analgesics? Count the client's respirations. Document the intensity of the client's pain. Withhold the medication if the client reports pruritus. Verify the number of doses in the locked cabinet before administering the prescribed dose. Discard the medication in the client's toilet before leaving the room if the medication is refused.
*Count the client's respirations. *Document the intensity of the client's pain. *Verify the number of doses in the locked cabinet before administering the prescribed dose. Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse should not discard an opioid in a client's room. Any waste of an opioid must be witnessed by another nurse.
A client has a suspected peptic ulcer in the duodenum. What should the nurse expect the client to report when describing the pain associated with this disease? An ache radiating to the left side An intermittent colicky flank pain A gnawing sensation relieved by food A generalized abdominal pain intensified by moving
A gnawing sensation relieved by food The act of eating allows the hydrochloric acid in the stomach to work on and be neutralized by food rather than irritate the intestinal mucosa. An ache radiating to the left side is not specific to duodenal ulcers. An intermittent colicky flank pain may indicate renal colic. A generalized abdominal pain intensified by moving is not specific to duodenal ulcers.
An 8-year-old child who is experiencing a sickle cell pain episode is admitted to the child health unit. What is the most appropriate nursing care during this acute period? Limiting fluids until the crisis ends Administering prescribed analgesics Applying cold compresses to painful joints Performing range-of-motion exercises of affected joints
Administering prescribed analgesics The priority is pain management; severe pain requires analgesics. Increased hydration is necessary to promote hemodilution, improve circulation, and prevent more sickling. Cold will constrict blood vessels, further depleting oxygenation to affected parts; warmth is preferable. There is too much swelling and pain in the joints during a crisis for the implementation of range-of-motion exercises.
A client is receiving morphine sulfate (MS Contin) for severe metastatic bone pain. To prevent complications from a common, serious side effect of morphine, the nurse should: Monitor for diarrhea Observe for an opioid addiction Assess for altered breathing patterns Check for a decreased urinary output
Assess for altered breathing patterns Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest. Morphine, an opioid, will cause constipation, not diarrhea. Addiction is not a concern for a terminally ill client. Although morphine sulfate may cause urinary retention, it is not a common side effect and is not life threatening.
What is the primary focus of nursing care for a client admitted with tetanus caused by a puncture wound? Monitoring urinary output Decreasing external stimuli Maintaining body alignment Encouraging high intake of fluid
Decreasing external stimuli The slightest stimulation can set off a wave of severe, painful muscle spasms involving the whole body. Nerve impulses cross the myoneural junction and stimulate muscle contraction caused by exotoxins produced by Clostridium tetani. Monitoring urinary output is not a major nursing concern for clients with tetanus. Body alignment is not an important consideration for clients with tetanus. Oral intake of fluids may not be possible because of excessive secretions and laryngospasms.
The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? Warm skin at site of injury Escalating pain in the fingers Rapid capillary refill in affected hand Bounding radial pulse in the injured arm
Escalating pain in the fingers Elevated tissue pressure restricts blood flow, causing increasing ischemia and increasing pain; it is the cardinal early symptom of compartment syndrome. The arm will feel cool, not warm, because of a decrease in circulation. Sluggish, not rapid, capillary refill is a sign of compartment syndrome. The pulse will be diminished, not bounding; increasing edema impairs circulation.
The nurse is teaching a prenatal breathing and relaxation class. What does the nurse suggest to best ease back discomfort during labor? Alternating lying on the back and side Having support persons use back massage techniques Using distraction techniques such as abdominal effleurage The knee-chest position before and after assessments of the fetal heart rate
Having support persons use back massage techniques The fetus exerts pressure against the spine during labor; provides counterpressure, which eases the discomfort. The back-lying position is contraindicated because the weight of the fetus compresses the vena cava, decreasing the flow of blood to the placenta. Although abdominal effleurage can serve as a distraction during labor, it will not relieve back discomfort. The knee-chest position will not relieve back pain during labor.
A client experiences an acute episode of rheumatoid arthritis. The nurse observes that the client's finger joints are swollen. The nurse concludes that this swelling most likely is related to: Urate crystals in the synovial tissue Inflammation in the joint's synovial lining Formation of bony spurs on the joint surfaces Escaped fluid from the capillaries that increases interstitial fluids
Inflammation in the joint's synovial lining The pathological process involved with rheumatoid arthritis is accompanied by vascular congestion, fibrin exudate, and cellular infiltrate, causing inflammation of the synovium. Urate crystals occur with gouty, not rheumatoid, arthritis. Formation of bony spurs on the joint surfaces is unrelated to rheumatoid arthritis. Increased interstitial fluid is only one aspect of the inflammatory response.
A client who is complaining of severe midsternal pain is brought to the emergency department. The client is diagnosed with a myocardial infarction. Which drug can the nurse expect to be prescribed to control this client's pain? Alprazolam ( Xanax) Meperidine ( Demerol) Morphine sulfate (MS Contin) Adenosine (Adenocard)
Morphine sulfate (MS Contin) Morphine sulfate is the drug of choice because it reduces severe pain, lowers systemic vascular resistance, and decreases venous return. Alprazolam, a benzodiazepine, lowers anxiety, which may reduce some pain, but it is not an effective analgesic. Although meperidine is an analgesic, morphine sulfate is the preferred drug in this situation. Adenosine is used to control ventricular ectopic activity, not pain.
A client who is 5 feet, 8 inches tall and weighs 220 pounds is admitted to the hospital with ureteral colic, blood in the urine, and a blood pressure of 150/90. The immediate objective of nursing care for this client is to decrease: Pain Weight Hematuria Hypertension
Pain Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is associated with ureteral distention and must be relieved. Weight loss is a long-term goal; reducing pain is the priority. Although the hematuria will be addressed, pain reduction is the priority. Although the client's hypertension will be addressed, pain reduction is the priority.
A client is admitted to the hospital for an emergency cardiac catheterization. What is the most common adaptation that the client is most likely to complain about after this procedure? Fear of dying Skipped heartbeats Pain at the insertion site Anxiety in response to intensive monitoring
Pain at the insertion site Pain at the arterial puncture site is attributable to entry and cannulation of the artery and is a common complaint after a cardiac catheterization. Fear of dying might occur during the precatheterization period. Although skipped heartbeats may occur during the procedure because of trauma to the conduction system, usually it does not continue after the procedure. Although some clients may be anxious, many feel safe when receiving ongoing monitoring.
A nurse is discussing the care of an infant with colic. What should the nurse explain to the parents is the cause of colicky behavior? Inadequate peristalsis Paroxysmal abdominal pain An allergic response to certain proteins in milk A protective mechanism designed to eliminate foreign proteins
Paroxysmal abdominal pain The traditional efforts to explain and treat colic center on the paroxysmal abdominal pain; multiple factors appear to be involved, including immaturity of the intestinal nervous system and lack of normal intestinal flora. Peristalsis is effective because these infants thrive physically and gain weight. The origin of colic is unknown at this time.
The nurse should monitor for which involuntary physiological response in a client who is experiencing pain? Crying Splinting Perspiring Grimacing
Perspiring Perspiration is an involuntary physiological response. It is mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high humidity, stress, and pain. Crying is an emotional response that may or may not be related to pain. Splinting is a voluntary action that may limit tension on the abdomen, thus reducing pain. Grimacing is a result of contraction of the facial muscles; it may or may not be a response to pain.
A client who is obese and has a history of alcohol abuse is admitted to the hospital with the diagnosis of acute pancreatitis. What is the priority expected client outcome in response to therapy at this time? Report decreased pain. Remain in fluid balance. Lose four pounds a week. Join Alcoholics Anonymous.
Report decreased pain. Pain relief is the priority. Severe pain is associated with acute pancreatitis caused by inflammation of the pancreas, peritoneal irritation, and biliary tract obstruction. Although remaining in fluid balance is extremely important, fluid balance is not the priority unless the client is vomiting, has dehydration, or has a nasogastric tube for decompression. Losing weight and joining Alcoholics Anonymous are later goals.
