Chapter 14 PrepU

In describing the ideal analgesic, what factors would be included? Select all that apply. a. Inexpensive b. Effective c. Have minimal adverse effects d. Addictive e. Decrease the level of consciousness

-Inexpensive -Effective -Have minimal adverse effects

A nurse is caring for a 30-year-old client who experiences intense one-sided headaches. Which additional characteristic would support a diagnosis of cluster headaches? Select all that apply. a. Pain behind the eye b. Nausea and vomiting c. Rhinorrhea on the same side as the headache d. Pain occurring with the menstrual cycle e. Headache preceded by an aura

-Pain behind the eye -Rhinorrhea on the same side as the headache

A nurse is caring for a 60-year-old client who experiences headaches several times a month. Which additional characteristics would support a diagnosis of tension headaches? Select all that apply. a. The pain responds to NSAIDs. b. The headache occurs 15 or more days per month. c. The pain occurs with the menstrual cycle. d. The pain is described as dull and aching. e. The headache is preceded by an aura.

-The pain responds to NSAIDs -The pain is described as dull and aching

A nurse assess an older adult client for signs and symptoms of infection. In the absence of a fever, for which will the nurse assess? Select all that apply. a. fatigue b. change in functional capacity c. depression d. weight gain e. decreased mental status

-fatigue -change in functional capacity -decreased mental status

Which core body temperature is within normal range? a. 38°C (100.4°F) b. 35.9°C (96.6°F) c. 35.5°C (95.9°F) d. 37.3°C (99.1°F)

37.3°C (99.1°F)

Which symptom indicates the next stage of a fever after a prodrome? a. A chill b. A flush c. Prodrome d. Defervescence

A chill

Infants are at greater risk of hypothermia than children because of which of the following? a. The inability of infants to state that they are cold b. Their inability to remove clothing c. An increased thickness of subcutaneous fat at birth d. A high ratio of surface area to body mass

A high ratio of surface area to body mass

A client diagnosed with moderate hypothermia would likely experience the instillation of warmed fluids into the gastrointestinal tract and extracorporeal blood warming. This type of rewarming is referred to as: a. Active external b. Passive external c. Active core d. Passive core

Active core

For which older adult client would pain assessment likely be most challenging for the nurse? a. A 90-year-old client who takes multiple medications for cardiac and respiratory conditions b. An 87-year-old client with vascular dementia and numerous other health problems, such as heart failure c. An 82-year-old client who has been diagnosed with diabetes and an anxiety disorder d. A 77-year-old client who has sustained burns on the lower part of the body

An 87-year-old client with vascular dementia and numerous other health problems, such as heart failure

When conducting a health assessment that focuses on the pain experienced by an older client diagnosed with early dementia, the nurse will pay particular attention to which of the following? a. Cultural beliefs held by the client regarding the cause of pain b. Behavioral signs of pain demonstrated by the client c. The client's verbal perception of pain d. The client's comfort level regarding the discussion of pain

Behavioral signs of pain demonstrated by the client

A nurse caring for a client with hypothermia anticipates that the client's temperature will be: a. Below 100°F (37.7°C) b. Above 40°C (104°F) c. Below 35°C (95°F) d. Below 97°F (36.1°C)

Below 35°C (95°F)

Which principles should underlie the pain control strategy in the care of a child with a diagnosis of cancer? a. Opioids should be avoided in order to prevent liver and kidney insult. b. Dosing and timing should aim for a steady serum level of the prescribed drug. c. Drugs from numerous classifications should be used to maximize pain control. d. Doses of analgesia should be given only when the client's pain becomes severe.

Dosing and timing should aim for a steady serum level of the prescribed drug.

The nurse knows that chronic pain lacks which of the characteristic pain-related reactions? a. Increased heart rate b. Disturbed sleep patterns c. Depression d. Loss of appetite

Increased heart rate

A febrile, 3-week-old infant is currently undergoing a diagnostic workup to determine the cause of the fever. Which statement conveys the rationale for this careful examination? a. The immature hypothalamus is unable to perform normal thermoregulation. b. Infants are susceptible to serious infections, because of their decreased immune function. c. Fever in infants is often evidence of a congenital disorder rather than an infection. d. Commonly used antipyretics often have no effect on the core temperature of infants.

Infants are susceptible to serious infections, because of their decreased immune function.

A client has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for which type of fever? a. Intrinsic b. Systemic c. Neurogenic d. Exogenous

Neurogenic

Which client is exhibiting headache symptoms that indicate a need for further evaluation? a. Pregnant mother with drowsiness and unrelenting headache b. Parent with general head pain after a night caring for an ill child c. College student with unilateral headache after eating a chocolate bar d. Older adult with a headache after missing the evening meal

Pregnant mother with drowsiness and unrelenting headache

A client has a mild headache and fatigue. He also states he has some aches and pains. Which stage of fever does the nurse determine the client is experiencing? a. Defervescence b. Prodrome c. Chill d. Flush

Prodrome

The nurse is providing nonpharmacologic pain relief for a client who has a pain level of 2 in the leg. What intervention provided by the nurse would be considered distraction? a. Applying heat to the legs b. Sitting with the client and having a conversation c. Having the client imagine that she is at the beach listening to the waves d. Slow, rhythmic breathing exercises

Sitting with the client and having a conversation

About 30 minutes following the morning medication pass, the nurse's aide informs the nurse that one of the clients on their team is complaining of "hot sweats." The aide also states that the client's temperature is now 101.5°F (38.6°F). Knowing that some medications can cause hyperthermia, the nurse reviews the medications. Which client is at high risk for developing an elevated temperature? a. Postoperative client receiving oxycodone for pain b. Client with hypertension being treated with lisinopril c. Client with C. difficile receiving vancomycin IV every 6 hours d. Suicidal client who overdosed on a monoamine oxidase (MOA) inhibitor

Suicidal client who overdosed on a monoamine oxidase (MOA) inhibitor

Which client is most likely to be susceptible to developing a neurogenic fever? a. Has stage 2 Alzheimer disease b. Became delirious after the administration of a benzodiazepine c. Takes a selective serotonin reuptake inhibitor (SSRI) for the treatment of depression d. Sustained a head injury in a bicycle crash

Sustained a head injury in a bicycle crash

A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later? a. T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg b. T 97.2ºF (36.2°C), P 70/min, R 12/min, BP 114/60 mmHg c. T 99.7ºF (37.6°C), P 86/min, R 18/min, BP 130/82 mm Hg d. T 98.4ºF (36.9°C), P 82/min, R 16/min, BP 106/70 mm Hg

T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg

A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for: a. Hypothermia b. Urinary output c. Respirations d. Temperature

Temperature

The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy? a. Cluster b. Sinus c. Migraine d. Tension

Tension

A recovery room nurse monitoring a client for adverse effects of cold cardioplegia assesses for: a. Postoperative migraine b. Ventricular dysrhythmia c. Postoperative anxiety d. Increased intercranial pressure

Ventricular dysrhythmia

A client is admitted to the acute care facility with severe pain in the abdomen related to inflammatory bowel disease. What type of pain will the nurse be administering medication to relieve? a. Visceral pain b. Referred pain c. Somatic pain d. Cutaneous pain

Visceral pain

A client with a history of migraine headaches tells the physician that he or she usually experiences an aura before the onset of the headache. The client is most likely experiencing: a. Visual disturbances b. Dizziness c. Lethargy d. Dysphasia

Visual disturbances

While sponging a client who has a high temperature, the nurse observes the client begins to shiver. At this point, the priority nursing intervention would be to: a. administer an extra dose of aspirin. b. stop sponging the client and retake a set of vital signs. c. increase the room temperature by turning off the air conditioner and continue sponging the client with warmer water. d. place a heated electric blanket on the client's bed.

stop sponging the client and retake a set of vital signs.

A client asks if pain threshold and pain tolerance are the same. The best response by the health care provider would be: a. "Pain threshold is the point at which a stimulus is perceived as painful." b. "Pain tolerance is the minimum intensity of pain a client will endure." c. "Pain tolerance is not affected by psychological, familial, cultural, and environmental factors." d. "Pain threshold is not varied from person to person."

"Pain threshold is the point at which a stimulus is perceived as painful."