Foundations Week 13: Safety, Comfort & Pain Management

what is a chemical restraint?

medications, such as antipsychotics, that are used to manage a client's behavior or freedom of movement

what occurs during a behavior (voluntary) response to pain?

moving away from painful stimuli grimacing, moaning, crying restlessness

what is the reversal agent of an opioid overdose?

naloxone

How should infants be sleeping?

on their back

dull pain

pain is not as intense or acute as sharp pain more annoying than painful

diffuse pain

pain that covers a large area patient is usually unable to point to a specific area without moving the hand over an entire surface (ex: abdomen)

sharp pain

pain that is sticking in nature and that is intense

referred pain

pain that originates in one part of the body but the pain is felt in a different place

what is visceral pain?

poorly localized and originates in body organs in the thorax, cranium, and abdomen

what is your first PRIORITY in a fire?

rescue the patient

what is the primary assessment for the nurse caring for a client with a PCA?

respiratory system assessment

what does 4 indicate on a sedation scale?

somnolent with minimal or no response to stimuli; want to discontinue opioid, consider use of naloxone

what is cutaneous pain?

superficial pain that involves skin/subcutaneous tissue

which of the following is considered to be the most potent neuromodulator? a) endorphins b) enkephalins c) efferent d) afferent

a) endorphins

how often do verbal restraint prescriptions have to be renewed?

every 24 hours

what occurs during an affective (psychological) response to pain?

exaggerated weeping and restlessness withdrawal anxiety/depression anorexia fatigue hopelessness/powerlessness

How long after oral pain medication administration should you reassess your patient?

1 - 2 hours later

How long after IV pain medication administration should you reassess your patient?

15 - 20 minutes later

what is the daily maximum dose allowed for acetaminophen?

4 g/day (4,000 mg/day)

what is the FLACC pain scale?

F = faces L = legs A = activity C = cry C = consolability

what occurs during a physiologic (involuntary) response to pain that is severe and deep?

N/V fainting/unconsciousness decreased BP, pulse rapid & irregular breathing

shifting pain

Pain moves from one area to another, such as from the lower abdomen to the area over the stomach.

what is the RACE model for fire safety?

R = rescue A = alarm C = contain E = extinguish

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? a) Most people who die in house fires die of smoke inhalation rather than burns b) Most fatal home fires occur while people are cooking c) About 10% of home fire deaths occur in a home without a smoke detector d) Most home fires are caused by children playing with matches

a) Most people who die in house fires die of smoke inhalation rather than burns

How should the nurse position the head of the bed for a client receiving epidural opioids? a) elevated 30 degrees b) flat c) Reverse Trendelenburg d) Trendelenburg

a) elevated 30 degrees

endorphins typically give what type of feeling to a client?

analgesia

what is an extremity restraint used for?

appropriate for short-term use designed to control all movement

what do nociceptors do?

are the peripheral nerve fibers that transmit pain

A school nurse is preparing an education session on safety for parents of school-age children. What would be an appropriate topic for this age group? a) selecting toys for the developmental level b) providing drug, alcohol, and sexuality education c) teaching stress reduction techniques d) providing close supervision to prevent injuries

b) providing drug, alcohol, and sexuality education

What is the primary role of the nurse in the care of clients who experience domestic violence? a) Calling the police b) Identifying health education and counseling measures for the family c) Providing prompt recognition of the potential or actual threat to safety d) Serving as a witness in court

c) Providing prompt recognition of the potential or actual threat to safety

what is neuropathic pain?

caused by a lesion or disease of peripheral or central nerves (tingling, stabbing pain)

which of the following pain assessments is recommended for use with neonates ages 0 - 6 months? a) Oucher Pain Scale b) Wong-Baker FACES c) FLACC pain scale d) CRIES pain scale

d) CRIES pain scale

The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client? a) acute b) chronic c) diffuse d) intractable

d) intractable

what is a physical restraint?

devices that immobilize or reduce the ability of a client to freely move their arms, legs, body, or head

what is somatic pain?

diffuse or scattered pain that originates in tendons, ligaments, bones, blood vessels, and nerves

what is the leading cause of death for 1 - 4 year old children?

drowning

what is the requirement for the fit of physical restraints?

ensure that 2 fingers can fit between the restraint and the client's extremity; restraints should be removed every 2 hours

what occurs during a physiologic (involuntary) response to pain that is moderate and superficial?

increases BP, pulse and respiratory rates pupil dilation muscle tension & rigidity

what does 1 indicate on a sedation scale?

indicates that the client is alert and awake (no action necessary)

what does 3 indicate on a sedation scale?

indicates that the client is frequently drowsy, arousable but drifts off to sleep during conversation (reduce dose)

what does S indicate on a sedation scale?

indicates that the client is sleeping but easy to arouse (no action necessary)

what does 2 indicate on a sedation scale?

indicates that the client is slightly drowsy but easy to arouse (no action necessary)

what happens if a "never event" occurs while a patient is hospitalized?

the hospital must bear any costs for treating the acquired client's injury

how do the neuromodulator enkephalins work?

thought to reduce pain by inhibiting the release of substance P from the terminals of afferent neurons