Fundamentals Week 2

An older adult verbalizes to the nurse that he/she is having pain in his/her left wrist. Which of the following would be the most appropriate response by the nurse?

"Tell me more about the pain." Whenever anyone reports pain, the nurse needs to complete a thorough pain assessment. Pain is common among older adults, but it is not a normal process of aging. Pain indicates pathology or injury and should always be assessed. Remember, pain is what the patient says it is. Fear of addiction is a common reason for underreporting of pain. While older adults may be more sensitive to medications, their pain should still be treated reasonably.

Respirations Ranges

0-1 is 24-38 1-3 is 22-30 4-6 is 20-24 7-9 is 18-24 10-14 is 16-22 15-18 is 14-20 Adults is 10-20

The rectal temperature

0.4 to 0.5 (0.7 to 1F) highter than oral temp.

Remembering Celsius

104 F - 40 C 98.6 F - 37 C 95 F - 35 C

healthy BMI

18.5-25 kg/m2

Normal oral temperature

37C (98.6F) with a range of 35.8 to 37.3 (96.4 to 99.1)

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?

A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

A nurse is performing a general client survey and find that the client has a body mass index (BMI) of 23. Which of the following should the nurse document?

A client has a BMI within the expected reference range

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?

A client who has pain for over 6 years

What type of pain is short and self-limiting and dissipates after the injury heals?

Acute Acute pain is short-term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Chronic pain lasts 6 months or longer; the pain persists after the predicted trajectory. Persistent pain is another term for chronic pain. Breakthrough pain starts again or escalates before the next scheduled analgesic dose.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?

Apply the oxygen source loosly if the SPO2 decreases during the procedure, use surgical asepsis to remove and clean the inner cannula, and clean the outer canula surfaces in a circular motion from the stoma site to outward.

Anatomical terms and landmarks to describe location of pain.

Ask clients to point to the location.

The nurse is completing an assessment of a nonverbal patient who had an appendectomy the previous day. The patient is restless, holding his hand over his abdomen, sweating, and his vital signs are: heart rate 100 bpm, respirations 20, blood pressure 135/90. Which of the following would be the most appropriate action by the nurse?

Ask the patient to nod "yes" or "no" and ask him or her if he or she is experiencing pain. Even though the patient is nonverbal, he or she may be able to answer yes/no questions by nodding his or her head. While these could be signs of other concerns, the nurse should always be concerned about pain in a postoperative patient. All of the noted vital signs are elevated and the patient's behaviors are common for person's experiencing moderate-to-intense levels of pain. It is important to teach the patient about the importance of walking after surgery to prevent postoperative complications. However, these behaviors and the elevated vital signs should raise the nurse's level of concern that the patient is experiencing pain or another postoperative issue. Healing music is a helpful nonpharmacologic pain treatment method. However, the patient is exhibiting behaviors consistent with moderate-to-intense pain and it is more appropriate for the nurse to provide pharmacologic methods to assist with decreasing pain.

A nurse caring for a client who is having difficulty breathing. The client is lying in the bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Assist the client into Fowlers position

A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics?

Balance

What is the source of deep somatic pain?

Bones and joints Deep somatic pain comes from the blood vessels, joints, tendons, muscles, and bones. Cutaneous pain is derived from skin surface and subcutaneous tissues. Visceral pain originates from the larger interior organs such as the pancreas. Visceral pain originates from the larger interior organs such as the intestine.

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effect should the nurse identify as an adverse effect of opioids?

Bradypnea, orthostatic hypotension, and nausea

A nurse is performing a respiratory assessment on a client. The nurse ausculates a wet, popping sound upon inspiration of the client's breathing. The nurse should idenitify this observation as which of the following findings?

Cackles

Idiopathic pain

Chronic pain without identifiable physical or psychological cause

Cutaneous skin stimulation

Cold for inflammation Heat to increase blood flow and to reduce stiffness

The nurse documents the following findings for the behavioral portion of the general survey assessment, "patient demonstrates flat affect, lack of eye contact, hair not brushed, and strong body odor". The nurse should be concerned that the patient is which of the following?

Depression

A nurse is preparing to perform a comprehensive phyiscal assessment on a client. Which of the following actions should the nurse plan to take first?

Develop a plan of care (assessment, analysis, planning, implementation, and evaluation

The nurse is completing a general survey for an older adult and notices the patient demonstrates a wider gait with short, uneven steps. Which of the following would be the most important action of the nurse?

Document this as normal findings.

Top of the foot pulse (between the tendons of the greater toe and those next to it?

Dorsalis Pedis

A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for the middle adulthood?

Erickson task for a middle adult as generatively vs. stagnation. Include showing concern for the next generation as an example for this age group.

Interpretations of findings for Respiratory Rate

Expected range 95% to 100% Acceptable range 91% to 100% Some illness 85% to 89% Under 90% can reflect hypoxia

stridor

Harsh or high-pitched respiratory sound, caused by an obstruction of the air passages

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommended?

Have and eye exam 1/3 years, have DXA scan for osteoporosis, obtain adequate protein and fruit, vegies, and whole grains, and screen for anxiety and depression

Which of the following has been found to influence pain sensitivity in women?

Hormonal changes Gender differences are influenced by societal expectation, hormones, and genetic makeup. Hormonal changes are found to have strong influences on pain sensitivity for women. Age has not been found to influence pain sensitivity in women. Parity has not been found to influence pain sensitivity in women. Weight has not been found to influence pain sensitivity in women.

Intensity, strength, and severity are "measures" of the pain: using a pain scale

How much pain do you have now? What is the worst/best the pain has been? Rate your pain on a scale of 0 to 10?

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

I should tell the nurse if the pain doesn't stop while I'm using this device

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include?

Insert the earpieces at a downward angle toward your nose

A nurse is performing a complete head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first?

Inspection< look at the client first

A nurse is performing a physical examination of th spine for an older adult client? What is common with aging?

Kyphosis, (hunchback)

Chronic pain

Lasts longer than 6 months. Can be categorized as cancer pain or non cancer pain.

A nurse is collecting history and physical examination date from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions?

Metabolism, causing weight gain. Decreases in bicarbonate and gastric mucus, risk of peptic ulcer. Lose nephron units which decline in glomerular filtration units.

Normal Heart Rate Infants and children

Newborn 100-180awake 80 to 160 sleep up to 220 1wk to 3mnths 100-220, 80-200 and up to 220 3mth to 2 yr 80-150, 70-120, up to 220 2 to 10yr 70-100, 60-90, and 195-215 10 to 20yr 55-90, 50-90, and 195-215

head circumference

Newborn-32-38 (about 2cm larger than the chest circumference)

A nurse is collecting date from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the clients pain?

Offer the client a pain scale to measure their pain

Reasons for low SPO2 reading

Old age or dark skin Hypothermia, poor peripheral flow, to much light, low hemoglobin, jaundice, movement, metal studs in nails, and nail polish

1st cranial nerve

Olfactory (smell)

What occurs during transduction (the first phase of nociceptive pain)?

Pain signals move from the site of origin to the spinal cord. Transduction is the first phase of nociceptive pain. During this phase, injured tissue releases chemicals that propagate the pain message; an action potential moves along an afferent fiber to the spinal cord. During transmission (the second phase), the pain impulse moves from the level of the spinal cord to the brain. The third phase is perception; the person has conscious awareness of a painful sensation. In phase four, modulation, the neurons from the brainstem release neurotransmitters that block the pain impulse.

The nurse is completing a general survey assessing the level of consciousness of a person. Which of the following findings are expected in this assessment?

Patient is alert and oriented to person, place, time, and situation

Which of the following is the most reliable indicator for chronic pain?

Patient self-report The most important and reliable indicator for chronic pain is the patient's self-report. Chronic pain is transmitted on a cellular level, and current technology such as MRI cannot reliably detect this process. Chronic pain is transmitted on a cellular level, and current technology such as tissue enzyme levels cannot reliably detect this process. Chronic pain is transmitted on a cellular level, and blood drug levels cannot reliably detect this process.

A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there had been any accompanying nausea and vomiting? Which if the following pain characteristics is the nurse attempting to determine?

Presence of associated manifestation. Such as nausea, vomiting, fatigue.

A nurse collecting data to evaluate a middle adults psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks?

Psychosocially health middle adults strive to well in their environment as part of achieving eriksons stage of generativity, vs. stagnation. Accept life opportunities for creativity and productivity. Work to contribute to future generations through community involvement and parenting.

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the clients abdomen should the nurse attempt to ausulate first?

RLQ, listen for active bowel sounds (5-30 sounds/min)

A nurse is palpating a tender area of a clients abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document?

Rebound tenderness

A nurse is assessing a client who has an acute respiratory infection, increasing the ridk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is devleoping hypoxia?

Restlessness, tachpnea, confusion, and hypertension

Which of the following assessments should be included as part of the body structure portion of the general survey?

Stature, nutrition, and symmetry

Indications of hypoxia (LATE)

Stupor, Cyanotic skin, mucous membranes, bradypnea, bradycardia, hypotension, cardiac dysthymia's

Indications of hypoxia (EARLY)

Tachypnea, tachycardia, restlessness, anxiety, confusion, pale skin, mucous membranes, elevated BO, use of accessory muscles, nasal flaring, adventitious lung sounds.

Which of the following would be most appropriate when weighing an infant?

The infant should be weighed undressed on a platform-type scale.

Heat loss

Through radiation, conduction, convection, & evaporation

An adult with a body mass index (BMI) less than 18.5 kg/m2 is considered which of the following?

Underweight A person with a body mass index (BMI) less than 18.5 kg/m2 is classified as underweight. Classification of obesity is a body mass index (BMI) of 30 to 39.9 kg/m2. Classification of normal weight is a body mass index (BMI) of 18.5 to 24.9 kg/m2. Classification of overweight is a body mass index (BMI) of 25 to 29.9 kg/m2.

Quality refers to how the pain feels:

What does the pain feel like? Give me more than two choices: "is the pain throbbing, burning, or stabbing?"

Aggravating/relieving factors

What makes the pain better? What makes the pain worse? Are you currently taking any prescriptions, herbals, or OTC medications?

Associated findings: fatigue, depression, nausea, anxiety.

What other symptoms do you have when you are feeling pain?

Timing (onset, duration, frequency)

When did it start? How long does it last? How often does it occur? Is it constant or intermittent?

Setting:how does the pain effect daily life or ADL of pain

Where are you when the symptoms occur? What are you doing when the symptoms occur? How does the pain affect your sleep? How does the pain affect your ability to work or interact with others?

Which of the following statements regarding cultural/racial differences in the treatment of pain is true?

White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms. Various studies describe how black and Hispanic patients are often prescribed less analgesic therapy than white patients, although most of these differences are small. No evidence supports anything else.

A. Nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?

Working on developing intimate relationships with others.

friction rub

a scratching or squeaking sound that is heard over the lung fields or the precordium, indicating inflammation of the pleura or pericardial lining (does not clear with coughing)

Pain signals are carried to the central nervous system by way of

afferent fibers. Nociceptors carry the pain signal to the central nervous system by two primary sensory (or afferent) fibers. Perception indicates the conscious awareness of a painful sensation. Modulation inhibits the pain message producing an analgesic effect. Referred pain is pain felt at a particular site that originates from another location.

Factors affecting BP

age, gender, race, diurnal rhythm, weight, exercise, emotions, stress

A nurse is presenting to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines?

apply suction while withdrawing the catheter, use a new catheter for each suctioning attempt, and apply suction for 10 to 15 seconds.

Data collection for the general survey begins

at the first encounter.

Endogenous obesity is

caused by excess adrenocorticotropin (ACTH) production by the pituitary gland.

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions?

check the position of the cannula frequently, report any nausea or dyspnea, post no smoking signs

Wheezes

continuous high-pitched whistling sounds produced during breathing, common in asthma. Low pitch wheezes are called rhonchi

Classification for weight in children

for infants use to the nearest 10 g toddlers the nearest 100 g upright scale for 2 to 3

Temp is controlled by what part of the brain?

hypothalamus

The thermostat balances heat production from

metabolism, exercise, food, digestion, external factors.

The general survey consists of four distinct areas. These areas include

physical appearance, body structure, mobility, and behavior.

Neuropathic pain implies an abnormal

processing of the pain message. Neuropathic pain results from abnormal processing of the pain message. Neuropathic pain does not adhere to the typical and predictable phases inherent in nociceptive pain.

PQRST

provocative/palliative, quality, region/radiation, severity, timing

Risk factors for hypertension

smoking, dyslipidemia, diabetes, age > 60, male, postmenopausal women, family hx

Physical appearance includes statements that compare appearance with

stated age. Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features. Behavior is compared with mood and affect. Mobility is compared with gait. Body structure is compared with nutrition.

Risks for heart disease and type 2 diabetes

when fat is carried around the waist not the hips, BMI between 25/35, and waist circumference in men greater than 40 and women greater than 35