Comfort and Rest- PrepU
A nurse is caring for a very shy 4-year-old girl. During the course of a well child assessment, the nurse must take the girl's blood pressure. Which approach is best?
"Help me take your doll's blood pressure"
A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?
"I only eat a low-fiber diet."
A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which action will she perform?
Create a calming environment with little stimuli.
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?
Push with contractions and rest between them.
Which nursing action reflects evaluation?
The nurse assesses the client's response to pain medication.
A client with appendicitis has had an appendectomy. After surgery, what type of pain does the nurse anticipate the client will have?
acute pain
A client is receiving morphine to relieve chest pain. The order is for 4 mg IV now. The pharmacy supplies morphine sulfate at 5 mg per mL. How many mL will the nurse give the client? Enter the correct number ONLY.
0.8
Acute pain can be distinguished from chronic pain by assessing which characteristic?
Acute pain is specific and localized.
The client who had spinal anesthesia complains of a headache. Which of the following is an inappropriate action by the nurse?
Administer morphine sulfate.
The nurse is working at a first aid station in an amusement park. A 45-year-old client arrives reporting severe dizziness after a ride on the roller coaster. The nurse understands that a common cause of this sensation is:
Benign paroxysmal positional vertigo
A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?
Have the client lie on the back and lift the leg, keeping it straight.
When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?
Quiet, alert state
A client with complex somatic symptom disorder is complaining of significant pain in the joints. When providing care to this client, which would be most important for the nurse to keep in mind?
The client's experience of pain is real.
When describing the role of a doula to a group of pregnant women, the nurse would include which information?
The doula primarily focuses on providing continuous labor support.
The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?
This may prolong labor and increase complications.
A nurse is reviewing the history and physical examination of a client diagnosed with secondary dysmenorrhea for possible associated causes. Which etiology would the nurse need to keep in mind as being the most common?
endometriosis
A client who has had a left total mastectomy is about to view her surgical site for the first time. Which of the following would be most appropriate for the nurse to say?
"Do you feel like you're ready to look at your incision now?"
A nurse on a postsurgical unit is providing care for a 76-year-old female client who is two days post-hemiarthroplasty (hip replacement) and who states that her pain has been out of control for the last several hours, though she is not exhibiting signs of pain. Which guideline should the nurse use for short-term and long-term treatment of the client's pain?
Knowing that the client's self-report of pain is the most reliable indicator of pain
A client has a history of dysmenorrhea. During monthly menses, the client experiences incapacitating cramping and passes large clots. The client's primary care physician initiates conservative treatment. What interventions would the physician to recommend?
NSAID's
A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?
Providing a back rub before bed
A client who has been diagnosed with acute symptomatic viral hepatitis is now in the icteric period. The nurse would expect the client to manifest:
severe pruritus and liver tenderness.
A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as
"Acute pain tends to increase during the day and is called a routine pain response"
A newborn who is suspected of having leukemia is being prepared for bone marrow aspiration. The newborn's mother asks whether any type of sedation or anesthesia will be used. What statement should the nurse make in response?
"Because this is a painful procedure, your child will receive conscious sedation to alleviate pain."
Which phrase can do much to instill hope in the dying client?
"Let me tell you about your illness."
A client is concerned about taking pain medication after surgery and asks, "Are there other things I can do to alleviate my pain?" Which is the best response by the nurse?
"Positioning and massage can also help to alleviate pain."
A client with vulvodynia tells the nurse, "This is not getting better. I just can't live like this." What is the best response by the nurse?
"What bothers you the most about your condition?"
A mother asks the nurse how to swaddle her newborn because she heard that it helps infants calm down. Which statement will the nurse include in the teaching?
"Wrapping the infant too tightly can impaired breathing."
How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?
Administering the analgesics every three hours
The nurse recognizes which statement is true of chronic pain?
It may cause depression in clients.
An instructor is developing for a class a teaching plan about agents used for intravenous (IV) anesthesia. Which of the following would the instructor include in this plan about these agents and this type of anesthesia? Select all that apply.
More pleasant onset of anesthesia Ease of administration Need for little equipment
Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?
Pain assessment may require multiple methods in order to ensure accurate pain data.
A 7-year-old girl is in the intensive care unit following a bicycle accident. Which would be most helpful in providing support to the girl's parents?
Providing honest answers in a reassuring manner
A client presents to the ED with acute abdominal pain, fever, nausea, and vomiting. During the client's examination, the lower left abdominal quadrant is palpated, causing the client to report pain in the RLQ. This positive sign is referred to as ________ and suggests the client may be experiencing ________.
Rovsing's sign; acute appendicitis
A client has constant pain and peripheral neuropathy following chemotherapy for cancer. The nurse assesses the following behavior as a common characteristic of a person with a chronic illness:
The client stops taking some medications due to side effects that are disturbing to the client.
A client has been referred for a colposcopy by the primary care provider. The client wants to know more about the examination. Which information regarding a colposcopy should the nurse give to the client?
The test is conducted because of abnormal results in a Papanicolau test.
A nurse who "unblocks" and "clears" congested areas of energy in a client's body to promote comfort is applying the phenomenon known as:
Therapeutic Touch (TT)
A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:
gently but firmly set limits on how much time the client spends in bed during the day.
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise.
A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?
Assess for medication prescription for breakthrough pain.
A young child is flying on a plane for the first time. As the plane begins its decent for landing, his ears begin to hurt. The flight attendant sees that he is in pain and tells him to swallow until the pain goes away. Which structure is the child using to equalize the pressure and relieve the pain?
Swallowing pulls air through the eustachian tubes, allowing the air pressure to equalize in the inner ear.
