Exam 5: DA & Book Questions

Which statement made by a patient who is currently asymptomatic with an HSV-2 infection indicates the need for more education about the disease? A. "It's okay to have intercourse with my partner as long as we use a barrier method of protection and I take my antiviral medications." B. "It's more likely that I could spread the HSV-2 infection if I have sexual relations when I have open ulcers and pain." C. "When I get pregnant, I will be certain to tell my gynecologist about my HSV-2 infection." D. "I understand that I could still transmit the virus if I don't have symptoms."

A. "It's okay to have intercourse with my partner as long as we use a barrier method of protection and I take my antiviral medications."

Ms. Ellicott states to you that she is interested in CAM. You explain to her that the goals of CAM are: (Select all that apply.) A. To improve quality of life B. To repair and restore qi, the Life Force C. To promote wellness D. To treat hypertension E. To eliminate stress

A. To improve quality of life C. To promote wellness E. To eliminate stress

The nurse is teaching a group of teenagers about measures to prevent skin cancer. Which statement made by a teen indicates the need for further teaching? "I should wear clothing to protect the skin." "I should use a sunscreen with a sun protection factor (SPF) of at least 15." "I should wear a hat with at least a 2- to 3-inch brim." "I should limit the time spent in the sun between 10 a.m. to 4 p.m."

"I should use a sunscreen with a sun protection factor (SPF) of at least 15." Rationale: should be at least 30 SPF

The nurse is teaching the student nurse about the care to be provided to a patient with pain. Which statement made by the student nurse indicates a need for further teaching? "I will provide pain medication on a regular schedule." "I will titrate the doses according to the patient's comfort." "I will provide analgesics in combination with other agents." "I will not limit the use of medications due to constipation and pruritus."

"I will provide pain medication on a regular schedule."

A registered nurse is teaching about Zero Balancing (ZB) therapy. Which statement indicates a need for further teaching? "It uses skilled touch to address the relationship between the energy and structures of the body." "It consists of low impact body movements and breathing techniques, which flow into each movement." "It increases the vitality and better postural alignment by addressing the deepest and most dense tissues of the body." "It focuses primarily on specific skeletal joints that conduct and balance forces of gravity, posture, and movement."

"It consists of low impact body movements and breathing techniques, which flow into each movement."

Which questions asked by a nurse are most likely to facilitate assessment of the onset of a patient's pain? Select all that apply. "Can you describe the severity of your pain?" "Can you tell me the exact location of your pain?" "Was your pain sudden, gradual, or ongoing?" "Can you describe your pain using descriptive words?" "Can you describe the activity you were doing when the pain started?"

"Was your pain sudden, gradual, or ongoing?" "Can you describe the activity you were doing when the pain started?"

The nurse receives hand-off report on a group of patients. Which patient is the highest risk for developing pressure injury? Select all that apply. A young adult who is a quadriplegic An older adult who is bedridden and diaphoretic A middle-aged adult with a body mass index (BMI) of 13.6 and incontinent of stool A middle-aged adult with a Braden scale score of 7 A middle-aged adult with controlled diabetes who is ambulating three times a day

A young adult who is a quadriplegic An older adult who is bedridden and diaphoretic A middle-aged adult with a body mass index (BMI) of 13.6 and incontinent of stool A middle-aged adult with a Braden scale score of 7

What should the nurse teach the patient to expect during and following cryosurgery for the removal of a basal cell carcinoma? A. "You may experience some discomfort during and immediately after the procedure. Local wound care may be required because of minor skin sloughing in the next few days." B. "You will not have any pain with this procedure and need to see your provider only if complications develop." C. "You may experience some discomfort during the procedure, but there is no follow-up care required." D. "You will receive a local anesthetic just prior to the procedure. In the next few days, you may experience burning and itching at the site."

A. "You may experience some discomfort during and immediately after the procedure. Local wound care may be required because of minor skin sloughing in the next few days."

This nurse is receiving hand-off report for these patients. Which patient is the highest risk for pressure injury? A 73 year old female; 182 lbs; stress incontinence B 92 female; HF; 3+ edema, ambulatory C 5 months; male;croup D 85 male; dementia & shingles; Wanders the halls

A 73 year old female; 182 lbs; stress incontinence

The nurse incorporates which content in the teaching plan for the patient receiving Coumadin? A. "It is important to take a stool softener to prevent constipation." B. "Over-the-counter NSAIDs may increase the anticoagulation effect of Coumadin." C. "This medication may cause drowsiness, so please do not take it before driving." D. "You will need to monitor your blood glucose levels while on this medication."

B. "Over-the-counter NSAIDs may increase the anticoagulation effect of Coumadin."

Which individual is at greatest risk for developing skin cancer? A. A fair-skinned, blue-eyed teenager who works outside in the summers, uses sunscreen with sun protection factor (SPF) of 50, and wears long-sleeved dark shirts B. A woman with a medium to dark complexion who applies sunscreen once in the midmorning and afternoon while she is playing tennis C. A 10-year-old child who plays outside in the early morning and late afternoons and uses SPF 30 D. A surfer who wears a wet suit with long sleeves and legs and applies sunscreen to his face periodically throughout the day

B. A woman with a medium to dark complexion who applies sunscreen once in the midmorning and afternoon while she is playing tennis

The classifications of CAM include which of the following? (Select all that apply.) A. Hypertension prevention B. Guided imagery C. Recreational therapy D. Massage therapy E. Dietary supplementation

B. Guided imagery D. Massage therapy E. Dietary supplementation

In completing a skin assessment, the nurse correlates erythema, redness, and warmth with which phase of wound healing? A. Hemostasis B. Inflammatory C. Proliferative D. Maturation

B. Inflammatory

What is the rationale for using ketorolac as the preferred NSAID to treat Mrs. Jessup? A. It is both high potency and has a long half-life for less breakthrough pain. B. It targets both prostaglandins and leukotrienes. C. It does not cause respiratory depression or constipation. D. It can be given every hour as needed to manage pain.

B. It targets both prostaglandins and leukotriene

A patient with a history of inflammatory bone disease has been prescribed a medication for painful dermatitis. After a course of corticosteroids, the patient tells the nurse, "I have noticed an elevation in my mood and appetite." Which mechanism of action is most related to the medication prescribed to the patient? Inhibiting the cyclooxygenase-2 isoenzyme Blocking synthesis of prostaglandins and leukotriene Activating the body's natural pain-inhibiting neurochemical systems Minimizing structural and functional reorganization of central pain processing synapses

Blocking synthesis of prostaglandins and leukotriene

The nurse is admitting a client with a stage III pressure injury. Which serum lab values would the nurse expect to be drawn on the client during the hospital stay? B-type natriuretic peptide and lactic acid Prothrombin time/international normalized ratio and partial thromboplastin time (PTT) C-reactive protein and erythrocyte sedimentation rate Hemoglobin and hematocrit

C-reactive protein and erythrocyte sedimentation rate

A mother brings in her 8-year-old child because of a new rash of annular patches, raised borders, and central clearing. What should be done first? A. Obtain a scraping of the rash for KOH microscopy. B. Explain to the mother that this is probably tinea corporis and an antifungal ointment will successfully treat it. C. Obtain a focused history to include medications, activities in which the patient partakes, and any history of skin disorders or fungal rashes. D. Explain to the mother that the rash will subside on its own

C. Obtain a focused history to include medications, activities in which the patient partakes, and any history of skin disorders or fungal rashes.

The nurse is caring for an older adult. Which considerations need to be made when creating the plan of care? In older adults, the number of dermal cells increases. The growth of subcutaneous tissue is rapid in older adults. The moisture retention in the skin of the older adults is increased. The skin of older adults is more susceptible to shear, trauma, friction, and moisture retention.

The skin of older adults is more susceptible to shear, trauma, friction, and moisture retention.

The nurse is teaching an older adult patient about skin care to prevent reoccurrence of a fungal skin infection under the breasts and in the groin. What should be included in the instructions? Select all that apply. Wear loose clothing that is breathable. Keep skin dry, using blotting cloths. Do not share contaminated personal items. Apply moisturizer to the rash. Allow areas to air dry at night.

Wear loose clothing that is breathable. Keep skin dry, using blotting cloths. Do not share contaminated personal items. Allow areas to air dry at night.

In which stage does a pressure injury show a partial loss in the thickness of the dermis? Stage I Stage II Stage III Stage IV

Stage II

The nurse is choosing to use the FACES pain scale to evaluate a patient in chronic pain. In which situation would it be most appropriate? With a young child With someone who is blind With someone who does not speak English With someone who is illiterate

With a young child

The nurse is assessing a pressure ulcer with full thickness tissue loss, visible subcutaneous fat with no bone, muscle, or tendons exposed. Slough is present, but does not obscure the depth of tissue loss. There is some undermining and tunneling. What stage is this pressure ulcer? Stage I Stage II Stage III Stage IV

Stage III

The nurse is reviewing the data of patients who are receiving complementary and alternative medicine. Which patient received the appropriate therapy based on the given data? Patient A: recurrent illness; mind body Patient B: cancer; manipulative & body-based therapy Patient C: musculoskeletal pain; mind-body therapy Patient D: recent spinal cord injury; manipulative & body-based therapy

Patient B: cancer; manipulative & body-based therapy

Which patient is most likely to have a nodule type of lesion, based on the assessment findings in the chart? Patient A: circumscribed, elevated, nonpalpable, <1 cm Patient B: circumscribed, flat, palpable, 1-2 cm Patient C: irregularly shaped, elevated, solid, pale red in color Patient D: flat, elevated, firm, rough to touch, >1 cm

Patient B: circumscribed, flat, palpable, 1-2 cm

The nurse is caring for a patient with each of these factors. Which ones have an influence on the pain experience? Select all that apply. Patient identifies with a culture that values stoicism. Patient moved to the United States as a young adult. Patient and family practice traditional holiday customs. Patient believes in being respectful to others. Patient lives in a community that does not use social media.

Patient identifies with a culture that values stoicism. Patient moved to the United States as a young adul

The nurse is caring for a bedbound patient with a pressure injury of the coccyx and a Braden score of 9. Which nursing action is the priority? Maintain a prone position. Provide bedding with additional cushioning. Position the head of the bed less than 30°. Position the wound such that it lies toward the bed.

Position the head of the bed less than 30°.

The nurse is caring for a patient who has experienced a motor vehicle accident and is experiencing back and spinal pain and stiffness. Which complementary and alternative medicine (CAM) therapy is most beneficial for this patient? Osteopathic medicine Chiropractic medicine Native American medicine Traditional Chinese medicine

Chiropractic medicine

An 18-year-old with psoriatic plaques on the elbows, knees, and legs has been successfully treated with a combination of therapies including phototherapy. Because the patient is an avid soccer player and expects to receive a college scholarship next year, which information is the most important aspect to teach at this time? A. The importance of knowing the clinical manifestations of PsA (soft tissue swelling, limitations of movement) because as many as 30% of those who have psoriasis develop PsA B. The importance of adhering to the medication regimen C. The importance of finding a support group to help cope with stress and anxiety that can develop as a response to treatment and can exacerbate the disease D. The importance of using sunscreen while outside

D. The importance of using sunscreen while outside

Ms. Ellicott has decided that she would like to learn more about massage therapy, acupuncture, and guided imagery. She states, however, that she has concerns about the safety and efficacy of the treatments. Which of the following resources should you refer her to so that she can learn more about CAM? A. National Center for Complementary and Integrative Health (NCCIH) B. White House Commission on Complementary and Alternative Medicine C. Center for Integrated Medicine D. American Association of Acupuncture and Oriental Medicine E. All of the above

E. All of the above

The nurse has spent the day walking in new shoes and developed a friction blister. Which type of wound dressing is best to insulate the blister from breaking? Foams Alginates Collagens Hydrocolloids

Foams

During assessment, the nurse observes an inflamed nodule overlying with a pustule along a hair follicle. The primary health-care provider prescribes intranasal mupirocin ointment. Which condition is observed in the patient? Impetigo Furuncle Carbuncle Folliculitis

Furuncle Rationale: Furuncle is infection of hair follicle. Forms small abscess by extending thru dermis into SubQ. Mupirocin ointment used in tx.

Which is true regarding alternative medicine? Select all that apply. It can be used to help manage stress and anxiety/depression. It can be used to help manage substance abuse. It can be used to help manage Alzheimer's disease. It can be used to help manage pain caused by osteoarthritis (OA). It can be used to help manage pain from urinary problems.

It can be used to help manage stress and anxiety/depression. It can be used to help manage pain caused by osteoarthritis (OA). It can be used to help manage pain from urinary problems.

Which topical antifungal medication can be used to treat tinea capitis? Butenafine Miconazole Terbinafine Itraconazole

Itraconazole

A patient tells the nurse, "This pain is much worse than when I broke my arm." Which characteristic of pain is the patient describing? Onset of pain Quality of pain Severity of pain Radiation of pain

Severity of pain

A nurse is teaching about complementary/alternative medicine (CAM) therapies that can be used to reduce heart rate and blood pressure. Which therapy indicates a need for further teaching? Shamanism Chiropractic therapy Tai Chi Osteopathic medicine

Shamanism

The nurse is caring for a patient with pain. Which functions are impacted by chronic or acute pain? Select all that apply. Sleep Activity Anxiety Depression Nutrition pattern

Sleep Activity Nutrition pattern

The nurse should anticipate that cold therapy is most effective for which client ailments? Select all that apply. Spastic lower back pain Dull, throbbing headache Muscle pain after ambulation Post-gynecologic procedures Pleuritic chest pain

Spastic lower back pain Muscle pain after ambulation Post-gynecologic procedures

Upon admission, the nurse knows that all patients must be assessed using the Braden Scale to evaluate the patient's risk for skin breakdown. Which of the following areas are included when assessing the patient using the Braden Scale? Select all that apply. Activity Nutrition Mobility Body mass index Gender

Activity Nutrition Mobility

The nurse is caring for an older adult patient with severe orofacial pain. Which complementary treatment regimen is most useful in addition to the prescribed analgesics? Acupressure and music therapy Relaxation training with deep massage Exercise regimen with focused stretching Deep tissue massage and heat application

Acupressure and music therapy

The nurse is caring for a client with a pressure injury. Which comorbidities could the nurse expect to treat? Select all that apply. Anemia Varicose veins Peripheral vascular disease Diabetes Plantar fasciitis

Anemia Peripheral vascular disease Diabetes

Arrange the steps in the order that they are to be followed when guiding a patient through complementary and alternative medicine (CAM) therapy. Ask about the patient's condition and family status. Explain the effect of life forces and vital forces. Explain health promotion and treatment of disease through broad concepts. Encourage the patient to know how lifestyle choices are related to changes in the patient.

Ask about the patient's condition and family status. Encourage the patient to know how lifestyle choices are related to changes in the patient. Explain health promotion and treatment of disease through broad concepts. Explain the effect of life forces and vital forces.

Which skin layers have been affected by Ms. Bloom's allergic contact dermatitis? A. Dermis only B. Epidermis only C. Both epidermis and dermis D. Subcutaneous tissue

B. Epidermis only

Which clinical finding requires additional investigation by the nurse? A. CRT less than 2 seconds B. New-onset petechial rash C. A macule with symmetrical shape, regular border, and uniform color D. Pale or cyanotic nail bed after exposure to cold temperatures

B. New-onset petechial rash D. Pale or cyanotic nail bed after exposure to cold temperatures

The nurse is admitting a patient to the unit who is a paraplegic and has a history of healed sacral pressure injuries, verified by the large scars on the sacrum. What action should the nurse take first? A. Apply a moisturizing lotion to the sacrum. B. Place a dressing such as a silicone foam dressing over the scars. C. Place the patient in a sitting position to keep pressure off the sacrum. D. Help the patient choose the most nutritious foods on the menu.

B. Place a dressing such as a silicone foam dressing over the scars.

The nurse correlates which findings to the pathophysiology of chronic malignant pain? A. Recent trauma B. Rapidly dividing cells C. Direct damage to nerve fibers D. Persistent pain with no known etiology

B. Rapidly dividing cells

The nurse correlates respiratory depression and decreased gastrointestinal motility with the actions of which opioid receptor? A. Delta B. Kappa C. Mu D. Beta

C. Mu

The nurse in the emergency department is triaging patients. Which patient requires immediate attention? A. A 16-year-old with a laceration that was sutured closed 3 days ago and now has erythema extending 2 cm beyond the suture line B. A 30-year-old patient with an open sacral pressure injury with exposed bone with purulent exudate C. A 48-year-old patient with an indurated, erythematous area on his thigh who is complaining of 10/10 pain and has had a fever for 24 hours D. A 60-year-old patient with diabetes mellitus who has a nail embedded in his foot because he could not feel it in his shoe

C. A 48-year-old patient with an indurated, erythematous area on his thigh who is complaining of 10/10 pain and has had a fever for 24 hours

A 78-year-old patient fractured a hip 1 week ago and is now being admitted to a rehabilitation facility for physical therapy because of difficulty ambulating. During the admission skin assessment, the nurse notes an area of nonblanchable erythema on the sacrum. What is the nursing priority at this time? A. Order a redistributing mattress for the patient's bed. B. Consult the nutritionist for a complete nutritional assessment. C. Perform and document the admission skin and risk assessments. D. Apply a hydrocolloid dressing over the area to protect it from further trauma.

C. Perform and document the admission skin and risk assessments.

A nurse is discharging a patient after a surgery who continues to have pain. The patient tells the nurse that he plans to seek complementary/alternative medicine. What additional instructions should the nurse provide? "Be sure that whoever you see is properly trained and educated with a college degree." "Be prepared, you may need to buy special equipment or supplies." "Be sure to explore the risks with your surgeon before you begin." "You'll want to see if they are covered by your insurance before you schedule an appointment."

"Be sure to explore the risks with your surgeon before you begin.

The nurse is assessing a patient with chest pain. Which statement made by the patient indicates the severity of the pain? Select all that apply. "I am not able to sleep." "I cannot sit for long periods of time." "I can feel the pain as though somebody is stabbing me." "The pain moves near my abdomen sometimes." "I can feel the pain for 10-15 seconds three or four times a day."

"I am not able to sleep." "I cannot sit for long periods of time."

The nurse is observing a nursing student provide biopsy site care. Which statement made by the nursing student indicates the need for further teaching? Select all that apply. "I should change the dressing every other day." "I should leave the initial dressing in place for 4 days." "I should wash and dry my hands while performing site care." "I should instruct the patient to avoid the immersion of the wound in water." "I should clean the area with hydrogen peroxide when drainage develops from the wound."

"I should change the dressing every other day." "I should leave the initial dressing in place for 4 days."

The nurse is teaching a group of students about physical assessment of the integumentary system. Which statement made by the nursing student indicates the need for further teaching? Select all that apply. "I should document all the assessment findings." "I should use all the findings to determine the plan of care." "I should perform an assessment of the client from head to toe." "I should perform a visual inspection to identify the abnormalities." "I should perform the assessment in a well-lit area when the client is fully clothed."

"I should perform a visual inspection to identify the abnormalities." "I should perform the assessment in a well-lit area when the client is fully clothed."

The nurse is explaining to the student nurse the difference between undermining and tunneling. How should the nurse explain the two terms? "Undermining is measuring a passageway under the skin surface and tunneling is the destruction of tissue extending under the wound edges." "Undermining is the measurement of the wound's length from head to toe and tunneling is the measurement of the wound's widest point perpendicular to the length." "Undermining is the destruction of tissue under the wound edges and tunneling is the development of a passageway under the skin's surface." "Undermining is the development of infection in the wound bed of the wound and tunneling is the development of necrotic tissue over the wound."

"Undermining is the destruction of tissue under the wound edges and tunneling is the development of a passageway under the skin's surface."

The nurse recognizes that pressure injury is most probable in which areas in the patient positioned in a supine position? (Select all that apply.) A. Occiput B. Nares C. Behind the knees D. Sacrum E. Heels

. Occiput D. Sacrum E. Heels

The nurse is reviewing the data of patients. Which patient requires the provider's approval before receiving qi gong therapy? Select all that apply. A patient with muscle spasms A patient in the 24th week of pregnancy A patient with recent history of shoulder surgery A patient with chronic fatigue and low energy levels A patient with uncontrolled hypertension

A patient in the 24th week of pregnancy A patient with recent history of shoulder surgery A patient with uncontrolled hypertension

A patient with fibromyalgia verbalizes pain and stiffness in the muscle and joints. On assessment, the nurse notes that the patient also has disturbed sleep, depression, and anxiety. What is most likely responsible for these symptoms? Select all that apply. Abnormalities in the brain Altered neuroendocrine function Stimulation of peripheral nerve fibers Invasion of rapidly dividing cells distorting bone and other tissues Prolonged stress or emotional trauma

Abnormalities in the brain Altered neuroendocrine function Prolonged stress or emotional trauma

A client has undergone knee replacement surgery. The nurse should perform which priority assessment after the client has received a dose of celecoxib for pain? Assess respiratory rate Auscultate lung sounds Re-assess pain Check surgical wound for bleeding

Assess respiratory rate

The complementary/alternative (CAM) in this picture includes a combination of herbs, yoga, massage, and diet to restore balance. Which CAM is this? Ayurvedic medicine Native American medicine Tai Chi Qi Gong

Ayurvedic medicin

The defining characteristics of CAM include which of the following? (Select all that apply.) A. Rooted in scientifically proven theories B. Rooted in ancient wisdom traditions C. A collection of old-world traditions D. A collection of old-world healthcare practices E. Works in isolation from conventional medicine

B. Rooted in ancient wisdom traditions C. A collection of old-world traditions D. A collection of old-world healthcare practices

The nurse correlates the use of KOH testing with the definitive diagnosis of which skin disorder? A. Bacterial infections B. Herpes simplex C. Fungal infections D. Psoriasis

C. Fungal infections

The nurse chooses which pain scale to most effectively assess pain in an older patient with limited vision? A. FACES scale B. Numeric scale C. Verbal scale D. Visual scale

C. Verbal scale

A patient reports abdominal pain to the nurse. What are the steps, in order, that the nurse takes to arrive at the appropriate action? Prioritize the pain treatment options available. Perform a physical abdominal assessment. Sort data into significant clusters or diagnostic clues. Decide and perform the priority action. Complete a pain assessment score rating with pain description.

Complete a pain assessment score rating with pain description. Perform a physical abdominal assessment. Sort data into significant clusters or diagnostic clues. Prioritize the pain treatment options available. Decide and perform the priority action.

A patient verbalizes tender, sharp, and itchy pain in the neck region from a sunburn. Which type of pain is the patient most likely suffering from? Somatic pain Visceral pain Cutaneous pain Neuropathic pain

Cutaneous pain

Which position is best to reduce the risk of skin tears in an immobile, older adult patient? A. In a side-lying position B. Foot of the bed elevated to no greater than 15 degrees C. In a chair with feet on the floor D. Head of the bed elevated no greater than 30 degrees

D. Head of the bed elevated no greater than 30 degrees

The nurse is planning to obtain a swab culture of a deep wound. Arrange the steps of obtaining a culture chronologically. Moisten the swab with normal saline. Evaluate the wound bed to locate the area. Send the specimen to the laboratory without delay. Place the swab into a sterile container and label it. Prepare to use sterile technique to obtain specimen. Rotate the swab with gentle pressure on the wound tissue. Clean the entire wound bed using a non-antiseptic solution.

Evaluate the wound bed to locate the area. Clean the entire wound bed using a non-antiseptic solution. .Prepare to use sterile technique to obtain specimen. Moisten the swab with normal saline. Rotate the swab with gentle pressure on the wound tissue. Place the swab into a sterile container and label it. Send the specimen to the laboratory without delay

The nurse is planning to obtain a swab culture of a deep wound. Arrange the steps of obtaining a culture chronologically. Prepare to use sterile technique to obtain specimen. Place the swab into a sterile container and label it. Moisten the swab with normal saline. Evaluate the wound bed to locate the area. Rotate the swab with gentle pressure on the wound tissue. Send the specimen to the laboratory without delay. Clean the entire wound bed using a non-antiseptic solution.

Evaluate the wound bed to locate the area. Prepare to use sterile technique to obtain specimen. Clean the entire wound bed using a non-antiseptic solution. Moisten the swab with normal saline. Rotate the swab with gentle pressure on the wound tissue. Place the swab into a sterile container and label it. Send the specimen to the laboratory without delay.

The nurse is caring for a patient with uremia and continually scratching at the arms and legs. Which type of secondary skin lesion is formed due to abrasions from scratching? Scale Erosion Excoriation Lichenification

Excoriation

When a client is suffering from acute pain, the nurse should anticipate which characteristics? Select all that apply. Insidious onset of pain in the lumbar region Phantom limb pain following amputation Pain present for several months' duration Guarding of a midline abdominal incision Sharp, stabbing pain in a specific area

Guarding of a midline abdominal incision Sharp, stabbing pain in a specific area

Which is true regarding the energy paradigm associated with complementary/alternative medicine (CAM)? Select all that apply. Health is defined in the context of the patient's body. Health is considered to be harmonious and balanced. Life Force permeates and bonds all living things. All living things have a universal spirit and wholeness. Broad concepts are used for the promotion of health and wellness.

Health is defined in the context of the patient's body. Health is considered to be harmonious and balanced. Life Force permeates and bonds all living things. All living things have a universal spirit and wholeness.

The nurse should include which questions when assessing a client's pain following a fractured ankle injury? Select all that apply. Intensity Onset How much weight he is able to bear Location What makes it better or worse

Intensity Onset Location What makes it better or worse

After assessing a patient's condition, the nurse concludes that the patient has visceral pain. Which observations in the patient helped the nurse reach this conclusion? Select all that apply. Low heart rate Excessive sweating Numbness around pain region Worsening of pain during night Reflex muscle contractions and muscle tenderness

Low heart rate Excessive sweating

The nurse is performing preoperative teaching for a patient experiencing a lot of pain and stress. Which alternate therapy should be implemented to alleviate the discomfort? Manipulative and body-based therapy Mind/body therapy Energy healing therapy Herbal medication therapy

Manipulative and body-based therapy

The nurse is caring for a client with a stage IV pressure injury on the coccyx. The nurse advises the client to increase which types of foods in the diet to assist in the healing process? Bread and starches (carbohydrates) Meat and dairy (protein) Fats Fruits and vegetables

Meat and dairy (protein)

A postoperative patient reports nausea and suggests an alternative therapy for relief. Which alternate therapies are ideal? Select all that apply. Mind/body therapy Acupuncture therapy Manipulative and body-based therapy Energy healing therapy Dietary supplements

Mind/body therapy Manipulative and body-based therapy Dietary supplements

The nurse is caring for a patient with severe pain. An opioid is delivered. What assessment should the nurse make after the administration? Monitor weight. Monitor platelet levels. Monitor glucose levels. Monitor respiratory rate.

Monitor respiratory rate.

The nurse recognizes that which pharmacologic agents may be prescribed for a client suffering from chronic pain? Select all that apply. Narcotic analgesics Nonsteroidal anti-inflammatory drugs Antidepressants Loop diuretics Corticosteroids

Narcotic analgesics Nonsteroidal anti-inflammatory drugs Antidepressants Corticosteroids

A patient with diabetes is suspected of having carpal tunnel syndrome. Which complementary and alternative medicine (CAM) therapy is most appropriate in this patient? Qi gong Imagery Reflexology Naturopathy

Naturopathy

Louanne struggles to maintain a nutritious diet. What should the nurse encourage during the hospital stay for better wound healing? Carbohydrates Protein Fats Fruits Vegetables

Protein Rationale: The client should increase protein intake to assist in wound healing. The nurse should include this information in client education, along with examples of nutritious, protein-rich foods. Baseline lab work would be ordered during hospitalization to assess the client's protein status. A dietitian could be consulted per facility policy.

A registered nurse is explaining mind/body therapies to a patient. Which therapy explained by the nurse is a martial art? Guided imagery Tai Chi Zero Balancing Yoga

Tai Chi

During assessment, the nurse observes that the patient has yellow, brittle, thick nails. The primary health-care provider identifies this as onychomycosis and suggests a topical treatment. Which medication will most likely be prescribed? Nystatin Tavaborole Itraconazole Ketoconazole

Tavaborole

The nurse discusses a patient's cultural preferences upon admission. Which is true regarding traditional Native American medicine practices? The focus of care is to support health, instead of curing illness. The goal of treatment is to sustain the balance or flow of qi. Therapies include acupuncture, hydrotherapy, manipulative therapy, homeopathy, and botanicals. The healing traditions include ceremonial practices such as chanting, dancing, and singing.

The healing traditions include ceremonial practices such as chanting, dancing, and singing.

The nurse is caring for a patient with this pain management device. Which statement about it is correct? It delivers continuous, low-dose pain medication. The mechanism of action is not clearly understood. The patient with acute, short-term pain benefits most. The electrodes are applied to the scalp.

The mechanism of action is not clearly understood.

The nurse is caring for a postsurgical patient requesting nonpharmaceutical, alternative therapy for pain management? What should be the nurse's next action? The nurse should provide a body massage therapy. The nurse should perform an assessment. The nurse should notify the acupuncturist. The nurse should suggest a mind/body therapy.

The nurse should perform an assessment

A 68-year-old female patient has a history of chronic renal insufficiency. The patient undergoes coronary bypass surgery and is on pain medications. Which factor has the biggest impact on the patient's response to pain medication? The patient's age The patient's gender The patient's previous pain experience The patient's history of renal insufficiency

The patient's history of renal insufficiency

A nurse performing preoperative assessments notes that the patient is dependent on herbal remedies for managing pain. What is true regarding the herbal remedies' impact during surgery? They will decrease nausea. They carry no potential risks. They can decrease the effectiveness of anesthesia. They will support the patient's heart health.

They can decrease the effectiveness of anesthesia.

Which is true regarding autolytic wound debridement on a wound? Select all that apply. This method can be used for larger debridement. This method can increase the risk of maceration to the adjacent skin. This method can be performed in any type of setting. This method can be performed on patients who require fast debridement. This method does not cause pain if the dressing is in place.

This method can increase the risk of maceration to the adjacent skin. This method can be performed in any type of setting. This method does not cause pain if the dressing is in place.

Arrange the steps to be followed by a nurse when cleaning and preparing a wound. Assess and measure the wound. Wash hands and apply clean gloves. Remove the gloves and wash hands. Remove the soiled wound dressing and discard. Wipe the surface of the wound with a sterile gauze. Remove the excess saline from the wound with dry sterile gauze. Apply clean gloves and irrigate the wound thoroughly with sterile normal saline.

Wash hands and apply clean gloves. Remove the soiled wound dressing and discard. Remove the gloves and wash hands. Apply clean gloves and irrigate the wound thoroughly with sterile normal saline. Wipe the surface of the wound with a sterile gauze. Remove the excess saline from the wound with dry sterile gauze. Assess and measure the wound.

The nurse recognizes that the incidence of pain is greatest in which patient population? A. Active teenagers B. Unemployed adults regardless of age C. Employed middle-aged and older adults D. Older patients who are institutionalized

D. Older adults who are institutionalized

A patient expresses pain in the abdominal area. Which question should the nurse ask the patient to determine the severity of pain? "Can you sit for long periods?" "Can you describe your pain to me?" "Does walking make the pain worse?" "What do you believe is causing this pain?"

"Can you sit for long periods?"

A nurse is educating a patient about self-management of acute and chronic pain. Which statement indicates a need for further teaching? "I should have multiple pain relief options." "I should consider a single-dimension pain scale to measure pain intensity." "I should learn about nonpharmacological treatment options." "I should receive written instructions regarding primary and adjuvant medications."

"I should consider a single-dimension pain scale to measure pain intensity."

A nurse is teaching a group about meditation for stress relief in patients who are hospitalized. Which statement indicates a need for further teaching? "Breath meditation involves the process of inhaling and exhaling." "Mindfulness meditation focuses on the present moment." "Meditation consists of low impact body movements and breathing techniques that flow into each movement." "Meditation is a self-directed technique that is used to quiet the mind and relax the body."

"Meditation consists of low impact body movements and breathing techniques that flow into each movement."

A nurse is teaching about chronic pain. Which statements indicate effective teaching? Select all that apply. "Chronic pain can be easily localized." "Arthritis pain is an example of chronic pain." "Phantom limb pain is an example of chronic pain." "Chronic pain is pain that is present for more than 3 to 6 months." "Chronic pain is responsive to common pain management treatment."

"Phantom limb pain is an example of chronic pain." "Chronic pain is pain that is present for more than 3 to 6 months."

Which questions should you ask Mr. Jones in order to conduct a focused pain assessment? Select all that apply. "When did your pain begin?" "Can you describe your pain for me?" "Are there any activities that make your pain worse?" "When was the last time you received pain medication?" "Can you trace your pain for me?"

"When did your pain begin?" "Can you describe your pain for me?" "Are there any activities that make your pain worse?" "Can you trace your pain for me?" Rationale: OPQRST-AAA is a useful mnemonic the nurse can use to evaluate pain symptoms, with each letter representing an important line of questioning:• O - Onset of pain• P - Provocation• Q - Quality of pain• R - Region or radiation• S - Severity• T - Time and duration• AAA - Aggravating/alleviating factors and associated symptoms.

Despite the nurse's attempts to keep Louanne's heels away from the pressure of the mattress, she continues to kick the pillow out from under her legs. She tells the nurse "It doesn't hurt me, I don't see what the big deal is." How should the nurse respond? "It's your decision since they're your feet." "When your heels rest on the mattress, the continued pressure to the site creates injury." "I'm glad it doesn't hurt, it looks like it would." "We'll have to ask your provider if we can get rid of the pillow, since she ordered it to be there." "Did you know you could end up with an amputation?"

"When your heels rest on the mattress, the continued pressure to the site creates injury." Rationale: The response by the nurse should provide education as to why the pillow is necessary, since Louanne may not understand. B is the most direct response to the issue of concern.

What clinical manifestations can the nurse use to indicate the level of Mrs. Jessup's pain on a.m. assessment? (Select all that apply.) A. A subjective report of 6/10 pain level; shallow, guarded breathing; short, terse responses to questions B. Mrs. Jessup's report of poor overnight sleep and decreased supported ambulation C. Facial grimacing and observed rubbing of lower back and legs by patient D. Decrease in blood pressure

A. A subjective report of 6/10 pain level; shallow, guarded breathing; short, terse responses to questions B. Mrs. Jessup's report of poor overnight sleep and decreased supported ambulation C. Facial grimacing and observed rubbing of lower back and legs by patient

The nurse is teaching skin care guidelines to the caretaker of a 79-year-old incontinent female who has a total Braden score of 14 with a score of 2 in the mobility category. What are appropriate educational priorities? (Select all that apply.) A. Gently cleanse and dry the skin immediately after an incontinence episode B. Use a toileting schedule to minimize episodes of incontinence C. Aggressively clean the patient's skin after an incontinence episode D. Assist the patient with repositioning at least every 2 hours E. Use diapers for stool and urine containment

A. Gently cleanse and dry the skin immediately after an incontinence episode B. Use a toileting schedule to minimize episodes of incontinence D. Assist the patient with repositioning at least every 2 hours

Which of the following symptoms of Ms. Ellicott are listed among the NCCIH's top 10 reasons that adults seek CAM therapies? (Select all that apply.) A. Migraine headaches B. Depression C. Hypertension D. Anxiety E. Stress

A. Migraine headaches B. Depression D. Anxiety

Which properties of the epidermal and dermal layers contribute to wound healing? (Select all that apply.) A. The 30-day maturation time of epidermal keratinocytes B. Eccrine gland sweat production C. Melanocytes in a 1:36 ratio with keratinocytes D. Presence of Langerhans cells, macrophages, and mast cells E. Blood vessels in the dermis and subcutaneous tissue

A. The 30-day maturation time of epidermal keratinocytes C. Melanocytes in a 1:36 ratio with keratinocytes D. Presence of Langerhans cells, macrophages, and mast cells E. Blood vessels in the dermis and subcutaneous tissue

Mr. Jones is now 3 days postoperative. His pain is being managed with scheduled doses of ibuprofen (800 mg every 8 hours by mouth) and prn doses of acetaminophen with hydrocodone. Mr. Jones has not had a bowel movement since surgery. Which nursing action is appropriate based on the current data? Notify the healthcare provider immediately. Administer the prn dose of docusate sodium. Assist the client in a guided imagery exercise. Place the client on a bedpan and provide privacy. Check Answer

Administer the prn dose of docusate sodium. Rationale: Constipation is a known side effect for clients who are receiving opioid analgesics in the treatment of acute pain. The most appropriate nursing action based on the current data is to administer the prn dose of docusate sodium, a stool softener. There is no reason to notify the healthcare provider immediately regarding the client's constipation. Guided imagery is a nonpharmacological intervention to treat pain and is not effective in treating constipation. Placing the client on a bedpan and providing privacy is not indicated at this time.

The nurse is caring for an older adult who is malnourished. The patient is confused and has bilateral leg contractures. The patient is incontinent of urine and on aspiration precautions. What should be included in the plan of care? Select all that apply. Elevate the head of the bed to 45 degrees and lower the foot of the bed when feeding the client. Apply barrier cream to the skin as needed. Turn the patient every 4 hours. Keep linens and gowns dry and wrinkle free. Use a wedge pillow to keep the legs apart.

Apply barrier cream to the skin as needed. Keep linens and gowns dry and wrinkle free. Use a wedge pillow to keep the legs apart.

The hydromorphone administered at the beginning of the shift worked well to address Mr. Jones' pain. Thirty minutes' post administration, he rated his current level of pain at a 3 on a 1 to 10 scale. It is now early afternoon and Mr. Jones is preparing for physical therapy. Which nursing action is most appropriate at this time? Assessing the client's current level of pain Monitoring the client for respiratory depression Asking the therapist to initiate therapy on the next shift Administering a prn dose of prescribed oral pain medication Check Answer

Assessing the client's current level of pain Rationale: Physical therapy often causes an exacerbation in the level of pain experienced by the client. It is important for you to assess Mr. Jones' current level of pain and implement an intervention to manage his pain in preparation for physical therapy. There is no indication that you have administered an opioid pain medication necessitating an assessment for respiratory depression. Although administering a pain medication prior to physical therapy may be appropriate, you cannot make this determination prior to conducting a pain assessment.

You are responsible for providing care to Mr. Jones, a 58-year-old salesman who was admitted to the surgical unit for a left total knee replacement surgery. Mr. Jones is 12 hours post-op. During shift report, the assigned nurse shares the following information with you:• Pain rating of an 8 of 10 during initial assessment• Prescribed pain medication (morphine) administered per order• Post-medication administration assessment revealed pain rated at 5 of 10.Client was restless most of the overnight. You enter Mr. Jones' room to complete a shift assessment. Which is your priority action? A) Palpating a radial pulse B) Monitoring blood pressure C) Conducting a pain assessment D) Inspecting the surgical incision

C) Conducting a pain assessment Rationale: Pain assessment and management is your priority based on the information shared during the shift assessment, which portrays the concern that the client's pain has not been controlled with morphine alone. The American Pain Society champions this relatively straightforward way to improve pain management, since inclusion of a pain assessment when assessing vital signs (blood pressure, pulse, and respirations) gives the pain assessment clinical priority.

The nurse is reviewing the admission laboratory results for Louanne. Which of these laboratory findings are indicative of inflammation or infection? C-reactive protein (CRP) elevation Erythrocyte sedimentation rate (ESR) elevation White blood cell (WBC) elevation Red blood cell (RBC) elevation Platelet elevation

C-reactive protein (CRP) elevation Erythrocyte sedimentation rate (ESR) elevation White blood cell (WBC) elevation Rationale: CRP, ESR, and WBC elevation are all signs that may indicate inflammation or infection, but RBC and platelet elevation does not.

As a nurse who understands the guiding principles of CAM, your first step in guiding the patient is: A. Referring the patient to a massage therapist to help manage stress B. Explaining that the patient's qi is out of balance C. Asking questions related to the presenting symptoms, work, and family to start building trust and rapport with the patient D. Giving information related to a specific symptom the patient has reported to build a partnership with him or her

C. Asking questions related to the presenting symptoms, work, and family to start building trust and rapport with the patient

What is the best physiological explanation of why Mrs. Jessup may be experiencing chronic back pain? A. The injury she has in her back has just never healed. B. Non-nociceptive pain messaging has overtaken nociceptive pain messaging. C. Hyperexcited neurons at the time of injury created new pathological synaptic connections that persist. D. Chronic inflammation has reduced the effectiveness of descending inhibitory pathways.

C. Hyperexcited neurons at the time of injury created new pathological synaptic connections that persist.

Which statement accurately describes the skin's protective capabilities? A. The epidermis can resist damage when exposed to continuous moisture. B. Melanocytes always provide adequate protection to underlying structures from UV exposure. C. Langerhans cells, located in the epidermis, often provide the initial signal to the immune system that pathogen invasion has occurred. D. Temperature is regulated by blood vessels and sweat glands.

C. Langerhans cells, located in the epidermis, often provide the initial signal to the immune system that pathogen invasion has occurred.

A patient presents with a new-onset, erythematous rash that contains intact pustules. Subjective symptoms include itching and burning. Which diagnostic evaluation is most helpful in determining the underlying etiology? A. Excisional biopsy B. Skin scraping C. Sterile collection of pustule roof D. Cryosurgery

C. Sterile collection of pustule roof

Ms. Ellicott is expressing concerns about being touched. You explain to her that there are CAM therapies that have a meditative and restful quality and do not involve touch. As the nurse, which of the following therapies do you suggest? A. Homeopathy B. Reflexology C. Yoga or prayer D. Massage therapy

C. Yoga or prayer

A client with a respiratory rate of 26 breaths/minute and an oxygen saturation of 92% on room air complains of pain as a 10/10 following a motor vehicle crash. What is the nurse's priority of care for this client? Client verbalizes a tolerable level of pain. Client remains free from further injury. Client demonstrates improved respiratory status. Client uses incentive spirometer hourly as instructed.

Client demonstrates improved respiratory status.

Which of these assessments is the priority during a focused pain assessment? Select all that apply. Client reports pain level of 2/10 on 0-10 scale. Client reports the pain is sharp, with movement. Client's monitor displays sinus tachycardia. Client reports pain is "worse than yesterday." Client says, "I think I twisted my ankle."

Client reports the pain is sharp, with movement. Client reports pain is "worse than yesterday." Client says, "I think I twisted my ankle." ???

What clients are at risk for pressure injury? Select all that apply. Clients with advanced age Clients with malnutrition Clients with insomnia Clients with urinary or fecal incontinence Clients with dehydration

Clients with advanced age Clients with malnutrition Clients with urinary or fecal incontinence Clients with dehydration

A patient reports abdominal pain to the nurse. What are the steps, in order, that the nurse takes to arrive at the appropriate action? Prioritize the pain treatment options available. Complete a pain assessment score rating with pain description. Sort data into significant clusters or diagnostic clues. Decide and perform the priority action. Perform a physical abdominal assessment.

Complete pain assessment score rating with pain description Perform physical abdominal assessment Sort data into significant clusters or diagnostics clues Prioritize the pain treatment options available Decide & perform the priority action

The nurse questions which intervention in the stable patient with the nursing diagnosis "Impaired skin integrity related to draining skin lesions on right lower extremity"? A. Place patient on isolation precautions B. Obtain a swab specimen from wound bed after cleansing with a non-antiseptic solution C. Educate patient about wound and skin treatment regimen D. Administer broad-spectrum antibiotic before obtaining a culture

D. Administer broad-spectrum antibiotic before obtaining a culture

In assessing a patient's pain, the nurse asks the patient, "What makes the pain worse?" Which aspect of pain is the nurse determining? A. Onset and duration B. Intensity C. Quality D. Aggravating factors

D. Aggravating factors

Ms. Ellicott's provider is considering starting a hypertensive medication along with an anti-anxiety agent. Ms. Ellicott states that she has heard of herbal remedies that can help with depression and lower blood pressure. She states that she would like to take something more natural. As the nurse, your best response is: A. To discuss the use of herbal remedies with the provider B. To agree with Ms. Ellicott that because she is newly diagnosed with hypertension, trying an herb first is a good idea C. To explain to Ms. Ellicott that even though an herb is natural, there are contraindications when combining herbs with pharmaceutical medications D. To suggest further discussion with the provider along with a review of resources and collaboration with a pharmacist naturopath, or herbalist

D. To suggest further discussion with the provider along with a review of resources and collaboration with a pharmacist naturopath, or herbalist

The nurse is caring for a hospitalized client whose home medications include daily acetaminophen for headaches. Which associated assessment finding should the nurse report to the health care provider immediately? Pain level of 4/10 Urinary output 75 mL/hr Dyspepsia Dark urine

Dark urine

A patient is taking ketorolac for pain management. Which assessment finding present in the patient is most concerning? Dark-colored urine Constricted pupils Gastrointestinal bleeding Decreased platelet count

Dark-colored urine Indicates drug toxicity

The home care nurse assesses a stage I pressure injury on an older adult patient who has limited mobility from a stroke. What should the nurse include when educating the patient's daughter about her care? Select all that apply. Deliver high protein shakes twice a day. Exercise the extremities actively and passively every 4 hours. Be sure she changes positions at least every 2 hours. Keep the skin moist and layer the sacral area with extra sheet layers. Use pillows to pad all bony prominences.

Deliver high protein shakes twice a day. Exercise the extremities actively and passively every 4 hours. Be sure she changes positions at least every 2 hours. Use pillows to pad all bony prominences.

The pain score of a patient experiencing acute pain is assessed as a 6 on a 0 to 10 scale. Which actions should the nurse take? Select all that apply. Document this in the patient's chart. Perform an immediate clinical assessment. Inform the physician immediately. Determine the appropriate pain management. Determine whether the patient is being truthful.

Document this in the patient's chart. Perform an immediate clinical assessment. Determine the appropriate pain management.

A client expresses pain due to shortness of breath. What is the nurse's best action to alleviate the client's discomfort? Assist client into a side-lying position. Encourage an upright, forward-leaning position. Apply heating pad to anterior chest. Administer narcotics intravenously.

Encourage an upright, forward-leaning position.

The nurse is caring for a patient with expressive aphasia. Which pain scale should the nurse use? FACES Visual Verbal Numerical

FACES

An older adult has suffered a stroke and exhibits expressive aphasia. When assessing for pain, which tool is best for the nurse to utilize with this client? Numerical scale FACES scale Wong-Baker Faces Verbal scale

FACES scale

The nurse is assigned to a patient who is preparing to go to surgery for wound debridement. The nurse explains to the patient the purpose of the wound debridement, including which of the following? Select all that apply. Facilitates healing Removal of tissue for a biopsy Removal of necrotic tissue Reduces the risk of infection Reduces the risk of fluid imbalance

Facilitates healing Removal of necrotic tissue Reduces the risk of infection

he nurse assesses Mr. Jones' current level of pain and finds that it is back to an 8 on a 1 to 10 scale. He describes the pain in his left knee as "stabbing and angry." Which prescribed pain medication should you administer to Mr. Jones? aspirin morphine ibuprofen hydromorphone

Hydromorphone Rationale: Mr. Jones' is experiencing acute, severe pain; therefore, it is appropriate to administer an intravenous opioid to address his pain. Although morphine and hydromorphone are both intravenous analgesics, the client's pain has not been addressed by morphine thus far; therefore, hydromorphone is the most appropriate pain medication to administer at this time. Hydromorphone is eight times more potent than morphine. Aspirin is often contraindicated after a surgical procedure due to the risk for bleeding. Ibuprofen, a non-steroid anti-inflammatory drug (NSAID), is appropriate to treat chronic pain due to inflammation.

Mr. Jones received a dose of acetaminophen with codeine prior to the physical therapy session. After the session Mr. Jones states, "I am very uncomfortable now that therapy is over. I don't want a strong pain medication because it made me really drowsy. What else can I have to treat my pain?" You review Mr. Jones' medication prescriptions and find that he cannot receive anything for two more hours. Which nursing actions are appropriate based on the current situation? Select all that apply. Using acupressure on the affected knee Initiating guided imagery with Mr. Jones Applying cold therapy to Mr. Jones' left knee Repositioning Mr. Jones and elevating his left knee with a pillow Implementing passive range of motion to the lower left extremity

Initiating guided imagery with Mr. Jones Applying cold therapy to Mr. Jones' left knee Repositioning Mr. Jones and elevating his left knee with Rationale: Mr. Jones is not due to receive another dose of pain medication for two more hours. You should implement nonpharmacological pain management strategies to address his pain at this time, including guided imagery, cold therapy, and repositioning the client and elevating his left knee. These interventions have been proven to address the type of pain that Mr. Jones is experiencing after a physical therapy session. Acupressure and implementing passive range of motion may further aggravate Mr. Jones' current level of pain.

The nurse would implement which nursing interventions to decrease the chance of the client developing pressure injury? Select all that apply. Keep the draw sheet and any other bedding material located under the client clean, dry, and without wrinkles. Keep the client elevated to at least 45 degrees at all times. Develop and implement a turning schedule if the client is unable to turn independently. Use a skin risk assessment tool such as the Braden Scale per facility policy. Encourage client to sit in a chair for long periods of time.

Keep the draw sheet and any other bedding material located under the client clean, dry, and without wrinkles. Develop and implement a turning schedule if the client is unable to turn independently. Use a skin risk assessment tool such as the Braden Scale per facility policy.

A patient is undergoing therapy for pain management. During a follow-up visit, the patient tells the nurse about the aggravation of pain at night. What type of pain is the patient suffering? Somatic pain Visceral pain Cutaneous pain Neuropathic pain

Neuropathic pain

You are responsible for providing care to Mr. Jones, a 58-year-old salesman who was admitted to the surgical unit for a left total knee replacement surgery. Mr. Jones is 12 hours post-op. During shift report, the assigned nurse shares the following information with you:• Pain rating of an 8 of 10 during initial assessment• Prescribed pain medication (morphine) administered per order• Post-medication administration assessment revealed pain rated at 5 of 10. Which tool should you use to assess Mr. Jones' current level of pain? FACES pain scale FLACC pain scale Numerical pain scale Neonatal infant pain scale

Numerical pain scale Rationale: A numerical pain scale allows the client to rate current level of pain on a scale of 1 to 10. This unidimensional measurement is designed to assess treatment response to both pharmacologic and non-pharmacologic interventions for many forms of acute pain, including burns, postoperative pain, and chronic non-cancer pain. Evidence suggests that this unidimensional scale may be less effective as a measure of chronic pain or of mixed acute and chronic pain. The FACES scale is more appropriate for a pediatric client. The FLACC pain scale is more appropriate when assessing pain for an infant client. The neonatal infant pain scale, referred to as NIPS, is designed for a neonate.

A patient in postsurgical care asks the nurse to suggest a complementary alternative therapy to help relieve pain. Which body manipulation therapy should the nurse suggest? Zero balancing therapy Reiki therapy Therapeutic touch therapy Reflexology therapy

Reflexology therapy

You administer the prescribed IV hydromorphone to Mr. Jones. Which is your priority assessment based on the current data? Pain Heart rate Respiration Blood pressure

Respiration Rationale: Although it is important to reassess Mr. Jones' level of pain, the priority assessment after administering an IV opioid drug such as hydromorphone is to monitor the client for the adverse reaction of respiratory depression. Heart rate and blood pressure are not priority assessments for this client based on the current data.

Louanne is 70 years old and lives with her husband of 52 years in a small rural community. Louanne was diagnosed with diabetes 5 years ago and the disease is poorly controlled. She presented to the office today with a deep red bruise on the heel of her foot that doesn't seem to be healing. She tells the provider that "I think something bit me."The provider removes Louanne's shoe and sees an area the size of a half dollar on the heel of her foot that is bright read and does not blanch. The provider notes that the shoes Louanne is wearing are very tight and too small for her foot. What type of injury is Louanne demonstrating? Stage 1 pressure injury Stage 2 pressure injury Stage 3 pressure injury Stage 4 pressure injury Deep tissue injury

Stage 1 pressure injury Rationale: A stage 1 pressure injury has intact skin with non-blanching redness to a localized area, usually on a bony prominence.

The provider encourages Louanne to wear different shoes and return to the clinic in a week. When she returns, she has a low-grade fever and the heel has darkened in color. The red area now has a quarter-sized serum-filled blister. Louanne says "I tried some other shoes but they were not comfortable, so I went back to these." What stage pressure ulcer is now present? Stage 1 pressure injury Stage 2 pressure injury Stage 3 pressure injury Stage 4 pressure injury Unstageable pressure injury

Stage 2 pressure injury

A few days later, the nurse performs a focused assessment and identifies that Louanne's pressure injury is now full thickness. There is some bone showing. There is eschar on the edges of the site along with some tunneling. What stage injury should the nurse document? Stage 1 pressure injury Stage 2 pressure injury Stage 3 pressure injury Stage 4 pressure injury Unstageable pressure injury

Stage 4 pressure injury Rationale: Stage 4 injury includes full thickness tissue sloughs with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often undermining and tunneling are present.

A nurse is assessing a patient's skin and notes a 1 cm shallow crater on the coccyx. The site is painful to palpation. How should the nurse document the stage of this wound? Stage I Stage II Stage III Stage IV

Stage II

The nurse is caring for a patient with a pressure injury that is a shallow, open ulcer with a red-pink wound bed, without slough. How should the nurse document the finding? Stage I Stage II Stage III Stage IV

Stage II Rationale: pressure injury resembles shallow open ulcer w/ red-pink wound bed w/o slough. Partial thickness, loss of dermis

The wound care nurse is educating a group of nursing students about the stages of a pressure injury. Which statement is correct when describing a stage III pressure injury? There is full-thickness skin and tissue loss that can extend to the muscle, bone, or tendon. A stage III pressure injury is when the skin is intact but does not blanch. Stage III is full-thickness skin loss with exposure of the adipose tissue. There is a partial-thickness loss of skin with exposed dermis.

Stage III is full-thickness skin loss with exposure of the adipose tissue.

A patient verbalizes to the nurse that they have recurrent pain when the prescribed pain management therapy reaches the end of its dose. What does the nurse infer about the patient's condition? The patient is suffering from acute pain. The patient is suffering from chronic pain. The patient is suffering from persistent pain. The patient is suffering from breakthrough pain.

The patient is suffering from persistent pain.

Louanne's Braden Scale score is an 11. What conclusions can the nurse make? Since she is ambulatory with assistance the skin score in insignificant. Today she's an 11, but it may be different tomorrow. The risk is minimal and not a concern. The risk is moderate so some interventions are important including a special mattress. The risk is high and referrals are needed for therapy services and wound care.

The risk is high and referrals are needed for therapy services and wound care. Rationale: The Braden scale score - Mild risk - 15 to 18 - Moderate risk - 13 to 14 - High risk - 10 to 12 - Very high risk - 9 or below

Which is true regarding the benefits of energy healing therapies for postsurgical patients? Select all that apply. They can relieve pain in the musculoskeletal system. They can help in the management of gastrointestinal problems. They can help in increasing stamina. They can provide a sense of comfort and well-being. They can help in decreasing the heart rate and blood pressure.

They can relieve pain in the musculoskeletal system. They can help in increasing stamina. They can provide a sense of comfort and well-being.

The nurse is caring for a patient at risk for skin breakdown. Which nursing interventions are appropriate to implement to minimize the effects of injury? Select all that apply. Keep the head of the bed less than 60 degrees. Use a draw sheet when moving the patient. Minimize the amount of time the patient is in one position. Firmly massage reddened areas noted on the back, hips, and coccyx. Use alcohol-based skin products.

Use a draw sheet when moving the patient. Minimize the amount of time the patient is in one position.

Because Louanne has a fever, the provider performs lab work and finds that her white blood cell count is elevated. Louanne is admitted to the hospital for intravenous antibiotics. What should the nurse include in the plan of care? Select all that apply. Wound care to the site. Functional assessment. Braden scale assessment. Positioning so that heal is not resting on the bed. Nutritional assessment

Wound care to the site. Functional assessment. Braden scale assessment. Positioning so that heal is not resting on the bed. Nutritional assessment Rationale: The wound site care should include a dressing and prevention of further injury. Both a functional assessment and Braden skin assessment are important to see her level of mobility and risk for further skin injury. The nutritional assessment will determine if she has a balanced diet with adequate protein. Nutritional planning may also help to control her blood sugars.