Module 11

A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (select all that apply)

- Furosemide -Ibuprofen

A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make?

"You will have a small probe placed in your ear canal during the test."

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

"Your staples will be removed in about 2 weeks."

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?

A client who is incontinent and is taking a prescribed diuretic.

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)

Difficulty maintaining attention Agitation Hallucinations Rambling speech

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? (Select all that apply.)

Ensure the client wears their hearing aids. Use a sign language interpreter. Communicate using paper and pen. Face the client when speaking.

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take?

Offer to assist the client with nonpharmacological relief strategies.

If the eye pressure is high or optic nerves looks unusual, what does the doctor measure the cornea thickness using?

Pachometer

nociceptive pain

arises from damage to or inflammation of tissue

neuropathic pain

arises from direct injury to nerves

Mixed hearing loss

combination of conductive and sensorineural

transduction

conversion of painful stimuli to an electrical impulse through peripheral nerve fibers

olfactory sensory neurons

creates our ability to smell. small patch of tissue inside of the nose.

Hypogeusia

decreased ability to taste

Hyposmia

decreased sense of smell

bone oscillator test

determines how effectively vibrations are transmitted through the ossicles.

phantosmia

disorder where a nonexistent smell is percieved.

glaucoma

increased intraocular pressure due to the buildup of fluid or aqueous humor that causes compression of the optic nerve.

otitis media

inflammation of the middle ear

diabetic retinopathy

leakage and blockage of the retinal blood vessels. Most common cause of impaired vision and blindness during adulthood. Maintain good control of blood glucose level, bp, and cholesterol levels to slow the progression.

Diabetic neuropathy

nerve damage that occurs in clients who have diabetes mellitus. From high blood glucose levels.

idiopathic neuropathy

neuropathy due to nerve damage of an unknown cause

stage 1 pressure injury

non-blanchable erythema of intact skin

Peripheral neuropathy

or spinal cord injury. Occurs following damage or malfunction of a peripheral nerve.

stage 2 pressure injury

partial thickness skin loss with exposed dermis

Dysgeusia

persistent salty, rancid, or metallic taste

phantom taste perception

persistent, foul taste when the mouth is empty

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply)

-Bradypnea -Orthostatic hypotension -Nausea

A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression?

A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN

Electrolarynx

emits vibrations that mimic the vocal cords allowing the client to speak.

Reduction of pain stimuli

environment

Middle ear consists of

eustachian tube and ossicles

A nurse is caring for a client who states, "My doctor said I should have an EMG. What is that?" Which of the following responses should the nurse make?

"It is a test that determines if there is nerve damage affecting a muscle."

Three common sensory alterations:

-Deficits -Deprivation -Overload

A nurse is caring for a client who had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply)

-Make sure only one person speaks at a time -Allow plenty of time for the client to respond -Use brief sentences with simple words

Humans have 5 basic senses:

-Sight -Smell -Hearing -Taste -Touch

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (select all that apply)

-Weber test showing lateralization to the right ear -Rinne test showing less time for air and bone conduction

How many taste buds do humans have?

10,000. Number decreases after age 50

A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client's knee for how long?

20 min

A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply.)

A 3-year-old toddler who has a fractured femur A 14-year-old client who has severe cognitive and developmental delays A 5-year-old preschooler who is experiencing pain during a sickle cell crisis

A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following information should the nurse include?

A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.

Delirium

disturbance in mental ability resulting in confused thinking and reduced awareness of the enviroment.

A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?

A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?

Nonmaleficence

do no harm

A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy?

A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.

astigmatism

A refractive error whereby the eye cannot focus light evenly on the retina, causing blurred vision or distortion.

A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse include?

A tuning fork is placed against the client's mastoid bone during the Rinne test.

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? (Select all that apply.)

A walking cane A walker

A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take?

Administer 1 mg IM.

Over age 65 should go how often for an eye exam?

Annual

A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? (Select all that apply.)

Asks for questions to be repeated Withdraws from social activities Describes sounds as being muffled

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions?

Availability of aids to enhance vision

sensory processing disorder

Brain has difficulty interpreting and responding appropriately to the stimuli.

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II?

Check the client's visual acuity using a Snellen chart.

A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client's pain?

Chronic pain

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?

Clean the wound with 0.9% sodium chloride.

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take?

Cover the client's wound with a sterile saline dressing.

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?

Dehiscence

A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity?

Dermatitis

How often should adults until age 65 have an eye exam?

Every 2 years unless eye problems are detected then every year.

tactile defensiveness

Experience physical pain with hugs wearing clothing or wind on their skin. Avoid touch as much as possible.

A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments?

Glaucoma

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? (Select all that apply.)

Grimacing Restlessness Increased diaphoresis

Aspirin can affect?

Hearing

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound?

Hydrogel

A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I take the batteries out of my hearing aids when I take them off at night

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?

Increased blood glucose

A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? (Select all that apply.)

Inspect the feet every day. Wear closed-toe shoes. Manage glucose levels.

A nurse is providing care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client?

Keep the client's environment free from clutter.

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? (Select all that apply.)

Loop diuretics NSAIDS Aminoglycoside antibiotics

applanation tonometry

Measures pressure needed to flatten part of cornea, tests for glaucoma

A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.)

Muscular pain Backache Menstrual discomfort

Range order

Nurse should start with the lowest dose and increase the dose in increments if ineffective. Do not administer another dose until the peak is reached, cannot split the dose.

What does the outer ear consist of?

Pinna, auditory canal and the tympanic membrane.

PQRST

Precipitating cause quality region severity timing

A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as an age-related change?

Presbyopia

When does the ophthalmologist recommend children have their first comprehensive eye exam?

Prior to entering 1st grade.

A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement?

Provide a private room and limit stimulation.

Tinnitus

experience of hearing sound when no external sound is present and is caused by age related hearing loss.

A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?

Risk factors for sensory deprivation include experiencing total vision or hearing loss.

Visual acuity tests

Snellen and Rosenbaum eye charts Snellen (distant vision) book (near vision)

A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.)

Stress Culture Social support Disease severity

Smoking increases the risk for cataracts and diabetic retinopathy.

TRUE

taste and smell are related

TRUE

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity?

The AP places the client in high-Fowler's position.

A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain?

The client is diaphoretic.

Hyperopia

farsightedness

A nurse is planning care for an older adult client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?

Tilt the client on their side at 30°.

Ototoxicity

Toxicity to the ears, often drug induced. medicine given too quickly - Diuretics

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? (Select all that apply.)

Trauma to the outer ear Inflammation Cerumen buildup Otitis media

Comprehensive aphasia

Wernicke's or fluent aphasia. Is caused by damage to the temporal lobe of the brain. Speaks in long sentences that have no meaning and not being able to understand what is said.

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII?

Whisper something in one ear while occluding the other ear.

aphasia

a disorder that affects a client's ability to articulate and understand speech and written language.

otosclerosis

abnormal growth of bone in the middle year.

presbyopia

age related farsightedness. Decrease in the ability to focus up close or small print.

Presbycusis

age related hearing loss. Bilateral and occurs in 1.2 of all adults over 75

expressive aphasia

also known as Brocas or nonfluent aphasia. Is due to damage to the frontal lobe of the brain. May understand speech but unable to speak the words.

acupuncture and acupressure

application of needles or pressure at specific points on the body in order to cure pain or disease

risks of pain

children are higher risk for having pain that's ignored and display pain differently

Nonverbal pain scale (NVPS)

based on FLACC scale, and used for clients who are unable to verbalize their pain level

opioid addiction

chronic condition SBIRT: screening brief intervention referral to treatment

global aphasia

causes severe impairments in communication. Caused by significant damage to various language areas of the brain.

cognitive-behavioral measures

changing the way a client perceives pain, and physical approaches to improve comfort

cataract

clouding of the lens of the eye that causes the clients vision to be blurry, hazy, or less colorful.

Inner ear consists of?

cochlea, semicircular canals, vestibular sacs

visceral pain

in internal organs

Anosmia

inability to smell

Ageusia

inability to taste

macular degeneration

loss of central vision from deterioration of the center of the retina.

Three small bones in the middle ear

malleus, incus, stapes

Tactile Hyposensitivity

may not be able to feel extremes in temperature or have limited ability to feel pain from bone fractures and touch things frequently in the environment.

Myopia

nearsightedness

noncontact tonometry

puff of air

morality

refers to an individuals sense of right and wrong or their personal values

Numeric pain scale

slight pain: 1-3 moderate pain: 4-7 severe: 8-10

Wong-Baker FACES pain scale

smiling face: 0 no hurt hurts a little: 2 hurts a little more: 4 hurts even more: 6 hurts a whole lot: 8 hurts worse: crying face, 10

Where are taste cells found?

tongue, soft palate, epiglottis, larynx, pharynx

justice

treating all clients fairly and equally

A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take?

Evaluate the client for pain by observing their behavior.

imagery

focusing on pleasant thought to divert focus

idiopathic pain

form of chronic pain without a known cause

stage 4 pressure injury

full thickness skin and tissue loss

stage 3 pressure injury

full thickness skin loss

Nonverbal Behaviors of Pain

guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis, change in vitals

A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter "R"?

"Can you point to where you are having your pain?"

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?

"I should increase my protein intake."

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?

"I should report pain at my wound site."

A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?

"Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present."

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?

"SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

"Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"The skin assists in the regulation of body temperature."

A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make?

"This test is performed using lenses of various prescription strengths."

Opioid addiction/death

70,000 overdose deaths have occurred from 1999-2017 2016-2017 deaths increased by 45% due to synthetic opioids

sensory deprivation

Client lacks the ability to receive sensory stimulus perception. Ex: Blindess

Tactile Hypersensitivity

Client may be unable to wear clothing that has a zipper or a shirt with long sleeves. Severe sensitivity to touch.

sensory overload

Client receives stimuli at a rate and intensity beyond his/her ability to process ex: In pain, critically ill

sensory deficit

Client who has difficulty with one or more of the main senses. Ex: Hearing deficit

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control? (Select all that apply.)

Consider each client's cultural preferences. Determine the effectiveness of nonpharmacological strategies. Use a pain scale specific to each client's cognitive abilities.

A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia?

Difficulty problem-solving

Patient-controlled analgesia (PCA)

Drug delivery system that allows patients to self-administer analgesic medications on demand. Morphine, fentanyl, hydromorphone

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?

Empty and measure the drainage.

A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.)

Face Legs Consolability

A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management? (Select all that apply.)

Fear of addiction Belief that pain is an expected part of their illness Inadequate pain assessment

Loop Diuretics can affect?

Hearing

NSAIDS medication can affect?

Hearing and taste

A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes?

Hearing loss

Antibiotics can affect?

Hearing, smell, taste

Nonopioid analgesics

NSAIDs and acetaminophen

A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression?

Naloxone

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age? (Select all that apply.)

Sour Bitter Salty

sensorineural hearing loss

alteration in the inner ear, auditory nerve, or hearing center of the brain.

parosmia

altered in odor perception

distraction

ambulation, deep breathing, visitors, television, games, prayer, and music

adjuvant

drugs typically used for other purposes, but also used to enhance the effect of opioids by providing additional pain relief

face, legs, activity, cry, consolability scale (FLACC)

observational pain measurement tool designed to be used with children ages 2-7, and clients who are cognitively disabled

modulation

occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli

perception or awareness of pain

occurs in various areas of the brain, with influences from though and emotional processes

laryngetomy

surgical removal of the larynx

Gustatory cells

taste cells that contain specific receptors that allow for differentiation between sour, sweet, bitter, salty, or savory flavors.

Conductive hearing loss

when sounds are not able to travel from the outer ear to the eardrum and middle ear. Sound waves are blocked.

A nurse is providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family?

"Your family member has the right to receive effective pain management."

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A bright pink incision site that is absent of exudate

A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use?

A transparent film

beneficence

Doing good and acting in the best interest of clients by providing care that benefits them

cancer pain

tumor, bone pain, treatment of cancer, radiation

A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include?

"You should write down the pain interventions you use and your pain rating before and after."

psychological factors of pain

clients mood, stress levels, ability to cope

malpractice

negligent act that has been performed by a professional

social factors

social environment the client lives in, economic, social support

A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?

"The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with?

Negligence

Opioids or narcotic analgesics

controlled substances (morphine, methadone, oxycodone). first line treatment for moderate to severe pain

autonomy

independence or freedom, ability to make one's own decisions

Acute pain

pain that lasts seconds to less than 6 months

A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make?

"Justice allows the client the opportunity to be treated fairly."

CRIES pain scale

Neonates (0-6 months), can be used for clients who are cognitively disabled and cannot report their pain.

A nurse is collecting data 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 client's pain?

Offer the client a pain scale to measure their pain.

A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.)

"You can be taught how to use TENS therapy at home." "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas." "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy."

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown?

"You should shift your weight off your buttocks at intervals throughout the day."

biological factors of pain

disease severity, inflammation, brain function

Pain assessment

location, intensity, character, frequency, duration

relaxation

meditation, yoga, progressive muscle relaxation

Elevation of edematous extremities

promotes venous return and decreases swelling

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?

A client who has a Braden Scale score of 9

A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain?

A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury

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 episodic back pain following a fall 2 years ago.

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown?

Flex the client's knees while in bed.

cutaneous stimulation

TENS, heat, cold, therapeutic touch, massage

A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.)

Transcutaneous electronic stimulating unit (TENS unit) Massage Acupuncture Cold therapy

transmission

electrical impulse travels along nerve fibers, where neurotransmitters regulate it

somatic pain

in bones, joints, muscles, skin or connective tissues

cutaneous pain

in the skin or subcutaneous tissue

pain tolerance

is the amount of pain a person is willing to bear

pain threshold

is the point at which the person feels pain

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply.)

"A client's religious beliefs might affect the way they respond to pain." "The client's past pain experiences are not related to their current pain and pain management." "Pain control might be harder to achieve if the nurse and client speak different primary languages."

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 am using this device."

A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions?

"I will keep the morphine bottle in a locked cabinet in my kitchen."

A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing?

"This type of dressing will need a secondary dressing for reinforcement."

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?

"This type of healing begins in the wound bed with the generation of granulation tissue."

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

Presence of associated manifestations

A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)? (Select all that apply.)

Respiratory rate Capnography Oxygen saturation

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?

The dermis contains blood vessels that help nourish the epidermis.

Factors that affect pain (select all that apply)

cultural, ethnic, religious beliefs, family, support systems, gender, age, environment, past experiences with pain, anxiety, stressors

negligence

failing to perform in a manner that a reasonable and prudent person should perform

Barriers to pain management

fear addiction, patient reluctance to complain, believe pain is expected, fear side effects, not believing patient, failure to be patient advocate

Chronic pain

pain that last 6 months or longer, intermittent or continuous can be emotionally debilitating

Nonpharmacologic pain interventions

positioning cutaneous stimulation heat/cold therapy therapeutic touch massage acupuncture hypnosis acupressure electronic stimulating device