Test #5: Sensory, Sleep & Rest, Pain

A mother expresses concern that her 7-year-old has episodes of nocturnal enuresis approximately three to four times per week. The nurse's best response would be which of the following? Select all that apply.

"Be patient; most children outgrow enuresis.", "You might consider purchasing protective pads for the bed."

An 86-year-old patient who was admitted with GI bleeding as a result of salicylate therapy is being discharged. As the nurse reviews the discharge medication list, the patient states that she doesn't understand why Tylenol doesn't work as well as the aspirin she had been taking. Which response is best?

"Tylenol does not help with inflammatory discomfort."

The nurse in a rehabilitation center is providing care to a client who complains of insomnia. The client states that the room is noisy, and that they often take naps during the day because they are a "night owl" from working the nightshift for several years. The nurse develops a care plan that allows the client to start their rehab therapy later in the day, provides the client with a sleep aide and a white noise fan in the room, and allows the client to nap during the day when tired. Which of the following would be a priority for this plan?

Allowing the client to sleep later in the day

The nurse is providing care to the client that has recently been diagnosed with obstructive sleep apnea (OSA). Which of the following are symptoms associated with OSA? Select all that apply.

Daytime Fatigue, Snoring

Which method would the nurse plan to use to assess kinesthetic deficit in a patient?

Have the patient perform alternating rapid movements

Which information will the nurse include when assessing the patient's central nervous system (CNS) function following sedative-hypnotic therapy? (Select all that apply.)

Level of alertness , Orientation , Ability to perform motor functions

Which type of blood work will be performed when a patient receiving diazepam (Valium) is complaining of nausea and vomiting and is becoming jaundiced?

Liver function tests

The student nurse is reviewing the sedative-hypnotic drug class and recognizes that which of the following are true regarding this drug class? Select all that apply.

Most of the drugs in this class alter the sleep cycle and can be habit-forming, REM rebound can be a problem when the medication is stopped

One hour after receiving ibuprofen 800 mg orally for right hip pain, the patient states that the pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take next?

Notify the prescriber that the current pain management plan is ineffective.

The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should

Observe the client carefully for changes in behavior or vital signs.

Avios using throw rugs on the floor

Olfactory

Which patient characteristic(s) will be assessed when performing a baseline neurologic assessment prior to the administration of an NSAID medication? (Select all that apply.)

Orientation to date, time, and place, Mental alertness

An older adult patient received a hypnotic agent at 9:00 PM. At 2:00 AM, the nurse discovers that the patient has removed her gown and is attempting to get out of bed without assistance. Which type of medication effect is the patient exhibiting?

Paradoxical

The nurse is providing care to client in the long-term care facility. The nurse notes that the night shift staff have reported that the client has appeared to have been sleepwalking this past week. What is the medical term for this behavior?

Parasomnias

The nurse is caring for an older patient recently admitted to an assisted living center who is experiencing insomnia associated with the recent relocation. Which non-pharmacologic nursing action will assist the patient to sleep?

Performing back massage

A patient who underwent right above-the-knee amputation reports pain in the left foot. The nurse should document this finding as what type of pain?

Phantom

Which nursing diagnosis has the highest priority for a patient with impaired tactile perception?

Risk for Injury

Which is the priority nursing diagnosis for a patient with visual impairment?

Risk for falls

A client states that many of his friends told him to ask for Valium or Ativan to help him sleep while hospitalized. The nurse knows that nonbenzodiazepines (e.g., Ambien) are often preferred over benzodiazepines (Ativan or Valium). Why is this?

The benzodiazepine Ativan can alter the sleep cycle and produce daytime sleepiness.

For any patient with an altered level of consciousness, the Glasgow Coma Scale score will help the nurse in planning care.

True

Which condition(s) may be managed by salicylates? (Select all that apply.)

Swollen joints, Fever, Muscle aches, Myocardial infarction

How should the nurse classify pain that a patient with bladder cancer is experiencing?

Visceral

Which priority action will the nurse take when a patient receiving morphine sulfate via a patient-controlled analgesia pump (PCA) has a shallow, irregular respiratory rate of 6 breaths/min?

Notify the healthcare provider and prepare to administer naloxone (Narcan).

The nurse teaches a class for new parents promoting safe sleep for infants. The nurse determines a participant understood the important safety points when a parent makes which statement?

"I will put my son on a firm crib mattress on his back and remove all padding."

Mr. Zenobia's chronic cancer pain has recently increased and he asks the home health nurse what can be done. In relation to his long-acting opioid, which is an appropriate response by the nurse?

"I'll call the primary care provider and ask for an increased dose."

Which question will the nurse ask an elderly patient to best assess level of orientation?

"What is your name and today's date? Can you tell me where you are?"

How many hours of sleep per night are thought to be optimal for good health?

7 to 8 hours

A patient is taking meperidine (Demerol) as needed for moderate to severe pain following an open appendectomy. The nurse assesses the following: current pain level 2, temperature 99°F, BP 130/76, respirations 10, lung sounds clear, abdomen soft and tender, bowel sounds present. Which is the primary problem based on this assessment information?

Breathing Pattern Alteration

Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 beats/min, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following?

Close the blinds, dim the lights, and ask the patient what other measures would help him rest.

Patient Scenario: You are a nurse on a medical-surgical unit in a hospital caring for one of your patients who is admitted several times per year due to her uncontrolled back and knee pain. She is 70 y/o and, by assessing her expression, it is hard to believe she is in pain at all. She can be a challenging patient because she prefers to not talk about her pain. She will often use the words "uncomfortable" or "tender" to describe her pain, although you can see tears welling up in her eyes when she attempts to ambulate to the bathroom. Unfortunately, this patient has many other disease processes that prevent her from using many of the available oral pain medications and she does not tolerate opioids at all. Knowing this information about this patient, which of the following would be the priority in beginning her pain management plan?

Performing a pain assessment using either a numerical scale or the Wong-Baker Faces scale.

Sally Nurse is providing discharge teaching to her patient who has been in the hospital after experiencing an ischemic stroke. The patient states that he doesn't understand why he is having pain in his arm when the stroke occurred in his brain. Sally explains that this is neuropathic pain related to the stroke. Which statement is true about neuropathic pain?

The pain is a result of nerve injury.

In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord?

Transmission

A patient who had surgery is receiving patient-controlled analgesia (PCA). Which statement by the patient indicates an understanding of PCA use?

"I will be the only one that presses the button."

The nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, "I don't know what is wrong with me. I have been napping all day and can't seem to think clearly." The nurse's best response is

"There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?"

A patient suddenly develops right-lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain?

Acute

A nurse is working in nursery and observes an infant crying after a procedure. Which action would be appropriate for the nurse to take?

Administer oral sucrose

Which instruction would the nurse include when providing discharge teaching for a patient who has a serious visual deficit?

Avios using throw rugs on the floor

It is most important for the nurse to understand the various ways in which pain is classified so that he or she can

Develop an effective pain management plan.

Patient Scenario: You are a nurse on a medical-surgical unit in a hospital caring for one of your patients who is admitted several times per year due to her uncontrolled back and knee pain. She is 70 y/o and, by assessing her expression, it is hard to believe she is in pain at all. She can be a challenging patient because she prefers to not talk about her pain. She will often use the words "uncomfortable" or "tender" to describe her pain, although you can see tears welling up in her eyes when she attempts to ambulate to the bathroom. Unfortunately, this patient has many other disease processes that prevent her from using many of the available oral pain medications and she does not tolerate opioids at all. What non-pharmacological measures would be appropriate for helping this patient manage her pain? Select all that apply

Distraction, Relaxation by utilizing deep breathing or listening to music , Application of heat or cold depending on the patient's preference

Which common adverse effect(s) is/are associated with opiate agonists? (Select all that apply.)

Dizziness, Orthostatic Hypotension, Respiratory Depression, Confusion

The nurse is caring for a client newly diagnosed with narcolepsy. What is the priority teaching point the nurse would share with the client?

Do not drive or operate heavy equipment.

The student nurse is reviewing medication cards prior to caring for a patient in clinical. She notices that the patient is prescribed a sedative-hypnotic medication PRN for sleep. The instructor asks the student what the benefit is of including a sedative in the patient's sleep medication. The student correctly answers which of the following?

Increased relaxation occurs with sedatives

Which information is most accurate regarding the nurse's understanding of the concept of pain management?

It's important to encourage patients to report pain before the pain becomes too severe.

The nurse is caring for a client admitted to the hospital's hospice unit with terminal cancer and acute cancer pain. What factors does this client have that will interrupt circadian rhythms? Select all that apply.

Poorly controlled pain, Fear of the unknown, Extraneous lights in the room

The client who has had a stroke states to the nurse, "You know I can't even tell where my left leg I S." This reflects lack of response to stimuli by the

Proprioceptors

A patient experiencing chronic pain as a result of metastatic cancer has a new order to apply a fentanyl (Duragesic) transdermal patch once daily. The initial patch is applied at 8 AM on Monday. At 8 PM on Monday, the patient reports a pain level of 8. Which action should be taken?

Provide a PRN analgesic medication as ordered.

A person who is deprived of rapid eye movement (REM) sleep for several nights in succession will usually experience:

REM rebound

The nurse is assessing the client in the family clinic, who asks about the difference between rest and sleep. Which of the following statements would explain the main difference between sleep and rest?

Sleep is characterized by an altered level of consciousness.

Which behavior by a parent indicates an understanding of teaching regarding stimuli used to develop the infant's auditory nervous system?

Speaking

Which initial action should the nurse take when finding a patient extremely agitated, yelling frequently, and attempting to get out of bed without assistance?

Spend uninterrupted time listening to the patient.