Adult 1 Exam 2

During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)? a. Sleep disturbances b. Multiple tender points c. Cardiac palpitations and dizziness d. Multijoint pain with inflammation and swelling e. Widespread bilateral, burning musculoskeletal pain

ANS: A, B, E These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia

A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to a. elevate the left leg. b. splint the lower leg. c. obtain information about the tetanus immunization status. d. check the popliteal, dorsalis pedis, and posterior tibial pulses.

ANS: D The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

The nurse will determine more teaching is needed if a patient with discomfort from a bunion says, "I will a. give away my high-heeled shoes." b. take ibuprofen (Motrin) if I need it." c. use the bunion pad to cushion the area." d. only wear sandals, no closed-toe shoes."

ANS: D The patient can wear shoes that have a wide forefoot (toe box). The other patient statements indicate the teaching has been effective.

The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? A. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. B. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements and/or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.

A patient with chronic cancer-related pain has started using MS Contin for pain control and has developed common side effects of the drug. The nurse reassures the patient that tolerance will develop to most of these side effects but that continued treatment will most likely be required for what? a. Pruritus c. Constipation b. Dizziness d. Nausea and vomiting

c. Although tolerance to many of the side effects of opioids (nausea, sedation, respiratory depression, pruritus) develops within days, tolerance to opioid-induced constipation does not occur. A bowel regimen that includes a gentle-stimulant laxative and a stool softener should be started at the beginning of opioid therapy and continue for as long as the drug is taken.

The nurse should question an order written for Percocet for a patient exhibiting which clinical manifestation? A. Severe jaundice B. Oral candidiasis C. Increased urine output D. Elevated blood glucose

A. Acetaminophen and oxycodone are the ingredients in Percocet. Because acetaminophen is metabolized in the liver, the patient could develop acetaminophen toxicity in the presence of severe liver disease (evidenced by jaundice). The prudent nurse would question the order before administration.

The registered nurse (RN) is caring for patients in a surgical unit. Which tasks may the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Administer oral pain medications to a patient after abdominal surgery. B. Teach the patient how to use patient-controlled analgesia after surgery. C. Determine strategies for pain management as part of a patient's discharge plan. D. Evaluate whether the pain management plan is providing adequate pain control.

A. An LPN/LVN may administer ordered pain medications, but depending on the state nurse practice act and agency policy, the LPN/LVN may not be able to administer medication by all routes. The tasks of teaching, evaluation, and discharge planning are within the scope of practice of an RN.

Before administering celecoxib (Celebrex), the nurse will assess the patient's medical record for which medication would increase the risk of adverse effects? A. Aspirin B. Scopolamine C. Theophylline D. Acetaminophen

A. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) of the cyclooxygenase-2 (COX-2) inhibitor type. Although celecoxib does not inhibit COX-1 and thus has a decreased risk of bleeding, bleeding is still of concern as an adverse effect. For this reason, the drug should not be taken with other drugs that increase the risk of bleeding, such as aspirin.

Which patient is most at risk for respiratory depression related to opioid administration for pain relief? A. 82-year-old patient who had abdominal surgery 4 hours ago B. 24-year-old patient who had a vaginal delivery 12 hours ago C. 32-year-old patient with chronic neuropathic pain for 6 months D. 20-year-old patient with a closed reduction of a fractured right arm

A. Patients most at risk for respiratory depression include those who are older, have underlying lung disease, have a history of sleep apnea, or are receiving other central nervous system depressants. For postoperative patients, the greatest risk is in the first 24 hours after surgery. Respiratory depression related to opioid administration is higher in hospitalized patients who are opioid naïve.

A patient has a new order for magnetic resonance imaging (MRI) to evaluate for left femur osteomyelitis after a hip replacement surgery. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? a. The patient has a pacemaker. b. The patient is claustrophobic. c. The patient wears a hearing aid. d. The patient is allergic to shellfish.

A. Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.

Which nursing intervention is most appropriate when turning a patient following spinal surgery? A. Placing a pillow between the patient's legs and turning the body as a unit B. Having the patient turn to the side by grasping the side rails to help turn over C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

A. Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort following spinal surgery. Having the patient turn by grasping the side rail to help, elevating the head of the bed, and turning with extended legs or turning the patient's head and shoulders and then the hips will not maintain proper spine alignment and may cause damage.

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that is likely to be present." D. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

A. The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics

A patient with osteoarthritis has been taking ibuprofen (Advil) 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge? A. Another NSAID may be indicated because of individual variations in response to drug therapy. B. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. C. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. D. The patient is probably not compliant with the drug therapy, and therefore the nurse must initially

A. Another NSAID may be indicated because of individual variations in response to drug therapy. Patients vary in their response to medications so when one NSAID does not provide relief, another should be tried. There is no evidence to ascertain any noncompliance to drug therapy.

Musculoskeletal assessment is an important component of care for patients on what type of long-term therapy? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers

A. Corticosteroids Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.

In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply a splint to the leg. f. Administer tetanus prophylaxis.

ANS: C, D, B, E, A, F The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.

Which action will the nurse include in the plan of care for a 40-year-old with newly diagnosed ankylosing spondylitis? a. Advise the patient to sleep on the back with a flat pillow. b. Emphasize that application of heat may worsen symptoms. c. Schedule annual laboratory assessment for the HLA-B27 antigen. d. Assist patient to choose physical activities that allow the spine to flex.

ANS: A Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (such as sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen levels are used for initial diagnosis, but are not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain

Which finding will the nurse expect when assessing a 58-year-old patient who has osteoarthritis (OA) of the knee? a. Discomfort with joint movement b. Heberden's and Bouchard's nodes c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: A Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA). Stiffness in OA is worse right after the patient rests and decreases with joint movement

A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? a. "You will need to assess and clean the pin insertion sites daily." b. "The external fixator can be removed during the bath or shower." c. "You will need to remain on bed rest until bone healing is complete." d. "Prophylactic antibiotics are used until the external fixator is removed."

ANS: A Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

ANS: A Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

When doing discharge teaching for a patient who has had a repair of a fractured mandible, the nurse will include information about a. when and how to cut the immobilizing wires. b. self-administration of nasogastric tube feedings. c. the use of sterile technique for dressing changes. d. the importance of including high-fiber foods in the diet.

ANS: A The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.

A patient who had arthroscopic surgery on the right knee 7 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 86/50 mm Hg. b. The white blood cell count is 11,500/µL. c. The patient is taking ibuprofen (Motrin). d. The patient says the knee pain is severe.

ANS: A The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

Before assisting a patient with ambulation on the day after a total hip replacement, which action is most important for the nurse to take? a. Administer the ordered oral opioid pain medication. b. Instruct the patient about the benefits of ambulation. c. Ensure that the incisional drain has been discontinued. d. Change the hip dressing and document the wound appearance.

ANS: A The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

A 63-year-old patient hospitalized with polymyositis has joint pain, an erythematous facial rash, eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is a. risk for aspiration related to dysphagia. b. disturbed visual perception related to swelling. c. acute pain related to generalized inflammation. d. risk for impaired skin integrity related to scratching.

ANS: A The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patient's airway.

A patient is seen at the urgent care center after falling on the right arm and shoulder. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The right arm appears shorter than the left. c. There is decreased range of motion of the shoulder. d. The patient is complaining of arm and shoulder pain.

ANS: B A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

The nurse determines that additional instruction is needed when a patient diagnosed with scleroderma says which of the following? a. "Paraffin baths can be used to help my hands." b. "I should lie down for an hour after each meal." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."

ANS: B Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective

A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Logroll the patient every 2 hours. b. Assist the patient with ambulation. c. Discuss the need for genetic testing with the patient. d. Teach the patient about the muscle biopsy procedure.

ANS: B Because the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing because the patient already knows the diagnosis.

Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Application of cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

Which information will the nurse include when teaching a 38-year-old male patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition? a. Exercise by taking long walks. b. Do daily deep-breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

ANS: B Deep-breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. "I am going to join a soccer team to get more exercise." b. "I will need to stop drinking so much coffee and soda." c. "I will call the doctor every time my symptoms get worse." d. "I should avoid using over-the-counter medications for pain."

ANS: B Dietitians frequently suggest that patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently, rather than calling the provider whenever symptoms get worse.

A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient's statement indicates the teaching has been effective? a. "I will keep my back straight when I lift above my waist." b. "I will begin doing exercises to strengthen and support my back." c. "I will tell my boss I need a job where I can stay seated at a desk." d. "I can sleep with my hips and knees extended to prevent back strain."

ANS: B Exercises can help strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back than keeping these joints extended. Sitting for prolonged periods can aggravate back pain. Modifications in the way the patient lifts boxes are needed, but the patient should not lift above the level of the elbows.

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care? a. Quadriceps-setting exercises b. Immobilization of the left leg c. Positioning the left leg in flexion d. Assisted weight-bearing ambulation

ANS: B Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fracture. Weight-bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures.

A patient has hip replacement surgery using the posterior approach. Which patient action requires rapid intervention by the nurse? a. The patient uses crutches with a swing-to-gait. b. The patient leans over to pull shoes and socks on. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing their teeth.

ANS: B Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

After the nurse has finished teaching a 68-year-old patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can take glucosamine to help decrease my knee pain." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."

ANS: B No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.

When planning care for a patient who has had hip replacement surgery, which nursing action can the nurse delegate to experienced nursing assistive personnel (NAP)? a. Teach quadriceps-setting exercises. b. Reposition the patient every 1 to 2 hours. c. Assess for skin irritation on the patient's back. d. Determine the patient's pain level and tolerance.

ANS: B Repositioning of patients is within the scope of practice of NAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

ANS: B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process

The nurse is preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patient's weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient out of bed to nursing assistive personnel (NAP).

ANS: B The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in a dependent position. b. handle the cast with the palms of the hands. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

ANS: B Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

Which information will the nurse include when teaching a patient with newly diagnosed chronic fatigue syndrome about self-management? a. Avoid the use of over-the-counter antihistamines or decongestants. b. A low-residue, low-fiber diet will reduce any abdominal distention. c. A gradual increase in your daily exercise may help decrease fatigue. d. Chronic fatigue syndrome usually progresses as patients become older.

ANS: C A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with chronic fatigue syndrome have allergies, antihistamines, and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. Chronic fatigue syndrome usually does not progress

The nurse is planning care for a patient with hypertension and gout who has a red and painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).

ANS: C Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain relief.

Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

ANS: C C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

When counseling an older patient about ways to prevent fractures, which information will the nurse include? a. Tack down scatter rugs in the home. b. Most falls happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Range-of-motion exercises should be taught by a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse identifies a need for additional teaching related to health maintenance when the nurse finds that the patient a. is frustrated with the length of treatment required. b. takes and records the oral temperature twice a day. c. is unable to plantar flex the foot on the affected side. d. uses crutches to avoid weight bearing on the affected leg.

ANS: C Foot drop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis.

Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? a. Ask the patient about any nausea. b. Obtain the patient's oral temperature. c. Review the patient's serum creatinine. d. Change the prescribed wet-to-dry dressing.

ANS: C Gentamicin is nephrotoxic and can cause renal failure as reflected in the patient's serum creatinine. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.

After a patient has a short-arm plaster cast applied in the emergency department, which statement by the patient indicates a good understanding of the nurse's discharge teaching? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site for the next 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

A 19-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. had several knee injuries as a teenager. b. recently returned from South America. c. is sexually active with multiple partners. d. has a parent who has rheumatoid arthritis.

ANS: C Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 38-year-old man who plays on a summer softball team. b. A 56-year-old man who is a member of a construction crew c. A 56-year-old woman who works on an automotive assembly line d. A 49-year-old woman who is newly diagnosed with diabetes mellitus

ANS: C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky.

The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which statement by a patient indicates additional patient teaching is needed? a. "I will need to participate in physical therapy after surgery." b. "I wish I did not need to have chemotherapy after this surgery." c. "I did not have this bone cancer until my leg broke a week ago." d. "I can use the patient-controlled analgesia (PCA) to manage postoperative pain."

ANS: C Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other statements indicate patient teaching has been effective.

An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to a. keep both feet flat on the floor when prolonged standing is required. b. twist gently from side to side to maintain range of motion in the spine. c. keep the head elevated slightly and flex the knees when resting in bed. d. avoid the use of cold packs because they will exacerbate the muscle spasms.

ANS: C Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. Prolonged standing will cause strain on the lumbar spine, even with both feet flat on the floor. Alternate application of cold and heat should be used to decrease pain.

A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

The nurse should reposition the patient who has just had a laminectomy and diskectomy by a. instructing the patient to move the legs before turning the rest of the body. b. having the patient turn by grasping the side rails and pulling the shoulders over. c. placing a pillow between the patient's legs and turning the entire body as a unit. d. turning the patient's head and shoulders first, followed by the hips, legs, and feet.

ANS: C The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.

Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider? a. Serous wound drainage b. Right arm pain with movement c. Right arm muscle spasms d. Temperature 101.4° F (38.6° C)

ANS: D An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.

When giving home care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include? a. Keep the hand immobile to prevent soft tissue swelling. b. Keep the right shoulder elevated on a pillow or cushion. c. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury. d. Call the health care provider for increased swelling or numbness.

ANS: D Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.

Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the health care provider? a. Bruising of the left thigh b. Complaints of left thigh pain c. Outward pointing toes on the left foot d. Prolonged capillary refill of the left foot

ANS: D Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.

The second day after admission with a fractured pelvis, a patient develops acute onset confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check pupil reaction to light. d. Assess the oxygen saturation.

ANS: D The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions also are appropriate but will be done after the nurse assesses gas exchange.

Which information in a 67-year-old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? a. The patient sprained her ankle at age 13. b. The patient's mother became shorter with aging. c. The patient takes ibuprofen (Advil) for occasional headaches. d. The patient's father died of complications of miliary tuberculosis.

B. A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient's current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.

During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? A. The presence of bowed legs B. A measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation

B. A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative it is present. A wide gait is used to support balance and does not indicate osteoporosis.

In reviewing bone remodeling, what should the nurse know about the involvement of bone cells? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are mature bone cells. D. Osteons create a dense bone structure.

B. Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure, but these are not involved with bone remodeling.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg

B. Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg.

After administering acetaminophen and oxycodone (Percocet) for pain, which intervention would be of the highest priority for the nurse to complete before leaving the patient's room? A. Leave the overbed light on at a low setting. B. Ensure that the upper two side rails are raised. C. Offer to turn on the television to provide distraction. D. Ensure that documentation of intake and output is accurate.

B. Percocet has acetaminophen and oxycodone as ingredients. Since the medication contains an opioid analgesic with sedative properties, the nurse must ensure patient safety before leaving the room, such as leaving the top two bedrails raised. This will help prevent the patient from falling from bed, while not restraining the patient (as four side rails would do). Leaving the light or television on will not provide a positive environment for healing sleep.

A 68-year-old man has chronic pain because of lung cancer that has metastasized to the bone in his back and hip. The nurse is teaching the patient and his family about tolerance and physical dependence on opioid medications. Which statement, if made by the patient, indicates a need for further teaching? A. "High doses of the medication may cause more side effects than lower doses." B. "If I need higher doses of the drug to relieve pain, I have developed an addiction." C. "Physical dependence is expected when this drug is used for long periods of time." D. "I may eventually need a higher dose of the medication to get the same pain relief."

B. Tolerance and physical dependence are not indicators of addiction. Tolerance and physical dependence are normal physiologic responses to chronic exposure to opioids. Tolerance is the need for an increased opioid dose to maintain the same degree of analgesia. Physical dependence is manifested by a withdrawal syndrome that occurs when blood levels of the drug are abruptly decreased.

A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? A. Atrophy B. Ankylosis C. Crepitation D. Contracture

B. Ankylosis Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement.

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient (select all that apply)? A. Ataxia B. Itching C. Nausea D. Urinary retention E. Gastrointestinal bleeding

B. Itching C. Nausea D. Urinary retention Common side effects of intraspinal opioids include nausea, itching, and urinary retention. Ataxia is a common side effect of intraspinal clonidine.

The nurse is caring for a patient who is receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication? A. Pain rating 3/10, awake and alert, respirations 24 B. Pain rating 2/10, awake and alert, respirations 18 C. Pain rating 2/10, drowsy but arousable, respirations 18 D. Pain rating 1/10, drowsy but arousable, respirations 16

B. Pain rating 2/10, awake and alert, respirations 18 Effective pain management is achieved when there is adequate pain control (rating of 3 or less on a scale of 0 to 10) with normal respirations and an absence of sedation. These data exhibit the best effectiveness of the pain medication in all of these areas

While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as a.hypertension. b.thyroid problems. c.diabetes mellitus. d.chronic bronchitis.

C. The nurse should question the patient about past medical problems because certain illnesses are known to affect the musculoskeletal system directly or indirectly. These diseases include tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities.

Which assessment is of the highest priority for the nurse to complete before the administration of morphine? A. Pain rating B. Blood pressure C. Respiratory rate D. Level of consciousness

C. A decreased respiratory rate below 12/min is a sign of opioid toxicity. Using the ABC approach in prioritization of care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine.

Which medication information will the nurse identify as a concern for a patient's musculoskeletal status? a. The patient takes a daily multivitamin and calcium supplement. b. The patient takes hormone therapy (HT) to prevent "hot flashes." c. The patient has severe asthma and requires frequent therapy with oral corticosteroids. d. The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).

C. Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.

The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate? A. Serum calcium B. Serum creatinine C. Serum phosphate D. Serum alkaline phosphatase

C. Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min).

A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication? A. Diarrhea B. Agitation C. Constipation D. Urinary incontinence

C. Morphine sulfate is an opioid analgesic that can lead to constipation as a side effect, and tolerance to opioid-induced constipation does not develop. It is very important to use measures, such as increased fiber and fluids in the diet, and exercise when possible, to prevent this side effect. A gentle stimulant laxative plus a stool softener are also frequently needed to prevent constipation in a patient who is likely to develop this side effect.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. 22-year-old female with gonorrhea who is an IV drug user B. 48-year-old male with muscular dystrophy and acute bronchitis C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago

C. Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

A 45-year-old woman who had abdominal surgery yesterday received IV pain medication 30 minutes ago. Which assessment by the nurse would most accurately determine the effectiveness of the medication? A. The patient is resting quietly with eyes closed and is not grimacing. B. The patient is talking with visitors and intermittently watching the television. C. The patient states the pain has decreased from an 8 to a 3 on a 0 to 10 pain scale. D. The patient's heart rate is 78 beats/minute with a blood pressure of 122/76 mm Hg.

C. Pain is a subjective experience. The patient is the best judge of his or her own pain and is the expert on the effectiveness of treatment of the pain.

The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest-calcium meal? A. Chicken stir-fry with 1 cup each onion and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C. The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium, but not as much as the sardines, yogurt, and milk

A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time? A. 9:30 PM B. 10:00 AM C. 11:00 AM D. 1:00 PM

C. 11:00 AM A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. 10:00 AM would be too early; 1:00 PM and 9:30 PM would be too late.

When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate drops down to or below which parameter? A. 16 breaths/min B. 14 breaths/min C. 12 breaths/min D. 10 breaths/min

C. 12 breaths/min To protect the patient from adverse effects of respiratory depression from this medication, the nurse should alert the physician as soon as the respiratory rate drops down to or below 12 breaths/min.

A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia

C. Back or neck pain Osteoporosis with resultant fractures is a frequent and serious complication of systemic corticosteroid therapy. The ribs and vertebrae are affected the most, and patients should be observed for signs of compression fractures (back and neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of the Achilles tendon. The highest risk is in people age 60 and older and in people taking corticosteroids. Antipsychotics and antidepressants may cause tardive dyskinesia, which is characterized by involuntary movements of the tongue and face.

Which clinical manifestation should the nurse attribute to the adverse effects of morphine sulfate administered via PCA? A. Diarrhea B. Urinary incontinence C. Nausea and vomiting D. Increased blood pressure

C. Nausea and vomiting Morphine sulfate promotes nausea and vomiting by directly stimulating the chemoreceptor trigger zone in the medulla. Other common side effects include constipation, sedation, respiratory depression, decreased blood pressure, and pruritus.

The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring? A Paresthesia B Pitting edema C Poor venous return D Compartment syndrome

D Compartment syndrome The nurse should suspect compartment syndrome with one or more of the following six Ps: paresthesia, pallor, pulselessness, pain distal to the injury and unrelieved with opioids, pressure increases in the compartment, and paralysis. Although paresthesia and poor venous return are evident, these are just some of the manifestations of compartment syndrome.

The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to A avoid crossing his legs. B use a toilet elevator on toilet seat. C notify future caregivers about the prosthesis. D maintain hip in adduction and internal rotation.

D maintain hip in adduction and internal rotation. The patient should not force hip into adduction or force hip into internal rotation as these movements could displace the hip replacement. Avoiding crossing the legs, using a toilet elevator on a toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

Which effect should the nurse instruct a patient receiving NSAIDs to report? A. Blurred vision B. Nasal stuffiness C. Urinary retention D. Black or tarry stools

D. Black, tarry stools could indicate GI bleeding, which is a risk associated with NSAIDs. For this reason, the patient should be taught to report this sign and other signs of bleeding immediately.

The patient is a known abuser of narcotics and just had surgery. The nurse is frustrated by drug addiction and worried about the high dose of narcotic analgesic prescribed for this patient. What is the best action for the nurse to take? A. Remember that pain can be observed in patients. B. Relieve this patient's pain to avoid adverse consequences. C. Be sure the patient is really in pain before giving the analgesic. D. This patient has the right to appropriate assessment and management of pain.

D. Patients with addictive disease and pain have the right to be treated with dignity, respect, and the same quality of pain assessment and management as all other patients. For an addict, severe pain should be treated with a single opioid at much higher doses than those used with drug-naïve patients. Observation of pain is not always evident. The stress of unrelieved pain may contribute to increased drug use in the patient actively abusing drugs.

The nurse who notes that a 59-year-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about a. discography studies. b. myelographic testing. c. magnetic resonance imaging (MRI). d. dual-energy x-ray absorptiometry (DXA).

D. The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.

A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. Two additional follow-up scans will be required. B. There will be only mild pain associated with the procedure. C. The procedure takes approximately 15 to 30 minutes to complete. D. The patient will be asked to drink increased fluids after the procedure.

D. The patient will be asked to drink increased fluids after the procedure. Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans that take 1 hour of lying supine.

A patient is receiving a continuous infusion of morphine via an epidural catheter following major abdominal surgery. Which actions should the nurse include in the plan of care (select all that apply)? a. Label the catheter as epidural access. b. Assess the patient's pain relief frequently. c. Use sterile technique when caring for the catheter. d. Monitor the patient's level of consciousness (LOC). e. Monitor patient vital signs (blood pressure, heart rate, respirations). f. Assess the motor and sensory function of the patient's lower extremities.

a, b, c, d, e, f. The major complications of epidural analgesia are catheter displacement and migration, accidental infusions of neurotoxic agents, and infection. These actions will help to reduce those risks.

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) a."The beads are used to directly deliver antibiotics to the site of the infection." b."There are no effective oral or IV antibiotics to treat most cases of bone infection." c."This is the safest method of delivering long-term antibiotic therapy for a bone infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics."

a, d. Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection.

Once generated, what may block the transmission of an action potential along a peripheral nerve fiber to the dorsal root of the spinal cord? a. The transmission may be interrupted by drugs such as local anesthetics. b. Nothing can stop the action potential along an intact nerve until it reaches the spinal cord. c. The action potential must cross several synapses, points at which the impulse may be blocked by drugs. d. The nerve fiber produces neurotransmitters that may activate nearby nerve fibers to transmit pain impulses.

a. Although a peripheral nerve is one cell that carries an impulse directly from the periphery to the dorsal horn of the spinal cord with no synapses, the transmission of the impulse can be interrupted by drugs known as membrane stabilizers or sodium-channel inhibitors, such as local anesthetics and some antiseizure drugs. The nerve fiber produces neurotransmitters only at synapses, not during the transmission of the action potential.

A patient with colorectal cancer has continuous, poorly localized abdominal pain at an intensity of 5 on a scale of 0 to 10. How does the nurse teach the patient to use pain medications? a. On an around-the-clock schedule b. As often as necessary to keep the pain controlled c. By alternating two different types of drugs to prevent tolerance d. When the pain cannot be controlled with distraction or relaxation

a. Analgesics should be scheduled around the clock for patients with constant pain to prevent pain from escalating and becoming difficult to relieve. If pain control is not adequate, the analgesic dose may be increased or an adjunctive drug may be added to the treatment plan.

A patient who has been taking ibuprofen (Motrin) and imipramine (Tofranil) for control of cancer pain is having increased pain. What would the healthcare provider recommend as an appropriate change in the medication plan? a. Add PO oxycodone (Oxycontin) to the other medications b. Substitute PO propoxyphene (Darvon), a mild opioid, for imipramine c. Add transdermal fentanyl (Duragesic) to the use of the other medications d. Substitute PO hydrocodone with acetaminophen (Lortab, Vicodin) for the other medications

a. As cancer pain increases, stronger drugs are added to the regimen. This patient is using a nonsteroidal anti-inflammatory drug (NSAID) and an antidepressant. A stronger preparation would be an opioid but because an NSAID is already being used, a combination NSAID/opioid is not indicated. An appropriate stronger drug would be an oral opioid, in this case, oral oxycodone, and this still leaves stronger drugs for expected increasing pain. Propoxyphene is not recommended in analgesic guidelines because of its limited efficacy and toxicities.

The patient has chronic pain that is no longer relieved with oral morphine. Which medication would the nurse expect to be ordered to provide better pain relief for this patient? a. Duragesic b. Oramorph SR c. Hydrocodone d. Intranasal butorphanol (Stadol)

a. Duragesic is frequently used for chronic pain in patients who are not opiate-naive. Oramorph SR given buccally will have the same absorption as morphine, so it would not be expected to be more effective than oral morphine. Hydrocodone is used for acute and short-term pain, not chronic pain. Intranasal butorphanol (Stadol) is used for acute headaches and recurrent, not chronic pain. The route used will depend on the swallowing ability of the patient.

A patient comes to the clinic with a complaint of dull pain in the anterior and posterior neck. On examination, the nurse notes that the patient has full range of motion (ROM) of the neck and no throat redness or enlarged head or neck lymph nodes. What will be the nurse's next appropriate assessment indicated by these findings? a. Palpation of the liver b. Auscultation of bowel sounds c. Inspection of the patient's ears d. Palpation for the presence of left flank pain

a. The right neck and flank are common areas of referred pain from liver damage and examination of the liver should be considered when pain occurs without other findings in these areas. Other commonly referred areas are the mid-scapular and left arm for cardiac pain, inner legs for bladder pain, and shoulders for gallbladder pain.

A patient with trigeminal neuralgia has moderate to severe burning and shooting pain. In helping the patient to manage the pain, the nurse recognizes what about this type of pain? a. Treatment includes the use of adjuvant analgesics b. Will be chronic in nature and require long-term treatment c. Responds to small to moderate around-the-clock doses of oral opioids d. Can be well controlled with salicylates or nonsteroidal antiinflammatory drugs (NSAIDs)

a. Damage to peripheral or cranial nerves causes neuropathic pain that is not well controlled by opioid analgesics alone and often includes the adjuvant use of tricyclic antidepressants or antiseizure drugs to help inhibit pain transmission. Salicylates and NSAIDs are not effective for the intensity of neuropathic pain.

List and briefly describe the five dimensions of pain

a. Physiologic—the anatomic and physical determinants of pain b. Affective—the emotional response to pain c. Cognitive—the beliefs, attitudes, and meanings attributed to pain d. Behavioral—observable actions that express or control pain e. Sociocultural—age and gender, family and caregiver influence, and culture that influences the pain experience

Which measures or drugs may be effective in controlling pain in the physiologic pain process stage of transduction (select all that apply)? a. Distraction b. Corticosteroids c. Epidural opioids d. Local anesthetics e. Antiseizure medications f. Nonsteroidal anti-inflammatory drugs (NSAIDs)

b, d, e, f. Distraction is effective in the perception stage. Epidural opioids are effective in the transmission stage.

While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient's heel. During care of the ulcer, what is the nurse's understanding of the patient's perception of pain? a. The patient will have a behavioral response if pain is perceived. b. The area should be treated as a painful lesion, using gentle cleansing and dressing. c. The area can be thoroughly scrubbed because the patient is not able to perceive pain. d. All nociceptive stimuli that are transmitted to the brain result in the perception of pain.

b. It is known that the brain is necessary for pain perception but because it is not clearly understood where in the brain pain is perceived, pain may be perceived even in a comatose patient who may not respond behaviorally to noxious stimuli. Any noxious stimulus should be treated as potentially painful.

A patient with multiple injuries resulting from an automobile accident tells the nurse that he has "bad" pain but that he can "tough it out" and does not require pain medication. To gain the patient's participation in pain management, what should the nurse explain to the patient? a. Patients have a responsibility to keep the nurse informed about their pain. b. Unrelieved pain has many harmful effects on the body that can impair recovery. c. Using pain medications rarely leads to addiction when they are used for actual pain. d. Nonpharmacologic therapies can be used to relieve his pain if he is afraid to use pain medications.

b. When a patient wants to be stoic about pain, it is important that he or she understand that pain itself can have harmful physiologic effects and that failure to report pain and participate in its control can result in severe unrelieved pain. No evidence that indicates fear of taking the medication is present in this situation.

On the first postoperative day following a bowel resection, the patient complains of abdominal and incisional pain rated 9 on a scale of 0 to 10. Postoperative orders include morphine, 4 mg IV q2 hr, for pain and may repeat morphine, 4 mg IV, for breakthrough pain. The nurse determines that it has been only 2 hours since the last dose of morphine and wants to wait a little longer. What effect does the nurse's action have on the patient? a. Protects the patient from addiction and toxic effects of the drug b. Prevents hastening or causing a patient's death from respiratory dysfunction c. Contributes to unnecessary suffering and physical and psychosocial dysfunction d. Indicates that the nurse understands the adage of "start low and go slow" in administering analgesics

c. Administering the smallest prescribed analgesic dose when given a choice is not consistent with current pain management guidelines and leads to undertreatment of pain and inadequate pain control. Without reassessing the pain within 30 minutes of the IV analgesic the nurse is unsure how well the previous dose of medication worked for the patient to determine the current dose needed. Unnecessary suffering, impaired recovery from acute illness, increased morbidity as a result of respiratory dysfunction, increased heart rate and cardiac workload, and other physical dysfunction can occur.

Pain has been defined as "whatever the person experiencing the pain says it is, existing whenever the patient says it does." This definition is problematic for the nurse when caring for which type of patient? a. A patient placed on a ventilator b. A patient with a history of opioid addiction c. A patient with decreased cognitive function d. A patient with pain resulting from severe trauma

c. Because the patient's self-report is the most valid means of pain assessment, patients who have decreased cognitive function, such as those who are comatose, have dementia, or are mentally disabled, might not be able to report pain. In these cases, nonverbal information and behaviors are necessary considerations in pain assessment.

The bone cells that function in the resorption of bone tissue are called a.osteoids b.osteocytes c.osteoclasts d.osteoblasts

c. Osteoclasts participate in bone remodeling by assisting in the breakdown of bone tissue.

Amitriptyline (Elavil) is prescribed for a patient with chronic pain from fibromyalgia. When the nurse explains that this drug is an antidepressant, the patient states that she is in pain, not depressed. What is the nurse's best response to the patient? a. Antidepressants will improve the patient's attitude and prevent a negative emotional response to the pain. b. Chronic pain almost always leads to depression, and the use of this drug will prevent depression from occurring. c. Some antidepressant drugs relieve pain by releasing neurotransmitters that prevent pain impulses from reaching the brain. d. Certain antidepressant drugs are metabolized in the liver to substances that numb the ends of nerve fibers, preventing the onset of pain.

c. Several antidepressants affect the modulatory systems by inhibiting the reuptake of serotonin and norepinephrine in descending modulatory fibers, thereby increasing their availability to inhibit afferent transmission of pain impulses. Although chronic pain is often accompanied by anxiety and depression, the antidepressants that affect the physiologic process of pain modulation are used for pain control whether depression is present or not.

List in order the nociceptive processes that occur to communicate tissue damage to the CNS. No. 1 is the first process and No. 4 is the last process. a. Perception b. Modulation c. Transmission d. Transduction

d-1, c-2, a-3, b-4

A postoperative 68-year-old opioid-naive patient is receiving morphine by patient-controlled analgesia (PCA) for postoperative pain. What is the rationale for not initiating the PCA analgesic with a basal dose of analgesic as well? a. Opioid overdose b. Lack of pain control c. Nausea and itching d. Adverse respiratory outcomes

d. The use of a basal dose may increase the risk of serious respiratory events in opioid-naive patients and those at risk for respiratory difficulties (older age, existing pulmonary disease, etc.). Overdose is not expected, as the dosages are calculated and the PCA pump is programmed to prevent this. Nausea and itching are common side effects but not related to a basal dose of analgesic. A lack of pain control would not be expected with or without a basal dose. The nurse would be assessing the patient and notify the physician if a lack of pain control occurs but, again, this is not related to receiving a basal dose of analgesic via PCA pump.