Comfort 1533
A client is experiencing uncontrollable back pain and a physical therapist suggests a back massage. The client asks the nurse how massage will help the pain. What is the best response by the nurse? -"Massage is widely practice by all hospitalized clients." -"A massage will relax muscles but does not work on ligaments and tendons." -"Massage is point stimulation used for orthopedic and neurological conditions." -"Massage is an alternative therapy that uses herbal supplements."
"Massage is point stimulation used for orthopedic and neurological conditions."
Which measure is contraindicated when the nurse assists a child who has leukemia with oral hygiene? -swabbing the mouth with moistened cotton swabs -cleaning the teeth with a toothbrush -applying petroleum jelly to the lips -rinsing the mouth with a nonirritating mouthwash
cleaning the teeth with a toothbrush
When planning pain control for a client with terminal gastric cancer, a nurse should consider that -pain medication should be given only when a client requests it. -clients with terminal cancer may develop tolerance to opioids. -only low doses of opioids are safe; higher doses may cause respiratory depression. -a client who can fall asleep isn't in pain.
clients with terminal cancer may develop tolerance to opioids
When caring for a client with acute osteomyelitis in the right tibia, which measure is most appropriate to implement when repositioning the client's leg? -Support the leg above and below the affected area when positioning. -Have the client move the leg by himself to decrease pain. -Apply warm, moist compresses to the leg before repositioning. -Hold the leg by the ankle when repositioning to avoid touching the tibia.
Support the leg above and below the affected area when positioning.
A nurse is caring for a child with intussusception. Which of the following is an expected client outcome related to the nursing diagnosis Acute pain related to cramping, which might be made for this child? -The child is very still. -The child has not vomited in 3 hours. -The child has a normal bowel movement. -The child exhibits no manifestations of discomfort.
The child exhibits no manifestations of discomfort.
A client is receiving cyclobenzaprine for management of a herniated lumbar disk. Which finding indicates the drug is providing the intended relief? -The client is sedated. -The client can take deep breaths. -The client's muscles are not in spasm. -The client is not anxious.
The client's muscles are not in spasm.
The nurse is caring for a client who has decided to bottle-feed her newborn after meeting with the lactation consultant. The client asks how to best reduce breast engorgement. What is the nurse's best response? -"We can speak to the healthcare provider about prescribing something to help slow milk production." -"Use ice packs, and avoid stimulating the breasts at all. It should resolve in a few days." -"You can relieve the pressure with gentle expression or by using a breast pump a few times a day." -"If you breast feed your baby, you will not have to deal with engorgement."
"Use ice packs, and avoid stimulating the breasts at all. It should resolve in a few days."
A client received propofol as the induction and maintenance agent for general anesthesia. What outcome of this drug should the nurse expect? -small tremors of the skeletal muscles -slow induction of anesthesia -minimal nausea and vomiting -hypertension
minimal nausea and vomiting
A young client is admitted with a diagnosis of somatic symptom disorder, but declines analgesic medications. The nurse learns that the client finds relief in regular hypnotherapy practice. The best response of the nurse should be: -"You have to believe in hypnosis for it to work." -"Explain how you find the procedure helpful." -"Hypnosis does not help with severe pain." -"Hypnosis is all entertainment and theater."
"Explain how you find the procedure helpful."
The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse? -"Some children distract themselves with play while in pain." -"The child's activity level is the best indicator of pain." -"Children don't experience as much pain after surgery as adults." -"A child who resumes usual play is not experiencing pain."
"Some children distract themselves with play while in pain."
A client hospitalized with Crohn's disease is experiencing a migraine aura. The client requests that the client's chiropractor be allowed to visit even though it is after visiting hours. What is the nurse's best response? -"I can bring you a PRN medication for your migraine." -"Chiropractors are not real doctors and cannot practice here." -"Tell me what helps your migraines outside of the hospital." -"You can't have a visitor if you are having migraine pain."
"Tell me what helps your migraines outside of the hospital."
A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse? -"Are you feeling all right?" -"Are you having pain in your leg?" -"Tell me what you are feeling." -"Do you need pain medication?"
"Tell me what you are feeling."
The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply. -"I can wash my face with cold water." -"If brushing my teeth is too painful, I'll try to rinse my mouth instead." -"Drinking fluids at room temperature should reduce pain." -"I'll eat food that is very hot." -"I'll try to chew my food on the unaffected side."
-"If brushing my teeth is too painful, I'll try to rinse my mouth instead." -"Drinking fluids at room temperature should reduce pain." -"I'll try to chew my food on the unaffected side."
A client who comes to the emergency department with multiple bruises on her face and arms, a black eye, and a broken nose says that these injuries occurred when she fell down the stairs. The nurse suspects that the client may have been physically assaulted. What should the nurse do next? -Ask the client specifically about the possibility of physical abuse. -Ask the client what she did to make someone beat her so badly. -Tell the client that it is difficult to believe that such injuries resulted from a fall. -Discuss with the client what she can do to deescalate the situation next time.
Ask the client specifically about the possibility of physical abuse.
The emergency department nurse is responsible for monitoring a 5-year-old client who is recovering from a moderate sedation procedure for reducing a forearm fracture. In the recovery phase, the child begins to wake up and is whimpering and crying, "Ouch, ouch, ouch." What should the nurse do? -Document normal recovery from procedure. -Titrate supplemental oxygen. -Assess pain using Wong-Baker FACES tool. -Evaluate client's ability to ambulate.
Assess pain using Wong-Baker FACES tool.
A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse? -Apply warm, moist heat to the right ankle area. -Repeat the dose of analgesic every hour. -Call the physician to report the finding. -Massage the client's foot in a circular motion.
Call the physician to report the finding.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? -Tilt the head back. -Compress the nares. -Collect the drainage. -Administer an antihistamine for postnasal drip.
Collect the drainage.
The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next? -Consult with a wound-ostomy-continence nurse specialist. -Reposition the client off the reddened skin and reassess in a few hours. -Complete and document a Braden skin breakdown risk score for the client. -Apply a moist-to-moist dressing, being careful to pack just the wound bed.
Reposition the client off the reddened skin and reassess in a few hours.
A community nurse is making a home visit to an elderly, depressed client. During the assessment, the client experiences periods of silence. What would be the appropriate nursing response during these periods of silence? -Change the subject by introducing a new topic of interest for the nurse. -Inform the client that the day is too busy to sit there in silence. -Sit quietly and allow the client to think. -Leave the client's home because the conversation is obviously finished.
Sit quietly and allow the client to think.
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? -Stop the feedings and check for residual volume. -Change the feeding container daily. -Place the client in semi-Fowler's position while feeding. -Give the feedings at room temperature.
Stop the feedings and check for residual volume.
The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control? -Get used to some pain, and use a little less medication than needed to keep from being addicted. -Take analgesics only when pain returns. -Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain. -Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain.
Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain.
A client receiving chemotherapy is nauseated and has lost 15 pounds (6.8 kg) in one month. Which nutritional instruction would the nurse include in the plan of care? -Increase fluids with meals and snacks. -Eat either hot or cold foods at meal times. -Eat two high-protein meals per day. -Eat frequent but small meals.
Eat frequent but small meals.
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? -supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware -providing comprehensive client teaching including symptoms of the disorder, treatment options, and expected outcomes -administering ordered analgesics and monitoring their effects -performing meticulous skin care
administering ordered analgesics and monitoring their effects
A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include -vigorous physical therapy for the joints. -administration of opioids for pain control. -administration of monthly intra-articular injections of corticosteroids. -administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.
administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.
A client with pancreatic cancer has been receiving morphine via a subcutaneous pump for 2 weeks. The client is requiring an increased dose of the morphine to manage the pain. How should the nurse document this finding? -showing addiction to morphine -developing a tolerance for the medication -tolerating the medication well -experiencing physical dependence
developing a tolerance for the medication
Which measure would the nurse expect to include in the teaching plan for a multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for cystitis? -avoiding the intake of acidic fruit juices until the treatment is discontinued -washing the perineum with povidone iodine after voiding -emptying the bladder every 2 to 4 hours while awake -limiting fluid intake to 1 L daily to prevent overload
emptying the bladder every 2 to 4 hours while awake
A client reports nausea unrelieved by a recent antiemetic dose. The client asks for another treatment for the nausea. What is an alternative therapy to treat nausea? -kava -raspberry -ginger -red clover
ginger
A client discusses with the nurse the possibility of using alternative therapies for management of hypertension and diabetes. Which is an expected alternative therapy used by the client? -melatonin -ginseng -kava -jojoba
ginseng
After a total hip replacement, the client tells the nurse that the pain in the operative hip has increased. Assessing the hip and leg, the nurse notes that the leg is internally rotated and shorter than the other leg and that the client has difficulty moving the leg. Based on this information, the nurse determines that the client: -has experienced a dislocation of the hip prosthesis. -would benefit from additional muscle-strengthening exercises. -requires repositioning to achieve better alignment of the leg. -has experienced increased pain due to a muscle spasm.
has experienced a dislocation of the hip prosthesis.
A client asks about complementary therapies for relief of discomfort related to pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching? -meditation -music therapy -acupuncture -herbal remedies
herbal remedies
A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide factor replacement and implements which intervention? -institutes rest, ice, compression, and elevation -initiates skin traction immobilization -begins physical therapy with active range of motion -administers an aspirin-containing compound
institutes rest, ice, compression, and elevation
Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? -weight loss -anemia -local joint pain -osteoporosis
local joint pain
When the nurse is assessing a client who reports a back injury, what should the nurse ask the client about first? -personal history of illness -mechanism of injury -family history of back problems -previous hospitalizations
mechanism of injury
A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen? -spasticity related to stroke -muscle spasms with paraplegia or quadriplegia from spinal cord lesions -acute, painful musculoskeletal conditions -skeletal muscle hyperactivity secondary to cerebral palsy
muscle spasms with paraplegia or quadriplegia from spinal cord lesions
A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective? -back -fundus -abdomen -perineum
perineum
A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to: -control internal bleeding. -maintain skin integrity. -prevent neurologic damage. -realign fracture fragments.
realign fracture fragments.
The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort? -red, warm, palpable linear cord along the vein that is painful on palpation -brown discoloration of the skin with edema in the lower left leg -absence of pain or swelling when the client dorsiflexes the left foot -dark, protruding veins of both legs that are uncomfortable when standing
red, warm, palpable linear cord along the vein that is painful on palpation
A client has an exacerbation of multiple sclerosis. The physician orders dantrolene, 25 mg P.O. daily. Which assessment finding indicates the medication is effective? -relief from constipation -relief from pain -increased ability to sleep -reduced muscle spasticity
reduced muscle spasticity
After the client returns from surgery for a deviated nasal septum, the nurse should place the client in what position? -reverse Trendelenburg's -semi-Fowler's -supine -left side lying
semi-Fowler's
The nurse is planning care for a group of clients who requested the use of yoga. The client with which condition is not a candidate for yoga? -spinal fusion -diabetes -arthritis -anxiety
spinal fusionSeal off the track left by the needle in the tissue.Seal off the track left by the needle in the tissue.
A client with chronic cancer pain has been receiving opiates for 4 months. She rated the pain as an 8 on a 10-point scale before starting the opioid medication. Following a thorough examination, there is no new evidence of increased disease, yet the pain is close to 8 again. What is the most likely explanation for the increasing pain? -placebo effect has decreased -tolerance to the opioid -withdrawal from the opioid -development of an addiction to the opioids
tolerance to the opioid
why would a nurse place a yanker at bedside of the patient? -during an ostomy irrigation -following nasal surgery -when the tracheostomy becomes obstructed -when the oral cavity has thick secretions
when the oral cavity has thick secretions
A client is admitted with an infectious wound. Contact precautions are initiated. To help the client cope with staff using isolation procedures, which nursing action is most helpful? -Don gloves when providing all client care. -Speak to the client from the doorway unless needing close contact. -Discuss the rationale for contact precautions. -Put stickers on the face mask to increase conversation.
Discuss the rationale for contact precautions.
A client is talking with the nurse about unsightly varicose veins and their discomfort. What information should the nurse provide to the client? -Avoid walking to reduce the discomfort. -Keep the legs elevated when sitting or lying down. -Contact a surgeon to perform a femoral-popliteal bypass graft. -Sclerotherapy can be used for cosmetic improvement.
Keep the legs elevated when sitting or lying down.
A short time after cataract surgery, the client has nausea. What should the nurse do first? -Explain that this is a common feeling that will pass quickly. -Medicate the client with an antiemetic, as prescribed. -Tell the client to call the nurse promptly if vomiting occurs. -Instruct the client to take a few deep breaths until the nausea subsides.
Medicate the client with an antiemetic, as prescribed.
A client with cholecystitis is taking propantheline bromide. What should the nurse tell the client to expect as a result of taking this drug? -absence of infection -increased bile production -decreased biliary spasm -relief from nausea
decreased biliary spasm
When bandaging a client's ankle, the nurse should use which technique? -spiral reverse -figure-eight -recurrent -circular
figure-eight
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? -Rub the nipples gently with lanolin cream. -Express a small amount of breast milk. -Offer the neonate a small amount of formula. -Apply an ice cube to the nipples.
Express a small amount of breast milk.
The nurse is assessing a client experiencing a sickle cell crisis who continues to rate the pain at 10 on a scale of 1 to 10. Which is true about pain? -Expression and perception of pain vary widely from person to person. -Tolerance of pain is determined by a person's genetic makeup. -Tolerance of pain is the same in all people. -Pain perception is the same in all people.
Expression and perception of pain vary widely from person to person.
A client is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) to manage the pain of rheumatoid arthritis. What information should the nurse give to the client about taking these medications? -Take antacids 1 hour after taking NSAIDs. -Take NSAIDs with food. -Take NSAIDs at least three times per day. -Exercise the joints at least 1 hour after taking the medication.
Take NSAIDs with food.
The client with first-time bacterial cystitis is being treated with an antibiotic to be taken for 7 days. What should the nurse instruct the client to do? -Take the entire prescription as ordered. -Use condoms if having sex. -Limit fluids to 1,000 mL/day. -Notify the health care provider (HCP) when the urine is clear.
Take the entire prescription as ordered.
While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which statement is the most therapeutic response by the nurse? -"I am sure the doctor has ordered the appropriate amount of narcotic." -"Do you want me to call the doctor now and explain that you are concerned?" -"You don't need to worry at this point about too much pain medication." -"You are concerned that the client is receiving too much narcotic medication?"
"You are concerned that the client is receiving too much narcotic medication?"
A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? -Place the client on NPO status, and notify the health care provider immediately. -Notify the dietitian to change the diet to clear fluids, and cancel physiotherapy until the client's strength resumes. -Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. -Administer an antiemetic to reduce the nausea, and send the client to physiotherapy.
Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.
The nurse gives a client an oral narcotic analgesic medication to treat postoperative pain. Which follow-up assessment most clearly indicates that the treatment was effective? -Within 10 minutes the client is moving down the hall. -Within 40 minutes the client breathes slowly with eyes closed. -Within 20 minutes the client is reading with a relaxed posture. -Within 30 minutes the client says that the pain is reduced.
Within 30 minutes the client says that the pain is reduced.
A client is describing to a nurse a special type of therapy using needles inserted in specific areas along channels in the skin. What type of therapy is the client describing? -herbal therapy -yoga -biofeedback -acupuncture
acupuncture
A client comes to the emergency department reporting severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? -risk for infection -imbalanced nutrition: less than body requirements -impaired urinary elimination -acute pain
acute pain
A nurse is caring for a client diagnosed with ovarian cancer. Diagnostic testing reveals that the cancer has spread outside the pelvis. The client has previously undergone a right oophorectomy and received chemotherapy. The client now wants palliative care instead of aggressive therapy. The nurse determines that the care plan's priority nursing diagnosis should be: -noncompliance. -knowledge deficit: chemotherapy. -acute pain. -impaired home maintenance.
acute pain.
The nurse is caring for a client postoperatively after having a low anterior resection of the colon 6 hours prior. The client rates incisional pain 6/10. The prescribed orders include morphine 1 to 2 mg IV every hour as needed for pain. The client is alert with vital signs within normal limits. How will the nurse best manage the client's pain? -administer morphine 2 mg IV and reassess pain level in 1 hour -administer morphine 1 mg IV and reassess pain level in 20 minutes -administer morphine 1 mg IV and repeat the dose in 1 hour -administer morphine 1 mg IV followed by morphine 2 mg IV in 1 hour
administer morphine 1 mg IV and reassess pain level in 20 minutes
A nurse is caring for a client 1 hour post-laparotomy who reports abdominal pain rating 5/10. What will the nurse prioritize when administering the ordered morphine? -administer the medication when the pain is reported as 9/10 -administer the medication every 3 hours around the clock -administer the medication before the pain becomes severe -minimize medication administration to avoid dependency
administer the medication before the pain becomes severe
A client in the hospital for gout reports an excruciating migraine but declines analgesic medications when offered. Later the nurse observes a visitor performing what appears to be a type of physical manipulation of the client's head and neck. The client reports that the visitor is a therapist. The best action for the nurse to take is to: -advise the client how the client might receive adjunct services. -notify the physician to restrict the client's visitors. -call security to escort the visitor out of the hospital. -alert staff that this client is receiving illicit treatment.
advise the client how the client might receive adjunct services.
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6° F (38.1° C). Which outcome would be a priority for this client? -alleviation of nausea -alleviation of pain -prevention of urinary tract complications -maintenance of fluid and electrolyte balance
alleviation of painThe child exhibits no manifestations of discomfort.
A postpartum woman who gave birth vaginally has unrelenting rectal pain despite the administration of pain medication. Which action is most indicated? -administering additional pain medications -preparing a warm sitz bath for the client -reassuring the client that such pain is normal after vaginal birth -assessing the perineum
assessing the perineum
A client who recently immigrated from Korea to the US or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time? -calling a family member to obtain information about the client -checking vital signs and assessing for nonverbal indications of pain -giving the client the ordered as-needed pain medication -documenting that the client is resting quietly and denies pain
checking vital signs and assessing for nonverbal indications of pain
The nurse is caring for a group of clients. The client with which condition is most likely to benefit from acupressure treatment? -venous lower leg ulcer -small bowel obstruction -chronic lower back pain -pneumonia with shortness of breath
chronic lower back pain
A client has been taking prescribed aspirin in large doses and reports having stomach irritation, sometimes with vomiting. Which food or beverage noted from the client's diet history should the nurse suggest the client avoid? -glass of wine -dry toast -scrambled eggs -sweetened tea
glass of wine
A professional artist is admitted to the psychiatric unit for treatment of bipolar disorder. During the previous 2 weeks, the client has created 154 paintings, slept only 2 to 3 hours every 2 days, and lost 18 lb (8.2 kg). Based on Maslow's hierarchy of needs, what should the nurse provide this client with first? -experiences that build self-esteem -the opportunity to explore family dynamics -help with reestablishing a normal sleep pattern -art materials and equipment
help with reestablishing a normal sleep pattern
Which nursing measure would most likely relieve postoperative gas pains after abdominal hysterectomy? -helping the client walk -applying a snugly fitting abdominal binder -providing extra warmth -offering the client a hot beverage
helping the client walk
A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority? -depression -pain -sexual dysfunction -self-consciousness
pain
For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep? -playing soft or soothing music -encouraging the client to be less active during the day -increasing the client's activity 2 hours before bedtime -serving the client a cup of coffee and a snack in the evening
playing soft or soothing music
Which action is most important when the nurse is planning pain management for a client after a lobectomy for lung cancer? repositioning the client immediately after administering pain medication reassessing the client after administering pain medication reassuring the client after administering pain medication readjusting the pain medication dosage as needed
reassessing the client after administering pain medication
A client in a double hip spica cast is constipated. The surgeon cuts a window into the front of the cast. Which outcome is intended? The window in the cast will allow: The window will allow the nurse to palpate the superior mesenteric artery. the nurses to reposition the client. the surgeon to manipulate the fracture site. relief from pressure due to abdominal distention.
relief from pressure due to abdominal distention.
The client with a fractured tibia has been taking methocarbamol. Which finding indicates that the drug is having the intended effect? -lack of infection -reduction in itching -relief of muscle spasms -decrease in nervousness
relief of muscle spasms
A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the drug is effective when it produces which outcome? -induces sleep. -stimulates the client's appetite. -relieves muscular spasticity. -reduces the urine bacterial count.
relieves muscular spasticity.
A client presents to the emergency department complaining of a dull, constant ache along the right costovertebral angle along with nausea and vomiting. The most likely cause of the client's symptoms is -overdistended bladder. -interstitial cystitis. -acute prostatitis. -renal calculi.
renal calculi.
When determining how to administer analgesics to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia since it is more effective because: -two opioids can be administered simultaneously. -the nurse interrupts the client less frequently and the client can get more sleep. -the client will control the amount of pain medication administered. -a different opioid can be used.
the client will control the amount of pain medication administered.
A client is resting in bed. The nurse visits the client to reassess the client's pain. The nurse notices that a visitor is in the room and is touching the client in various places on the client's body. The nurse understands that this type of practice is called: -herbal medicine. -yoga. -therapeutic touch. -traditional Chinese medicine.
therapeutic touch.
A client was discharged from the hospital for cancer-related pain. While in the hospital the pain was well controlled on patient-controlled administration (PCA) of IV morphine, and on discharge 2 days ago was taking oral morphine. The client now reports pain as an 8 on a 10-point scale and is asking the nurse about using PCA for the morphine at home. Which explanation is the most likely for the client's reports of inadequate pain control? The client is: -going through withdrawal from the IV opioid. -addicted to the IV morphine. -physically dependent on the IV morphine. -undermedicated on the oral opioid.
undermedicated on the oral opioid.
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? -"Increase your fluid intake to 2 to 3 L per day." -"Apply an antibacterial dressing to the incision daily." -"Be aware that your urine will be cherry-red for 5 to 7 days." -"Take your temperature every 4 hours."
"Increase your fluid intake to 2 to 3 L per day."
The nurse teaches a primigravid client how to do Kegel exercises. What does the nurse explain is the expected outcome of these exercises? -alleviating lower back discomfort -reducing the risk of hemorrhoids -strengthening the abdominal muscles -strengthening the perineal muscles
strengthening the perineal muscles
A parent is concerned about spoiling a 2-month-old child by picking up the child each time the child cries. Which suggestion should the nurse offer? -"Continue to pick up the crying baby because young infants need cuddling and holding to meet their needs." -"Leave your baby alone for 10 minutes. If the crying hasn't stopped then, pick up the baby." -"Crying at this age indicates hunger. Try feeding when your baby cries." -"If the baby's diaper is dry, leave the baby alone to fall asleep."
"Continue to pick up the crying baby because young infants need cuddling and holding to meet their needs."
The nurse gives a pamphlet that describes Kegel exercises to a client with stress incontinence. Which statement indicates that the client has understood the instructions contained in the pamphlet? -"I should perform these exercises every evening." -"I need to tighten my abdominal muscles to do these exercises correctly." -"It will probably take a year before the exercises are effective." -"I can do these exercises sitting up, lying down, or standing."
"I can do these exercises sitting up, lying down, or standing."
The nurse developed a plan of care for an adolescent who is receiving chemotherapy for lymphoma and has developed stomatitis. What statement made by the adolescent demonstrates understanding of the education provided from the plan of care? -"I will use an alcohol based mouthwash after brushing my teeth." -"I will remove the white patches from my tongue and cheek with a toothbrush." -"I will use a hard bristle toothbrush to clean my teeth." -"I will rinse my mouth every 2-4 hours with baking soda and water."
"I will rinse my mouth every 2-4 hours with baking soda and water."
The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which statement by the client indicates that the client understands the teaching? -"A heating pad, set on the lowest setting, will help decrease my discomfort." -"It's safe to apply a non-perfumed lotion to my skin." -"I can apply an over-the-counter cortisone ointment to relieve the dryness." -"I should take antihistamines to decrease the itching I'm experiencing."
"It's safe to apply a non-perfumed lotion to my skin."
A client with a moderate level of anxiety is pacing quickly in the hall and tells the nurse, "Help me. I can't take it anymore." What would be the nurse's best initial response? -"Let's go to a quieter area where we can talk if you want." -"Try doing your relaxation exercises to calm down." -"It would be best if you would lie down until you are calmer." -"I'll get some medicine to help you relax."
"Let's go to a quieter area where we can talk if you want."
A nurse is caring for a client who complains of lower back pain. Which instruction should the nurse give to the client to prevent back injury? -"Bend over the object you're lifting." -"Push or pull an object using your arms." -"Stand close to the object you're lifting." -"Narrow the stance when lifting."
"Stand close to the object you're lifting."
A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate? -"Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." -"Tell the health care provider about your symptoms. Maybe your analgesic medication can be increased." -"Take a warm tub bath or shower before exercising. This may help with your discomfort." -"You're probably exercising too much. Decrease your exercise to every other day."
"Take a warm tub bath or shower before exercising. This may help with your discomfort."
After teaching the client how to use the patient-controlled analgesia (PCA) pump, the nurse determines that the client understands the use of the PCA when the client makes which statement? -"The machine will give me only the prescribed amount of pain medication even if I push the button too soon." -"I should wait until the pain is really bad before I push the button to get more pain medicine." -"I have to be careful about pushing the button too many times or I will overdose." -"It's OK for my family to press the button for me if I'm too tired to do it myself."
"The machine will give me only the prescribed amount of pain medication even if I push the button too soon."
The nurse is caring for a client who is in the transitional stage of labor. The client's partner is concerned and asks, "What else can I do for my partner? She is so irritable." Which of the following interventions would the nurse suggest? Select all that apply. -"It is time to have your partner push. I will help you explain what to expect." -"Continue to praise your partner and give her encouragement." -"Encourage your partner to rest in between contractions." -"Your partner should not be this upset. I will call the doctor immediately." -"Stay by your partner's side. It is important that she knows you are there to support her."
-"Continue to praise your partner and give her encouragement." -"Encourage your partner to rest in between contractions." -"Stay by your partner's side. It is important that she knows you are there to support her."ginger
The nurse is caring for a client in labor. The client wishes to have a "nonmedicated" labor and birth. During the early stages of labor, the client becomes frustrated with the use of music and imagery. Which of the following would the nurse include in the client's plan of care? Select all that apply. -Offer the use of a yoga ball. -Administer butorphal IV. -Suggest a shower or bath. -Encourage ambulation. -Offer the client epidural anesthesia.
-Encourage ambulation. -Suggest a shower or bath. -Offer the use of a yoga ball.
The nurse is caring for a 5-year-old child in pain. What is the best method to assess the child's pain? -Ask the child to describe the way the pain feels. -Observe the child for behaviors such as crying and restlessness. -Ask the child to rate the pain intensity on a scale of 1 to 10. -Ask the child to point to a face drawing that indicates pain intensity.
Ask the child to point to a face drawing that indicates pain intensity.
A client has a transurethral resection of the prostate to treat benign prostatic hyperplasia. The client returns to the room with continuous bladder irrigation and reports bladder pain. What is the priority nursing action? -Calculate the client's recent intake and output. -Assess irrigation catheter for patency and drainage. -Administer morphine sulfate 2 mg IV, as prescribed. -Notify the healthcare provider immediately.
Assess irrigation catheter for patency and drainage.
The nurse is caring for a very anxious child whose pain has not been manageable. The parents stay in the child's room, crying and yelling at each other. Grandparents and other family members are also constantly in attendance. To effectively help the child with pain management, which action should be a priority for the nurse? -Request that hospital security remove all visitors from the child's room. -Administer medication to help the child sleep during the night. -Develop a visitation schedule with the family that allows the child to rest. -Tell the parents that their behavior is increasing the child's pain.
Develop a visitation schedule with the family that allows the child to rest.
A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? -Try to persuade the client to take the medication as ordered by the doctor. -Emphasize the rationale for taking the medication now as ordered. -Document the client's choice and re-assess pain in 1 hour. -Ask the client's spouse to hold the client's hands while the nurse puts the pill under the tongue.
Document the client's choice and re-assess pain in 1 hour.
Which recommendation would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks' gestation who is experiencing occasional heartburn? -Decrease fluid intake to four glasses daily. -Take a pinch of baking soda with water before meals. -Drink several cups of regular tea throughout the day. -Eat smaller and more frequent meals during the day.
Eat smaller and more frequent meals during the day.
An 18-month-old child is admitted to the pediatric unit. Which of the following can the nurse do to reduce the stress on the client during this hospitalization? -Minimize needle sticks to the client -Encourage play times with other children on the unit -Encourage the client's caregivers to be with the client as much as possible -Allow the child to explore the environment
Encourage the client's caregivers to be with the client as much as possible
An adolescent in the terminal stage of leukemia cries out for more pain medicine. What is the best action for a nurse to take in caring for this dying adolescent? -Give the adolescent more pain medication to control pain and suffering. -Withhold medication because the adolescent has a low pain threshold. -Maintain a strict medication administration schedule. -Withhold pain medication because the adolescent may become addicted to it.
Give the adolescent more pain medication to control pain and suffering.
A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first? -Give the child a nonopioid analgesic for pain. -Keep the child in a comfortable position and apply ice to the injured shoulder. -Ask the child to demonstrate full range of motion of the left arm. -Apply a warm compress to the injured shoulder.
Keep the child in a comfortable position and apply ice to the injured shoulder.
After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first? -self-catheterization -artificial sphincter use -Kegel exercises -fluid restriction
Kegel exercises
When developing the postoperative plan of care for a child who is scheduled to have a tympanostomy tube inserted into the right ear, which intervention should the nurse identify to facilitate drainage? -Apply warm compresses to the right ear. -Apply a gauze dressing to the left ear. -Position the child to lie on the right side. -Apply an ice pack to the left ear.
Position the child to lie on the right side.
A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which suggestion would be most helpful? -Drink a small glass of wine with dinner. -Drink a cup of hot chocolate before bedtime. -Exercise for 30 minutes just before bedtime. -Practice relaxation techniques before bedtime.
Practice relaxation techniques before bedtime.
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? -Providing a solution of viscous lidocaine for use as a mouth rinse -Recommending that the client discontinue chemotherapy -Monitoring the client's platelet and leukocyte counts -Checking regularly for signs and symptoms of stomatitis
Providing a solution of viscous lidocaine for use as a mouth rinse
A nurse is completing an admission assessment. The nurse asks the client about social support systems and the client asks the nurse to explain social support systems. Which statement describes a social support system? -"It is a source of payment options to aid in the hospital bill of the client." -"It is a health care system with a variety of educators available in the community." -"It is a group of health care providers who are available to assist with care needed for the client's family." -"It is a group of friends and colleagues at home and in the community that help a client in times of need."
"It is a group of friends and colleagues at home and in the community that help a client in times of need."
A client is admitted to the hospital following an inadvertent overdose with oxycodone. He reveals that he has chronic back pain that resulted from an injury on a construction site. He states, "I know I took too much oxycodone at once, but I can't live with this pain without them. You can't take them away from me." Which response by the nurse is most appropriate? -"You're going to be switched from the oxycodone to methadone for long-term pain management." -"The oxycodone will be stopped tomorrow, but you'll have lorazepam to help you with the withdrawal symptoms." -"Your pain will be controlled by tapering doses of oxycodone and with other pain management strategies and medicines." -"Once you're tapered off the oxycodone, you will find that nonaddictive pain medicines will be enough to control your pain."
"Your pain will be controlled by tapering doses of oxycodone and with other pain management strategies and medicines."
The client reports that the nasal packing is uncomfortable and asks when it will be removed. The nurse should tell the client the nasal packing is usually removed: -after nasal edema subsides. -24 to 48 hours after surgery. -after pain has diminished. -the day of surgery.
24 to 48 hours after surgery.
A nurse is preparing a 24-hour-old baby boy for circumcision. The hospital policy guidelines for circumcision support pain medication at least 1 hour prior to the start of the procedure. The provider did not order the pain medication. The provider arrives, and the nurse refuses to bring the baby for the circumcision stating that the pain medication was not ordered. Which is the rationale for refusing to bring the baby for the procedure? -A nurse is allowed to refuse orders only if another nurse can attest that the order is dangerous to the client. -A nurse can refuse and request another provider to perform the procedure because of inadequate prep. -A nurse can refuse until the order requiring premedication is changed. -A nurse has a right to refuse orders that might be harmful to the client.
A nurse has a right to refuse orders that might be harmful to the client.
A child experiences nausea and vomiting after receiving cancer chemotherapy drugs. What is most important for the nurse to include in the plan of care? -Eliminate perfumes and other odors during the chemotherapy session. -Administer an antiemetic 30 to 60 minutes before the next chemotherapy session. -Encourage the child to eat a bland diet after chemotherapy treatment. -Administer an antiemetic upon completion of chemotherapy treatment.
Administer an antiemetic 30 to 60 minutes before the next chemotherapy session.
The nurse is developing a care plan for a client with cancer receiving hospice home care. Which would be the most appropriate action for managing the client's chronic pain? -Administer analgesics regularly and additionally as needed for break-through pain. -Administer analgesics when vital signs indicate increased pain severity. -Avoid intravenous pain medication until the client is terminal. -Sedate the client with tranquilizers.
Administer analgesics regularly and additionally as needed for break-through pain.
Two days after surgery to amputate the left lower leg, a client states that they have pain in the missing extremity. There is an existing prescription for PRN pain medication. Which action by the nurse is most appropriate? -Administer medication for the reported discomfort. -Request a consult with a psychologist. -Contact the health care provider. -Do nothing because it isn't possible to have pain in a missing limb.
Administer medication for the reported discomfort.
A client complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses the pain, the client states, "My pain is a 7 out of 10." What action by the nurse would be most appropriate? -Provide diversional activities to distract the client. -Administer pain medication as ordered. -Ask the client what makes the pain better. -The nurse doesn't need to do anything for this pain level.
Administer pain medication as ordered.
A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? -Administer pain medication per prescription. -Replace ice packs to the perineum. -Begin sitz baths. -Initiate anesthetic sprays to the perineum.
Administer pain medication per prescription.
The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse should tell them? -Dehydration is expected during the dying process. -Dehydration may prolong the dying process. -Hydration is used only in extreme situations of dehydration. -The health care provider (HCP) will make the decision regarding hydration therapy.
Dehydration is expected during the dying process.
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next? -Report the incident to the team leader. -Ask the surgical resident to write a prescription for a stronger pain medication. -Wait until the next shift and ask the nurse on that shift to contact the HCP. -Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.
Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.
A client hospitalized for a round of chemotherapy reports being very distressed at being unable to sleep because of a series of roommates who have been actively withdrawing from opioids. The nurse responds that they must accept clients who are detoxing from prescribed and illicit drugs. Which action should the nurse take? -Recommend the client request to sign out against medical advice. -Explore difficulties, identify solutions, and negotiate short-term aids. -Advise the client to ask the physician to transfer to another ward. -Ask the client's physician for an order to avoid this type of roommate.
Explore difficulties, identify solutions, and negotiate short-term aids.
A client comes into the emergency department with severe back pain radiating to the left lower groin. The healthcare provider prescribes morphine sulfate 5-10 mg IV every 2 hours. One hour after receiving 10 mg of morphine, the client is restless and distressed, reporting the pain is still at 8 of 10. What action will the nurse take? -Review the client's medical record for evidence of past opioid misuse or drug-seeking behavior to help direct the best course of action. -Reassess the client's pain and associated symptoms, and report findings to the healthcare provider to advocate for better pain control. -Tell the client that the order is for every 2 hours, and explain that an additional dose cannot be given for at least one more hour. -Explain that a high dose of the pain medication has been administered and that taking more too soon can lead to respiratory depression.
Reassess the client's pain and associated symptoms, and report findings to the healthcare provider to advocate for better pain control.
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? -Reduce pain and myocardial oxygen demand. -Provide client education on medications and diet. -Monitor daily weights and urine output. -Limit visitation by family and friends.
Reduce pain and myocardial oxygen demand.
A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client? -Discuss nutritional strategies to decrease the possibility of heartburn. -Support the client's use of acetaminophen to relieve pain. -Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. -Refer the client to her health care provider for evaluation and treatment of the pain.
Refer the client to her health care provider for evaluation and treatment of the pain.
A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse? -Give the placebo but do not tell the client it is a stronger medication. -Consult with the pharmacist to discuss the dosage of the placebo. -Refuse to administer the placebo to the client. -Give the placebo as ordered by the physician.
Refuse to administer the placebo to the client.
A client is to receive an IM injection using a Z-track injection technique. The nurse holds the gauze pledget against an IM injection site while removing the needle from the muscle. What is the intended outcome of this technique? -Prevent organisms from entering the body through the skin puncture. -Seal off the track left by the needle in the tissue. -Avoid the discomfort of the needle pulling on the skin. -Speed the spread of the medication in the tissue.
Seal off the track left by the needle in the tissue.
A client is 2 days postoperative of a hip replacement. The prescriber removed the gauze dressing and gave the patient and nurse instructions to keep the site open to air. In the afternoon, the nurse observed the client rubbing an oil on the surgical site. What is likely the client's rationale regarding the application of the complementary oil? -Fish oil has antiviral properties. -Tea tree oil has antibacterial properties. -Antiperspirant will aid with vasoconstriction. -Baby oil can assist with smooth skin.
Tea tree oil has antibacterial properties.
The nurse is trying to establish a trusting relationship with a client experiencing pain. When the client asks for pain medication, the nurse notes that it is not time to give the medication. What is the best action by the nurse to facilitate a trusting relationship? -Tell the client a personal story about difficulty managing pain. -Tell the client how unfortunate the situation is and offer distraction. -Tell the client when the medication is due and return promptly at that time. -Tell the client that a more experienced nurse will administer the pain medication.
Tell the client when the medication is due and return promptly at that time.
The use of a patient-controlled analgesia (PCA) pump is effective in which situation? -There is decreased cost by decreasing use of intramuscular (IM) injections. -The family can assist the client in managing the pain. -The client does not become dependent on opioids postoperatively. -The client achieves a therapeutic level of analgesia.
The client achieves a therapeutic level of analgesia.
The nurse is caring for a client whose somatic symptom disorder is characterized by frequent descriptions of pain. What statement is true of this client's pain? -The pain is less than would be expected as a result of the underlying disorder the client identifies. -The pain is intentionally fabricated by the client to receive attention. -The pain is real to the client, even though the pain may not have an organic etiology. -The pain is what would be expected as a result of the underlying disorder the client identifies.
The pain is real to the client, even though the pain may not have an organic etiology.