Exam 1

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? a. Dysphagia b. Positive Babinski skin c. Decreased deep-tendon reflexes d. Ataxia

a. Dysphagia Rationale: Dysphagia is difficulty swallowing and can occur as a result of damage to Cranial Nerve IX (glossopharyngeal) and X (vagus).

A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? a. Transient pain b. Superficial pain c. Phantom pain d. Referred pain

d. Referred pain

Non-drug therapies

superficial and deep massage, exercise, transcutaneous electrical nerve stimulation (TENS), acupuncture, and thermal treatment distraction, hypnosis, and relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation

Results of stimulation of the parasympathetic nervous system are (select all that apply) A. constriction of the bronchi. B. dilation of skin blood vessels. C. increased secretion of insulin. D. increased blood glucose levels. E. relaxation of the urinary sphincters

A, B, C, D Parasympathetic nervous system stimulation results in constriction of the bronchi, dilation of blood vessels to the skin, increased secretion of insulin, and relaxation of the urinary sphincter. Sympathetic nervous system stimulation results in increased blood glucose levels.

Purpose of antiseizure drugs?

Antiseizure drugs affect peripheral nerves and the CNS Effective for neuropathic pain and preventative treatment of migraine headaches

Administration techniques

Appropriate analgesic scheduling focuses on prevention or control of pain rather than the provision of analgesics only after the patient's pain has become severe. • Analgesic titration is dose adjustment based on assessment of the adequacy of the analgesic effect versus the side effects produced.

The nurse should teach a patient to avoid which medication while taking ibuprofen? Aspirin Furosemide Nitroglycerin Morphine sulfate

Aspirin Rationale: The patient should not take aspirin while taking ibuprofen because the combination could increase the risk of gastrointestinal bleeding.

How do you assess the accessory (XI) nerve? A. Assess the gag reflex by stroking the posterior pharynx. B. Ask the patient to shrug the shoulders against resistance. C. Ask the patient to push the tongue to either side against resistance. D. Have the patient say "ah" while visualizing elevation of the soft palate

B. The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance. The other options are used to test the glossopharyngeal and vagus nerves.

The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? A. "Have you considered working with a physical therapist?" B. "What activities, if any, has your pain prevented you from doing?" C. "Would you please rate your pain on a scale from 1 to 10 for me?" D. "What effect does your pain medication typically have on your pain?"

B. "What activities, if any, has your pain prevented you from doing?"

A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following? a. Confusion b. Arousal c. Orientation d. Attention

B. Arousal Rationale: Withdrawing the hand in response to nailbed pressure indicates responsiveness to sensory stimulation. Wrong answers: Confusion: to demonstrate confusion, the client would have to respond in some way to specific questions that the nurse asks or behaves in a specific way. The nurse can use several tools such as the Confusion Assessment method to determine confusion. Orientation: To demonstrate orientation, the client would have to respond in some way to specific questions the nurse asks (e.g. current month, year). Attention: to demonstrate attention, the client would have to respond in some way to specific questions the nurse asks (being able to repeat a series of 3 numbers stated by the nurse).

A nurse in the emergency department is caring for a client who reports pain in her left leg following a motor-vehicle crash. The client's left leg has bruising, swelling, and displacement of bones. Which of the following actions should the nurse take first? a. obtain an x ray of the injured leg b. apply ice packs to the affected area c. check neurovascular status distal to injury d. elevate the affected leg on 2 pillows

C. Check neurovascular status distal to injury Rationale: The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the greatest safety risk to the client... The greatest risk to this client is impaired circulation to the limb from trauma and the resulting edema; therefore, the first action is to check the circulation, sensation, and movement distal to the level of injury.

Nonopioids can produce tolerance T/F

F

The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8 breaths/min. Which medication would the nurse prepare to administer to treat these symptoms?

Nalaxone

A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate? "PCA will never be effective unless a loading dose is given first." "The IV push dose will enhance the effects of the PCA for the next 8 hours." "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim."

"The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." Rationale: An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off.

Why are the data regarding mobility, strength, coordination, and activity tolerance important for you to obtain? A. Many neurologic diseases affect one or more of these areas. B. Patients are less able to identify other neurologic impairments. C. These are the first functions to be affected by neurologic disease. D. Aspects of movement are the most important function of the nervous system.

A Many neurologic disorders can cause problems in the patient's mobility, strength, and coordination. These problems can result in changes in the patient's usual activity and exercise patterns.

The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.) A. Past medical history of gastric ulcer B. Patient states last bowel movement was 4 days ago C. Stated allergy to aspirin D. Patient states has 2/10 intermittent joint pain E. Patient experienced respiratory depression after administration of an opioid medication

A. Past medical history of gastric ulcer C. Stated allergy to aspirin

A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate? A. "PCA will never be effective unless a loading dose is given first." B. "The IV push dose will enhance the effects of the PCA for the next 8 hours." C. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." D. "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim."

C. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off.

During a neurological assessment, a nurse asks how the client arrived at the appointment and with whom. Which of the following types of memory is the nurse testing? a. remote b. immediate c. recall d. past

C: recall

A nurse is preparing a client for an ECG (electroencephalogram). When the client asks what this test does, which of the following responses should the nurse provide? a. "An ECG measures the electrical signals to your brain from hearing, sight, and touch." b. "An ECG measures the electrical activity in your muscles." c. "An ECG identifies the magnetic fields produced by electrical activity in your brain." d. "An ECG records the electrical activity of your brain cells."

D. Rationale: An ECG measures brain waves via multiple electrodes the technician will attach to the scalp. This can help identify various problems such as: - seizure disorders - sleep disorders - inflammation - bleeding - (migraine) headaches

A nurse is providing teaching to the family of a client who has stage II Alzheimer's Disease (AD). Which of the following pieces of information should the nurse include in teaching? a. Place abstract pictures on the wall in the client's room. b. Provide music to the client using headphones. c. Reorient the client to reality frequently. d. Limit choices offered to the client.

D. Limit choices offered to the client Rationale: To reduce confusion and frustration.

A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take? a. Place a vest restraint on the client to protect others in the environment. b. Provide a variety of routines to keep the client from being bored c. Explain to the client that episodes of anxiety will decrease over time. d. Redirect the client to a different activity with a small group of people

D. Redirect the client to a different activity with a small group of people. Rationale: The nurse should redirect the client to another activity to distract from the anxiety. The client should not be exposed to a large group because this provides too much stimulation. Incorrect answers: A. Restraints should be a last resort. B. The nurse should maintain a consistent routine to reduce anxiety. C. Clients who have dementia are often not capable of reasoning or understanding explanations, especially when experiencing anxiety or agitation.

What is the best route when immediate pain relief and rapid tritation is necessary?

IV administration is the best route when immediate analgesia and rapid titration are necessary

The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain

Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.

A patient's eyes jerk while the patient looks to the left. How do you record this finding?

Nystagmus Nystagmus is fine, rapid jerking movements of the eyes.

The nurse should question an order written for acetaminophen with oxycodone for a patient exhibiting which clinical manifestation? Severe jaundice Oral candidiasis Increased urine output Elevated blood glucose

Severe jaundice Rationale: 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 nurse knows that which technique is best for assessing pain in a child who is 4 years of age? A. Ask the parents if they think their child is in pain. B. Use the FACES scale. C. Ask the child to rate the level of pain on a 0 to 10 pain scale. D. Check to see what previous nurses have charted.

Use the FACES scale.

Adjuvant Analgesic Therapy

Used alone or in conjunction with opioids and nonopioids Generally developed for other purposes, but also effective for pain antidepressants, antiseizure drugs, α-adrenergic agonists, and corticosteroids

When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? a. On a PRN (as needed) basis b. Conservatively c. Around the clock (ATC) d. Intramuscularly

c. Around the clock (ATC)

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." The nurse will document this as: a. somatic pain. b. referred pain. c. neuropathic pain. d.breakthrough pain.

d.breakthrough pain. Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.

How to manage delirium? What is the priority?

eliminating precipitating factors. If it is drug induced, medications are discontinued. It is important to keep in mind that delirium can accompany drug and alcohol withdrawal. Priority is given to creating a calm and safe environment.

Neuropathic pain quality

numbing, burning, shooting, stabbing, shock-like, or itchy sensation

A nurse is teaching a client about computed tomography (CT) scan of the brain. Which of the following teaching points should the nurse include? a. "You'll have to lie very still on a long, narrow table during the test." b. "You should be able to sit up during the test if you need to have a break." c. "You'll have many tiny electrodes on your scalp during the test." d. "You should expect the test to take at least an hour."

"You'll have to lie very still on a long, narrow table during the test." Rationale: Movement during the test interferes with the quality of the films.

Pain med considerations for older patients

- HCPs should titrate drugs slowly and monitor carefully for side effects in the older patient - use of NSAIDs in the older adult is associated with a high frequency of serious GI bleeding - Cognitive impairment and ataxia can be worsened when analgesics, such as opioids, antidepressants, benzodiazepines, and antiseizure drugs, are used

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

82-year-old patient who had abdominal surgery 4 hours ago 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.

Which statement is true for a patient who has pathology in Wernicke's area of the cerebrum? A. Receptive speech is affected. B. The parietal lobe is involved. C. Sight processing is abnormal. D. An abnormal Romberg test is present.

A Rationale: The temporal, not parietal, lobe contains the Wernicke area, which is responsible for receptive speech and integration of somatic, visual, and auditory data. Sight processing occurs in the occipital lobe. The Romberg test is used to assess the position sense of the lower extremities.

When assessing a patient with a traumatic brain injury, you notice uncoordinated movement of the extremities. How would you document this? A. Ataxia B. Apraxia C. Anisocoria D. Anosognosia

A Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellar disorders, or certain medications.

The nurse anticipates administering an opioid fentanyl patch to which patient? A.A 15-year-old adolescent with a broken femur B.A 30-year-old adult with cellulitis C. A 50-year-old patient with prostate cancer D. An 80-year-old patient with a broken hip

A 50-year-old patient with prostate cancer

The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer's disease (AD)? A 65-yr-old male patient does not recognize his family members and close friends A 59-yr-old female patient misplaces her purse and jokes about having memory loss A 79-yr-old male patient is incontinent and not able to perform hygiene independently. A 72-yr-old female patient is unable to locate the address where she has lived for 10 years.

A 72-yr-old female patient is unable to locate the address where she has lived for 10 years. An early warning sign of AD is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a manifestation of middle or moderate dementia (or AD). Incontinence and inability to perform self-care activities occur with severe or late dementia (or AD).

Which patient should receive a depression assessment first? A patient in the early stages of Alzheimer's disease A patient who is in the final stage of Alzheimer's disease A patient experiencing delirium secondary to dehydration A patient who has become delirious following an atypical drug response

A patient in the early stages of Alzheimer's disease Patients in the early stages of Alzheimer's disease are particularly susceptible to depression because they are acutely aware of their cognitive changes and the expected disease trajectory. Delirium is typically a short-term health problem that does not typically pose a heightened risk of depression.

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? a. add gestures when speaking with the client b. ask open-ended questions c. Limit visitors to 3 at a time d. use different words if the client does not understand a statement

A. Add gestures when speaking with the client Rationale: Increases the client's understanding of the conversation.

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 assess the patient's knowledge base and initiate appropriate teaching.

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.

A nurse in an acute care clinic is talking with a client who reports that the osteoarthritis pain in her knees is increasing each day. The client wants to discuss non-pharmacological approaches to help relieve her pain. Which of the following interventions should the nurse suggest? a. applying warm compress to sore joints b. decreasing the daily intake of dietary protein c. Keeping joints in extension during rest periods d. Limiting sleep to 6 or 7 hours per day

A. Applying warm compress to sore joints Rationale: Warm compress or warm packs are often effective for relieving arthritic pain. The nurse should teach the client to avoid temperatures that are hot enough to cause burns. She should plan a temperature just a little warmer than body temperature for comfort.

A nurse is preparing to test the function of Cranial Nerve X. Which of the following assessment procedures should the nurse use? a. Have the client open his mouth and say "Aah" b. Ask the client to identify the scent of coffee c. Use a tongue blade to provoke a gag reflex d. Have the client smile and raise his eyebrows

A. Have the client open his mouth and say Aah Rationale: The vagus X nerve has both sensory and motor functions. To test the motor functions, the nurse should have the client open his mouth and say, "aah." The palate and the uvula should move upward in response. The nurse should also assess the client's voice quality for hoarseness. Incorrect Answers: B. Asking the client to smell coffee is the function of CN I, the Olfactory Nerve. C. Using a tongue blade to provoke a gag reflex assesses the function of CN IX, the Glossopharyngeal Nerve. D. Having the client smile and raise his eyebrows is the function of CN VII, the Facial Nerve.

A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? A. Relaxation and guided imagery B. Transcutaneous electrical nerve stimulation (TENS) C. Herbal supplements with analgesic effects D. Pudendal block

A. Relaxation and guided imagery

During a neurological assessment, the nurse asks the client to name all his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? a. remote b. sensory c. immediate d. recall

A. remote Rationale: the nurse tests remote or long term memory by asking questions such as when the client was born, his age, when he graduated from high school, and what the birth dates of his children are.

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? a. the client's ability to clear oral secretions b. the client's ability to communicate verbally c. the client's ability to move all extremities d. the client's ability to remain continent of urine

A. the client's ability to clear oral secretions Rationale: The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's ability to clear secretions in order to protect the airway and reduce the risk of aspiration

A nurse is preparing a client for Magnetic Resonance Imaging (MRI). Which of the following information should the nurse give the client following the procedure? a. "You can have a mild sedative before the procedure." b. "You'll have to lie still on your back for 15 to 20 min" c. You can't have this test if you've had cataract surgery." d. "your exposure to radiation will be minimal"

A. you can have a mild sedative before the procedure Rationale: Some clients need mild sedation, when using an older closed MRI machine. Clients can feel claustrophobic and anxious as they slowly pass through what seems like a tunnel.

A 59-yr-old female patient with a frontotemporal lobar dementia has difficulty with verbal expression. While her husband was at work, she walked to the gas station for a soda but did not understand the request for payment. What can the nurse suggest to keep the patient safe? Adult day care Assisted living Advance directives Monitor for behavioral changes

Adult day care Rationale: To keep the patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.

Which patient has the greatest risk of developing delirium? An older patient whose recent CT scan shows brain atrophy. A patient with fibromyalgia whose chronic pain has worsened. A patient with a fracture who spent the night in the emergency department. An older patient who takes multiple medications to treat various health problems.

An older patient who takes multiple medications to treat various health problems. Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.

A patient with osteoarthritis has been taking ibuprofen 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? Another NSAID may be indicated because of individual variations in response to drug therapy. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. The patient may not be taking the drug correctly, so the nurse must assess the patient's knowledge base and provide teaching.

Another NSAID may be indicated because of individual variations in response to drug therapy. Rationale: 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. It does not take several months for the medication to reach therapeutic levels, and it should begin working after the first dose.

The patient's neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient's pain? (Select all that apply.) Fentanyl Antiseizure drugs β-Adrenergic agonists Tricyclic antidepressants Nonsteroidal antiinflammatory drugs

Antiseizure drugs Tricyclic antidepressants Rationale: Antiseizure drugs, tricyclic antidepressants, selective norepinephrine reuptake inhibitors, transdermal lidocaine, and α2-adrenergic agonists are used for multimodal treatment when opioid analgesics alone do not control neuropathic pain.

A nurse is caring for a client who is postoperative following a total knee athroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first?

Ask the client to describe the characteristics of the pain Rationale: Answering this item requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to acquire further data by asking the client to describe the characteristics of the pain.

How should you most accurately assess the position sense of a patient with a recent traumatic brain injury? A. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. B. Ask the patient to maintain balance while standing with his or her feet together and eyes closed. C. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. D. Place the two points of a calibrated compass on the tips of the fingers and toes, and ask the patient to discriminate the points.

B The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other tests of neurologic function do not directly assess position sense.

You are caring for a patient with peripheral neuropathy who is going to have electromyographic (EMG) studies tomorrow morning. What should you do to prepare the patient? A. Ensure the patient has an empty bladder. B. Instruct the patient that there is no risk of electric shock. C. Ensure the patient has no metallic jewelry or metal fragments. D. Instruct the patient that he or she may experience pain during the study.

B Electromyography (EMG) assesses electrical activity associated with nerves and skeletal muscles. Needle electrodes are inserted to detect muscle and peripheral nerve disease. You should inform the patient that pain and discomfort are associated with insertion of needles. There is no risk of electric shock with this procedure.

The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? A. Age and gender B. Anxiety and fear C. Culture D. Previous pain experience

B. Anxiety and fear

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? A. Call the rapid response team. B. Ask the patient to rate and describe the pain. C. Raise the head of the bed. D. Administer pain relief medications.

B. Ask the patient to rate and describe the pain.

After administering acetaminophen and oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room? A. Leave the overbed light on at 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. Ensure that the upper two side rails are raised. 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.

During neurologic testing, the patient is able to perceive pain elicited by a pinprick. Based on this finding, which assessment may be omitted? A. Position sense B. Patellar reflexes C. Temperature perception D. Heel-to-shin movements

C If pain sensation is intact, assessment of temperature sensation may be omitted because both sensations are carried by the same ascending pathways.

A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which assessment should you complete before this diagnostic study? A. Assess the patient's immunization history. B. Screen the patient for any metal parts or a pacemaker. C. Assess the patient for allergies to shellfish, iodine, or dyes. D. Assess the patient's need for tranquilizers or antiseizure medications.

C Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media for CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in most patients.

A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? A. "This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." B. "The patient is sleeping, so I pushed her PCA button for her." C. "I need to reassess the patient's pain 1 hour after administering oral pain medication." D. "It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."

C "I need to reassess the patient's pain 1 hour after administering oral pain medication."

A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? A. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." B. "You should take your medication after you walk to make sure you do not fall while you are walking." C. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." D "You need to take oral pain medications when you experience severe pain."

C. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain."

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. Constipation 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.

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

C. Respiratory rate 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.

A home health nurse is interviewing the adult child of a client who has Alzheimer's Disease. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following referrals should the nurse make for the caregiver? a. attorney b. physical therapy c. respite care d. occupational therapy

C. Respite care Rationale: Respite care can provide needed relief for caregivers in an expedient, short-term arrangement. wrong answers: attorney: only needed when the caretaker needs legal guidance or durable power of attorney for healthcare, but cannot help with feelings of fatigue and being overwhelmed occupational therapy: the caretaker did not express any concerns about working capacity, hence this is not an appropriate referral. physical therapy: there is no indication of physical limitations of the caregiver

The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness

C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions.

A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site, and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take? a. Take a photograph of the IV site b. Obtain and record the client's vital signs c. Stop the infusion d. Identify all medications

C. Stop the infusion Rationale: When applying the nursing vs. non-urgent priority setting framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's Hierarchy of Needs, the ABC-priority setting framework, and/or nursing knowledge to identify which finding is the most urgent. Many chemotherapy medications cause tissue damage (if extravasation occurs), so the nurse's first priority should be to stop the infusion immediately. Wrong answers: Take a photograph of the IV site: The nurse should take a photograph of the IV site for documentation of potential harm from extravasation, but there is another priority. Obtain and record vital signs: wrong because this should be done after, and there is another priority. Identify all medications: The nurse must identify all medications administered at the IV site for the past 24 hours , but there is another priority.

A home health nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse why the client becomes disoriented, confused, and often combative later in the day. Which of the following conditions should the nurse plan to report to the provider? a. electrolyte imbalance b. hypothyroidism c. sun-downing d. adverse effect of medication

C. Sundowning Rationale: Sundowning is an increase in confusion beginning in the afternoon and lasting into the night, is a common manifestation of AD. The client can become confused, aggressive, agitated, obsessive, leading to severe disorientation.

Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals

C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase.

A nurse is trying to assess the function of the trigeminal nerve (CN V). Which of the following items should the nurse gather for the test? a. sugar b. coffee c. cotton wisps d. snellen chart

C. cotton wisps Rationale: The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve V, the nurse should ask the client to clench the teeth.

A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? a. the client cannot name simple objects or formulate simple sentences. b. the client has difficulty articulating correctly due to muscle weakness of the mouth and tongue. c. the client is unable to understand words or sentences she hears d. the client speaks words that substitute for those she intends to say.

C: the client cannot understand words or sentences she hears Wrong answers: A. clients who cannot name simple objects or formulate simple sentences have have expressive aphasia B. Clients who have difficulty articulating correctly due to muscle weakness of the mouth and tongue due to muscle paralysis have dysarthria D. Client who speak words in place of those she intends to say have apraxia

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? Diarrhea Agitation Constipation Urinary frequency

Constipation Rationale: 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 patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? A. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." B. "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." C. "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." D. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

D. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

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 or tarry stools 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 receiving fentanyl (Duragesic) patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential adverse effect of this medication? A. Hypertension B. Pupillary dilation C. Urinary incontinence D. Decreased respiratory rate

D. Decreased respiratory rate Respiratory depression is a potentially life-threatening adverse effect of fentanyl (Duragesic), which is an opioid analgesic, via any route.

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? A. Superficial pain B. Idiopathic pain C. Chronic pain D. Visceral pain

D. Visceral pain

Paralysis of lateral gaze indicates a lesion of cranial nerve A. II. B. III. C. IV. D. VI.

D: IV (Abducens) Nerve Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle is innervated by cranial nerve VI and is the primary muscle that is responsible for lateral eye movement

A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give the client? a. perform passive range of motion exercises of the ankle hourly b. keep the affected extremity in a dependent position c. Wrap a loose dressing around the affected ankle d. Apply cold compress to the extremity intermittently

D: apply cold compress to the extremity intermittently Rationale: cold minimizes swelling and erythema to the affected area. Apply cold compress for no more than 20 minutes at a time.

A nurse is teaching a client with arthritis who is experiencing joint pain that impairs mobility. Which of the following instructions should the nurse include? a. Avoid using assistive devices when walking b. Perform passive exercises c. engage your joints in resistance exercises d. apply heat to your joints prior to exercising

D: apply heat to your joints prior to exercising Rationale: increases mobility and reduces pain.

When providing community health care teaching about the early warning signs of Alzheimer's disease (AD), which signs should the nurse ask family members to report? (Select all that apply.) Misplacing car keys Losing sense of time Difficulty performing familiar tasks Problems with performing basic calculations Momentarily forgets an acquaintance's name Becoming lost in a usually familiar environment

Losing sense of time Difficulty performing familiar tasks Problems with performing basic calculations Becoming lost in a usually familiar environment Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of AD. Misplacing car keys and momentarily forgetting a name is a normal frustrating event for many people.

The nurse in the long-term care facility cares for a 70-yr-old man with late-stage dementia who is undernourished and has problems chewing and swallowing. What should the nurse include in the plan of care for this patient? Limit fluid intake during mealtimes to prevent aspiration. Turn on the television to provide a distraction during meals. Provide thickened fluids and moist foods in bite-size pieces. Allow the patient to select favorite foods from the menu choices.

Provide thickened fluids and moist foods in bite-size pieces. If patients with dementia have problems chewing or swallowing, pureed foods, thickened liquids, and nutritional supplements should be provided. Foods that are easy to swallow are moist and should be in bite-size pieces. Distractions at mealtimes, including the television, should be avoided. Fluids should not be limited but offered frequently; fluids should be thickened. Patients with late-stage dementia have difficulty understanding words and would not have the cognitive ability to select menu choices.

The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with Alzheimer's disease? X ray Urinalysis MRI of the head Liver function tests Neuropsychologic testing Blood urea nitrogen and serum creatinine

Urinalysis MRI of the head Liver function tests Neuropsychologic testing Blood urea nitrogen and serum creatinine Because there is no definitive diagnostic test for Alzheimer's disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function. A chest x-ray examination is not used to investigate an alternate cause of memory or language problems.

A nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of Parkinson's Disease. Which of the following manifestations is the priority? a. Dysphagia b. emotional liability c. impaired speech d. self care dependency

a. Dysphagia Rationale: Use ABC priority framework: open airway, breathing in adequate amounts of oxygen, and having oxygen circulate to the body's organs via the blood. An alteration of any of these can indicate a threat to their life and should be the nurse's priority concern. When applying the ABC framework, the airway is the priority because it must be open for oxygen exchange to occur. Breathing is second priority because adequate ventilation is essential for oxygen exchange to occur. Circulation is third priority because the delivery of oxygen to organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Wrong answer: The nurse should educate the partner of a client of emotional liability, impaired speech, and self-care dependency. However, the priority is most important.

A patient who is using a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? a. Remove the fentanyl patch. b. Notify the health care provider. c. Continue to monitor the patient's status. d.Give the prescribed PRN naloxone (Narcan).

a. Remove the fentanyl patch. The assessment data indicate possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring also are needed, but the patient's data indicate that more rapid action is needed.

A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve (VIII)? a. dizziness and hearing loss b. weakness of the side of the tongue c. facial droop and asymmetrical smile d. loss of the same visual field in both eyes

a. dizziness and hearing loss Rationale: Dizziness and hearing loss reflect alterations in the vestibulocochlear area, which CN VIII innervates. Incorrect answers: B. Weakness of the tongue indicates damage to CN XII. C. Facial droop and asymmetrical smile indicates damage to CN VII. D. Hemianopsia indicates damage to the optical tract, which connects to CN II.

Which nursing action should the nurse delegate to nursing assistive personnel (NAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? a. Assess the skin under the heating pad. b. Check the respiratory rate every 2 hours. c. Monitor sedation using the sedation assessment scale. d. Ask the patient about whether pain control is effective.

b. Check the respiratory rate every 2 hours.Obtaining the respiratory rate is included in NAP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice.

The health care provider plans to titrate a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which of the following nursing actions regarding opioid administration are appropriate at this time (select all that apply)? a. Assessing for signs that the patient is becoming addicted to the opioid b. Monitoring for therapeutic and adverse effects of opioid administration c. Emphasizing that the risk of some opioid side effects increases over timed. Educating the patient about how analgesics improve postoperative activity level e. Teaching about the need to decrease opioid doses by the second postoperative day

b. Monitoring for therapeutic and adverse effects of opioid administration d. Educating the patient about how analgesics improve postoperative activity level Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain. Although postoperative patients usually need decreasing amount of opioids by the second postoperative day, each patient's response is individual. Tolerance may occur, but addiction to opioids will not develop in the acute postoperative period. The patient should use the opioids to achieve adequate pain control, and so the nurse should not emphasize the adverse effects.

A patient complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a. Cutaneous b. Visceral c. Superficial d. Somatic

b. Visceral

A nurse is caring for a client who is in the oliguric-anuric stage of kidney of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? a. administer an analgesic to the client b. check the client's electrolyte values c. measure the client's weight d. restrict the client's protein intake

b. check the client's electrolyte values Rationale: The nurse should apply urgent vs. non-urgent priority setting framework when caring for the client. Using this framework, the nurse should consider urgent needs to be the priority because they pose a greater threat to the client. The nurse might also need to use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent.

A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. The most appropriate action by the nurse is to a. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. consult with the health care provider about using a different treatment protocol to control the patient's pain. c. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

b. consult with the health care provider about using a different treatment protocol to control the patient's pain. PCAs are best for controlling acute pain; this patient's history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.

A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? a. notify the provider b. elevate the affected extremity c. Check for the affected extremity for warmth and redness d. prepare to administer unfractured heparin

c. Check the affected extremity for warmth and redness Rationale: The nurse must first assess the client's calf for swelling, redness, and warmth. These findings can indicate deep vein thrombophlebitis. Wrong answers: notify the provider: The nurse should notify the provider if there is a change in the client's condition, however there is another priority. elevated the affected extremity: the nurse should elevate the affected extremity to decrease swelling and relieve pain; however, there is another action that the nurse should take first. prepare to administer unfractured heparin: This is an anticoagulant and should be administered if prescribed to decrease the risk of further clot formation, however there is another priority.

A nurse is preparing a client who has a brain tumor for computed tomography (CT) scan. Which of the following factors affect the manner in which the nurse will prepare the client for the scan? a. No food or fluids consumed for 4 hrs b. Difficulty recalling recent events c. Development of hives when eating shrimp d. Parasthesias in both hands

c. Development of hives when eating shrimp Rationale: An allergy to shellfish is a contraindication for the use of contrast media during a CT scan. The nurse should inform the provider and explain to the client that this client might alter how the technician performs the CT scan.

A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is the top priority? a. monitor intake and output. b. administer antibiotics. c. monitor respiratory status. d. encourage food and fluid intake.

c. monitor respiratory status Rationale: ABC approach due to smoke inhalation, because it most likely involves thermal injury to the tracheobronchial tree. Edema from the inflammatory response to heat can obstruct the airway. Endotracheal intubation may become necessary to maintain a patent airway.

A nurse is caring for a client who has an impairment of Cranial Nerve II. Which of the following actions should the nurse perform to promote the client's safety? a. limit seizure precautions b. ensure the client receives a soft diet. c. provide an obstacle free path for ambulation d. instruct the client to use lukewarm water while showering

c. provide an obstacle free path for ambulation Rationale: Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial Nerve II is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation

A patient with chronic back pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Can you describe the quality of your pain?" b. "Has there been a change in the pain location?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does the pain keep you from doing things you enjoy?"

d. "Does the pain keep you from doing things you enjoy?" The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions also are appropriate to ask, but information about patient function is more useful in evaluating effectiveness.

When the nurse visits a hospice patient, the patient has a respiratory rate of 8 breaths/minute and complains of severe pain. Which action is best for the nurse to take? a Inform the patient that increasing the morphine will cause the respiratory drive to fail. b. Administer a nonopioid analgesic, such as a nonsteroidal anti-inflammatory drug (NSAID), to improve patient pain control. c. Tell the patient that additional morphine can be administered when the respirations are 12. d. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.

d. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief. The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient's respiratory rate.

These medications are ordered for an 86-year-old patient with arthritis in both hips who is complaining of level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse use as initial therapy? a. aspirin (Bayer) 650 mg orally b. naproxen (Aleve) 200 mg orally c. oxycodone (Roxicodone) 5 mg orally d. acetaminophen (Tylenol) 650 mg orally

d. acetaminophen (Tylenol) 650 mg orally Acetaminophen is the best first-choice medication. The principle of "start low, go slow" is used to guide therapy when treating elderly adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Nonopioid analgesics are used first for mild to moderate pain, although opioids may be used later. Aspirin and the NSAIDs are associated with a high incidence of gastrointestinal bleeding in elderly patients.

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? a. the client has a new tattoo b. the client is unable to sit upright c. the client has a history of peripheral vascular disease d. the client has a pacemaker.

d. the client has a pacemaker Rationale: An MRI uses strong magnets and radio waves that are evaluated using computer technology to view 3D images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures. notable wrong answers tattoo: An old tattoo can be a contraindication to an MRI; however, a new tattoo is not a contraindication to an MRI

The postoperative patient is receiving epidural fentanyl for pain relief. What are common side effects? Ataxia Itching Nausea Urinary retention GI bleeding

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

Unlicensed assistive personnel (UAP) working for a home care agency report a change in the alertness and language of an 82-yr-old female patient. The home care nurse plans a visit to evaluate the patient's cognitive function. Which assessment would be most appropriate? - Glasgow Coma Scale - Confusion Assessment Method (CAM) - Mini Mental State Examination (MMSE) - National Institute of Health Stroke Scale (NIHSS)

Mini-Mental State Examination (MMSE) Rationale: The MMSE is often used to assess cognitive function. Cognitive testing is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. The CAM is used to assess for delirium. The GCS is used to assess the degree of impaired consciousness. The NIHSS is a neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? a. Assessment b. Background c. Situation d. Recommendation

a. Assessment Rationale: Assessment: includes vital signs, pain assessment, and changes in assessment findings Wrong answers: Background: medical history, laboratory findings, allergies, code status Situation: Problems that the client is experiencing Recommendation: The nurse makes recommendations about treatment and asks the provider about additional treatment

The patient with a documented history of opioid use just had surgery. The nurse is concerned about the high dose of opioid analgesic prescribed for this patient. What is the best action for the nurse to take? Remember that pain can be observed in patients Relieve the patient's pain to avoid adverse consequences Be sure patient is really in pain The patient has the right to appropriate assessment and management of pain

This patient has the right to appropriate assessment and management of pain. Rationale: Patients with substance use disorder (SUD) 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 a patient with SUD, 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 with SUD.