Exam #2 Chronic/Palliative Care
Which objective symptom of a UTI is most common in older adults, especially those with dementia?
ANS: Change in cognitive functioning Explanation: The most common objective finding is a change in cognitive functioning, especially in those with dementia, because these clients usually exhibit even more profound cognitive changes with the onset of a UTI. Incontinence, hematuria, and back pain are not the most common presenting objective symptoms. *Chapter 55: Management of Patients With Urinary Disorders - Page 1618
The client, newly admitted to the hospital, is unsure of home medications and is wearing a transdermal fentanyl patch. What is most important for the nurse to do first?
ANS: Check the dose Explanation: The dosage of any medication should be checked for correctness. This is basic medication administration to prevent error. The nurse will also perform the other options listed. *Chapter 12: Pain Management - Page 247
When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?
ANS: Clay-colored or whitish Explanation: Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.
Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?
ANS: Risk for impaired gas exchange Explanation: Problems that may develop with opioid and opiate therapy include risk for impaired gas exchange related to respiratory depression, constipation related to slowed peristalsis, and risk for injury related to drowsiness and unsteady gait. *Chapter 12: Pain Management - Page 236
Acute pain can be distinguished from chronic pain by assessing which characteristic?
ANS: Acute pain is specific and localized. Explanation: Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury. *Chapter 12: Pain Management - Page 225
Which is the most common presenting symptom of colon cancer
ANS: Change in bowel habits Explanation: The most common presenting symptom is a change in bowel habits. Fatigue, anorexia, and weight loss may occur but are not the most common presenting symptoms. *Chapter 47: Management of Patients With Intestinal and Rectal Disorders - Page 1344
A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply.
ANS: 1. "Have you started a new medication?" 2. "What are your normal bowel habits?" 3. "Do you use laxatives?" Explanation: The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation. *Chapter 38: Bowel Elimination - Page 1421-1425
The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply.
ANS: 1. "How long have you experienced this pain?" 2. "Please point to where you are experiencing pain." 3. "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." 4. "What aggravates your chest pain?" Explanation: The nurse needs to assess pain as to intensity, timing, location, and aggravating factors. Assessing frequency is important, but the statement "You've never had this pain before, have you" is leading and nontherapeutic. *Chapter 12: Pain Management - Page 230-232
The nursing students have learned in class that causes of urinary obstruction and urinary incontinence include which of the following? Select all that apply.
ANS: 1. Structural changes in the bladder 2. Structural changes in the urethra 3. Impairment of neurologic control of bladder function Explanation: Urinary obstruction and urinary incontinence can be caused by several factors, including structural changes in the bladder, structural changes in the urethra, and impairment of neurologic control of bladder function. Changes in the gallbladder or pancreas do not cause urinary obstruction or incontinence. *Chapter 35: Disorders of the Bladder and Lower Urinary Tract - Page 913
A client is diagnosed with polycystic kidney disease and requires teaching on the management of the disorder. Which statement made by the client indicates a need for further teaching?
ANS: "As long as I have one normal kidney, I should be fine." Explanation: Polycystic kidney disease is characterized by the formation of multiple cysts on both kidneys. Polycystic kidney disease is inherited as an autosomal dominant trait. The fluid-filled cysts can cause great enlargement of the kidneys and interfere with kidney function, which can eventually lead to renal failure. *Chapter 54: Management of Patients With Kidney Disorders - Page 1574
The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is:
ANS: "As the disease progresses, you will most likely require renal replacement therapy." Explanation: There is no cure for polycystic kidney disease. Medical management includes therapies to control blood pressure, urinary tract infections, and pain. Renal replacement therapy is indicated as the kidneys fail. *Chapter 54: Management of Patients With Kidney Disorders - Page 1574
A first-time father calls the pediatric nurse stating he is concerned that his 4-year-old daughter still wets the bed almost every night. Remembering his own experience of being punished for wetting the bed at 4 years old, he is not sure punishment is the best approach to address this. Which nursing instruction is the most appropriate?
ANS: "Bedwetting is not uncommon in young children. Try to calmly change the bed without showing your frustration." Explanation: Occasional bedwetting is not uncommon for young preschoolers and is not a concern unless it continues past the age of 7. When the child does have an accident, treating it in a matter-of-fact way and providing the child with clean, dry clothing is best. The child should not be disciplined or made to feel he or she is socially unacceptable when bedwetting occurs. *Chapter 27: Growth and Development of the Preschooler - Page 1023
While reviewing a client's chart, the nurse notes the client has been experiencing enuresis. To assess whether this remains an ongoing problem for the client, the nurse asks which question?
ANS: "Do you urinate while sleeping?" Explanation: Enuresis is defined as involuntary voiding during sleep. The remaining questions do not relate to this problem associated with changes in the client's voiding pattern. *Chapter 53: Assessment of Kidney and Urinary Function - Page 1556
The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective?
ANS: "My urine will be eliminated through a stoma." Explanation: An ileal conduit is a non-continent urinary diversion whereby the ureters drain into an isolated section of ileum. A stoma is created at one end of the ileum, exiting through the abdominal wall. *Chapter 55: Management of Patients With Urinary Disorders - Page 1639
A client in the hospital is frustrated at the inconvenience of having to collect his urine for an entire day and night as part of an ordered 24-hour urine-collection test. The client asks the nurse why the test is necessary since the client provided a single urine sample 2 days prior. How could the nurse best respond?
ANS: "Often when an abnormal substance shows up in a urine test, a 24-hour urine collection is needed to determine exactly how much is present in your urine." Explanation: 24-hour urine tests are often used to quantify the amount of substances, such as proteins, that an individual's kidneys are spilling. Single urine samples are able to assess more parameters than just the presence of bacteria, and they are sufficient in quantity to detect numerous substances such as glucose. *Chapter 32 Structure and Function of the Kidney - Page 856
A community nurse is assessing a young child who has had a colostomy stoma for several years. The nurse notices that the stoma is dark pink and moist. What is the best response to the child's parents about the appearance of the stoma?
ANS: "The stoma looks healthy; continue your present care." Explanation: A normal, healthy stoma should be dark pink and moist. This child's parents should continue the present care. There is no indication of infection or irritation. There is no data that support the stoma being "too moist" or that there is skin breakdown.
A client is scheduled for a renal ultrasound. Which of the following would the nurse include when explaining this procedure to the client?
ANS: "You don't need to do any fasting before this noninvasive test." Explanation: Renal ultrasonography identifies the kidney's shape, size, location, collecting systems, and adjacent tissues. It is not invasive, does not require the injection of a radiopaque dye, and does not require fasting or bowel preparation. An x-ray of the abdomen to view the kidneys, ureters, and bladder is called a KUB. A contrast medium is used for computed tomography of the abdomen and pelvis. A pressure dressing is applied to the groin after a renal arteriogram. *Chapter 53: Assessment of Kidney and Urinary Function - Page 1562
The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is:
ANS: 20 mL/hour Explanation: Urine output decreases very quickly in hypovolemic shock. Compensatory mechanisms decrease renal blood flow as a means of diverting blood flow to the heart and brain. Oliguria of 20 mL/hour or less indicates inadequate renal perfusion. *Chapter 27: Disorders of Cardiac Function, and Heart Failure and Circulatory Shock - Page 721
The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition?
ANS: 300 mL Explanation: An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria. *Chapter 14: Shock and Multiple Organ Dysfunction Syndrome - Page 316
A geriatric nurse is caring for several clients. Which alterations in health should the nurse attribute to age-related physiologic changes?
ANS: A 78-year-old woman's GFR has been steadily declining over several years. Explanation: A gradual decrease in GFR is considered a normal age-related change. Increased creatinine or BUN would warrant follow up, as would the presence of protein in a client's urine. *Chapter 34: Acute Kidney Injury and Chronic Kidney Disease - Page 905
Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission?
ANS: A child quickly removing a hand when touching a hot object Explanation: Transduction, the first process involved in nociception, refers to the processes by which a noxious stimulus, such as a burn, releases of a number of excitatory compounds, which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual-mechanism analgesic agent, such as tramadol, involves many different neurochemicals as in the process of modulation. *Chapter 12: Pain Management, Figure 12-1, p. 226-229.
Which is a true statement regarding placebos?
ANS: A placebo should never be used to test a client's truthfulness about pain. Explanation: Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. The American Society for Pain Management Nurses contends that placebos should not be used to assess or manage pain in any patient, regardless of age or diagnosis. Reduction in pain as a response to placebo should never be interpreted as an indication that the person's pain is not real. *Chapter 12: Pain Management - Page 245
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
ANS: Administering a stool softener as ordered Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client. *Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1978
A client's most recent laboratory results suggest the presence of metabolic alkalosis. What action by the nurse best addresses a potential cause of this acid-base imbalance?
ANS: Administering an antiemetic to treat the client's frequent vomiting Explanation: Vomiting results in the loss of hydrogen ions, potentially resulting in metabolic alkalosis. Constipation and skin breakdown are not among the most common causes of metabolic alkalosis. Acid-base imbalances frequently affect cognition, but a change in level of consciousness would not be a cause of the imbalance. *Chapter 8: Disorders of Fluid and Electrolyte and Acid Base Balance - Page 183
How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?
ANS: Administering the analgesics on a regular basis Explanation: Routine scheduling of the administration of analgesics, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician. *Chapter 12: Pain Management - Page 234
The nurse is assessing a client's level of pain. How is the pain best described?
ANS: An unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery. Explanation: Pain is a privately experienced, unpleasant sensation usually associated with disease, injury, or surgery. Although pain can have an emotional component, referred to as suffering, this is not the source of all pain. Although pain can be the result of disease, it can also be caused by injury, surgery, emotional or mental conditions, or other causes. Pain is a normal aspect of nervous system functioning. Neuropathic pain is pain that is processed abnormally by the nervous system. *Chapter 12: Pain Management - Page 225
A patient who is postoperative day 1 following a discectomy has lit his call light and requested a dose of hydromorphone, which he receives on a p.r.n. basis for breakthrough pain. What should the nurse first do in response to the patient's request?
ANS: Assess the characteristics of the patient's pain. Explanation: The most appropriate immediate response to a patient's complaint of pain is an assessment of characteristics such as intensity, quality, onset, location, timing, associated or aggravating factors, and radiation. This assessment should normally precede the nurse's chosen interventions. *Chapter 12: Pain Management - Page 220-221
A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to?
ANS: Assess the reason for the client's anxiety. Explanation: Following the steps of the nursing process, the nurse needs to assess the reason for the client's anxiety. The client could be anxious about impending surgery, an unattended pet, a sick family member, etc. Then, the nurse intervenes appropriately by obtaining the assistance the client may need or administering anti-anxiety medication. The question is asking about treatment for anxiety. Pain medication should not be administered for anxiety. The nurse will not assist the client to a chair, because the client is on bedrest and in Buck's traction. *Chapter 12: Pain Management - Page 245
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?
ANS: Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. Explanation: The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop. *Chapter 54: Management of Patients With Kidney Disorders - Page 1578
The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for?
ANS: Bradypnea Explanation: Most patients experience sedation at the beginning of opioid therapy and whenever the opioid dose is increased significantly. If left untreated, excessive sedation can progress to clinically significant respiratory depression (bradypnea, or reduced breathing rate). *Chapter 12: Pain Management - Page 243
When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use?
ANS: Burning Explanation: When asking the patient to describe how the pain feels, the nurse should suggest to the patient descriptors such as "sharp," "shooting," or "burning," which may help identify the presence of neuropathic pain. *Chapter 12: Pain Management, p. 231, 232.
Which symptom will have a great impact on the extracellular fluid for water conservation?
ANS: Burns Explanation: The water saving, to regulate the concentration of solutes in the ECF, results in decreased urine output. Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery. *Chapter 37: Urinary Elimination - Page 1348
A client requires hemodialysis. Which type of drug should be withheld before this procedure?
ANS: Cardiac glycosides Explanation: Cardiac glycosides such as digoxin (Lanoxin) should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digoxin toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis. *Chapter 54: Management of Patients With Kidney Disorders - Page 1592
The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the most appropriate action by the nurse?
ANS: Consult with the prescriber regarding the need for an increased dose of the drug and not to reduce the frequency of administration. Explanation: The most appropriate action by the nurse would be to consult with the physician regarding the need for an increased dose of the drug and not to reduce its frequency of administration. As a rule of thumb, an ineffective dose should be increased by 25% to 50%. Informing the client that he will not be able to receive more medication is not acting as a client advocate nor acting in the best interest of the client. Suggesting a psychiatrist consultation would not be an appropriate action because the client has a chronic illness that requires medication. Taking a non-narcotic analgesic would not provide the client with the pain relief that he has. *Chapter 12: Pain Management - Page 238
When describing the functions of the kidney to a client, which of the following would the nurse include?
ANS: Control of water balance Explanation: Functions of the kidneys include control of water balance and blood pressure, regulation of red blood cell production, synthesis of vitamin D to active form, and secretion of prostaglandins. *Chapter 53: Assessment of Kidney and Urinary Function - Page 1549
Which of the following is the priority nursing diagnosis for the client preparing for a voiding cystourethrography?
ANS: Deficient knowledge: procedure Explanation: The client needs adequate information before experiencing the procedure. Information about its purpose, the actual steps of the procedure, and the client's role during and after the procedure is essential. Appropriate nursing diagnoses following the procedure would include risk for infection: urinary tract, acute pain, and urinary retention. *Chapter 53: Assessment of Kidney and Urinary Function - Page 1564
According to the Joint Commission, which of the following is a focus of assessment related to quality of pain?
ANS: Description in the client's own words Explanation: The focus of pain assessment is the description in the client's own words.
The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain?
ANS: Diaphoresis Explanation: Observe behavioral signs, e.g., facial expressions, crying, restlessness, diaphoresis (sweating), and changes in activity. A pain behavior in one patient may not be in another. Try to identify pain behaviors that are unique to the patient ("pain signature"). Increased heart rate, blood pressure, and respiratory rate would be more likely to be associated with pain rather than decreased levels of these measures. *Chapter 12: Pain Management - Page 226
While reading a client's history, the nurse notes that a client has a colostomy. When assessing the client, the nurse notes that the output is formed stool. What should the nurse do?
ANS: Document the output; this is normal. Explanation: Output from a colostomy is normally formed stool. Therefore the nurse should document the output as normal. There is no need to contact the physician at this time, assess for an obstruction, or give a laxative since the formed stool is normal.
A 20-year-old man has presented to the emergency department with a 24-hour history of abdominal pain. The nurse who is admitting the patient notes that he is diaphoretic, wincing, and guarding the lower right quadrant of his abdomen. The nurse asks the patient to rate his pain on a scale of 1 to 10, to which the patient responds, "One or two." How should the nurse best respond to this patient's statement?
ANS: Explain the 0-to-10 pain scale in greater detail. Explanation: Explain the 0-to-10 pain scale in greater detail. *Chapter 12: Pain Management - Page 219
A client has been using nonnarcotic analgesics daily over an extended period. Which of the following effects should the nurse carefully monitor for in this client?
ANS: Gastrointestinal bleeding Explanation: Some nonnarcotic analgesics when used daily over an extended period may cause undesirable side effects such as gastrointestinal bleeding and hemorrhagic disorders. Use of analgesics does not increase the risk for developing cardiac disorders, urinary tract infections, or hypothyroidism.
The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction?
ANS: Hemolytic Explanation: Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in clients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive and hepatocellular jaundice are the result of liver disease. Nonobstructive jaundice occurs with hepatitis. *Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1384
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
ANS: Hypovolemic shock caused by hemorrhage Explanation: If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack. *Chapter 54: Management of Patients With Kidney Disorders - Page 1606
A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?
ANS: Increase fiber slowly over a period of time to prevent gas. Explanation: Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. By introducing fiber over a period of time, the client can get used to fiber intake and note which foods cause more gas. Flatulence, or flatus, results from swallowing air while eating or sluggish peristalsis. Drinking soft drinks can increase gas and have no effect on fiber breakdown in the body. Another cause is the gas that forms as a byproduct of bacterial fermentation in the bowel. Protein does not produce gas that leads to flatus. *Chapter 38: Bowel Elimination - Page 1423
While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?
ANS: Stop the procedure, monitor heart rate and blood pressure. Explanation: When administering an enema, the client's vagus nerve may be stimulated, causing a decrease in the heart rate. The client will exhibit nausea, lightheadedness, dizziness, and clammy skin. The procedure should be stopped, heart rate and blood pressure monitored, and the health care provider notified. The other responses are not appropriate for a client exhibiting a vagal response. *Chapter 38: Bowel Elimination - Page 1439
About which issue should the nurse inform clients who use pain medications on a regular basis?
ANS: Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. Explanation: Clients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the client to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Clients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity. *Chapter 12: Adverse Effects of Nonopioid Analgesic Agents
When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain.
ANS: Intervertebral disk herniation Explanation: Chronic pain is found with degeneration or traumatic conditions and can sometimes be the cause of the patient's primary disorder. The other three choices refer to acute pain. Migraines could be chronic pain but are not the best example here. *Chapter 12: Pain Management - Page 225-226
A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing?
ANS: Neuropathic pain Explanation: An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Chronic pain sufferers may have periods of acute pain, which is referred to as breakthrough pain. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located. *Chapter 12: Pain Management - Page 227
A high school football player hurts his foot while playing a game. The client complains of intense pain with muscle spasms and swelling of the toe. Which pain assessment tool will the nurse most likely use to assess the client's pain level?
ANS: Numeric Rating Scale (NRS) Explanation: The NRS is most appropriate for this client. The VDS requires the patient to use words or phrases; in this situation, intense pain may affect the client's ability to use this scale appropriately. The FACES scale is most often used in adults and children as young as 3 years of age. The VAS is impractical for use in daily clinical practice. *Chapter 12: Pain Management, p. 230-231.
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
ANS: One part of the intestine telescopes into another portion of the intestine. Explanation: In intussusception of the bowel, one part of the intestine telescopes into another portion of the intestine. When the bowel twists and turns itself and obstructs the intestinal lumen, this is known as a volvulus. A hernia is when the bowel protrudes through a weakened area in the abdominal wall. An adhesion is a loop of intestine that adheres to an area that is healing slowly after surgery. *Chapter 47: Management of Patients With Intestinal and Rectal Disorders - Page 1328
The nurse is caring for a client newly diagnosed with acute glomerulonephritis? When receiving the pediatric client's history, which is anticipated?
ANS: Onset of a streptococcus infection last week Explanation: The nurse is correct to anticipate a streptococcus infection 1 to 3 weeks prior to the diagnosis of acute glomerulonephritis. The presenting symptom is typically gross bloody urine. Acute glomerulonephritis is not related to a kidney infection, does not exhibit symptoms similar to diabetes, or a recent viral infection.
As a nursing student is visiting a day care to observe growth and development in action. The nursing student completes assessments on infants and toddlers who are learning to walk, talk, and control elimination. According to Freud, in what developmental stage are they?
ANS: Oral; anal Explanation: During the oral stage, Freud indicates that the infant uses his or her mouth as the major source of gratification and exploration. Pleasure is experienced from eating, biting, chewing, and sucking. Freud goes on to say that toilet training is a crucial issue, requiring delayed gratification as the child compromises between enjoyment of bowel function and limits set by social expectations. Trust versus mistrust is Erikson's theory. The Phallic stage is Freud's preschool theory. The relationships and events theory belongs to Piaget. *Chapter 21: Developmental Concepts - Page 513
A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:
ANS: Prolonged in duration Explanation: A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged. *Chapter 12: Pain Management - Page 225-226
Which of the following is the most common symptom of a polyp?
ANS: Rectal bleeding Explanation: The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis. *Chapter 47: Management of Patients With Intestinal and Rectal Disorders - Page 1349
Sympathomimetics have which of the following effects on the body?
ANS: Relaxation of bladder wall Explanation: Sympathomimetics mimic the sympathetic nervous system, causing increased heart rate and contractility, dilation of bronchioles and pupils, and bladder wall relaxation.
The nurse is monitoring a client who is in the hospital and has a fentanyl patch in place for the control of breakthrough pain for breast cancer. What would be a concern for the nurse when she obtains vital signs for this client?
ANS: Respiratory rate of 10 breaths/minute Explanation: A fentanyl patch should not be administered if the client's respiratory rate is less than 12 breaths/minute. The temperature, blood pressure, and heart rate are within normal range. *Chapter 12: Pain Management - Page 241
The nurse asks the client about a reddened area on the left arm. The client states that he was bitten by an insect, and it burned briefly. What type of pain does the nurse document this as?
ANS: Superficial somatic pain Explanation: Superficial somatic pain, also known as cutaneous pain (such as that from an insect bite or a paper cut), is perceived as sharp or burning discomfort. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Causes for visceral pain are varied and include ischemia, compression of an organ, intestinal distention with gas, or contraction as occurs with gallbladder or kidney stones. Deeper somatic pain is caused by trauma and produces localized sensations that are sharp, throbbing, and intense. Neuropathic pain is processed abnormally by the nervous system and results from damage to either the pain pathways in peripheral nerves or pain-processing centers in the brain. *Chapter 12: Pain Management - Page 227
A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses
ANS: That the client's past experiences with pain may influence her perception of current pain Explanation: Clients who have had previous experiences with pain are usually more frightened about subsequent painful events, as in the client who experienced partial-thickness burns to more than 60% of her body. The clients in these situations are less able to tolerate pain. Insufficient data in the stem support that the client is dependent on drugs or that this current pain is related to the client's previous burn injuries. *Chapter 12: Pain Management - Page 232
Which of the following is a reliable source for quantifying pain?
ANS: The client's description of the pain Explanation: The client's description of the pain is the only reliable source for quantifying pain. Physiologic data such as vital signs or the extent or nature of the injury do not indicate the amount of pain. *Chapter 12: Pain Management - Page 230
The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness?
ANS: The costovertebral angle Explanation: The nurse is correct to assess the kidneys for tenderness at the costovertebral angle. The other options are incorrect. *Chapter 53: Assessment of Kidney and Urinary Function - Page 1556
The nurse is caring for a client who has produced an average of 20 mL/hour for the previous day. The nurse recognizes this compares in which way to the normal urine output?
ANS: The kidneys should produce about 1.5 L of urine each day. Explanation: The kidneys normally produce approximately 1.5 L or 1500 ml of urine each day. *Chapter 32 Structure and Function of the Kidney - Page 856
The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?
ANS: The nurse has omitted the time frame. Explanation: Outcomes are client-centered, use action verbs, identify measurable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do. *Chapter 16: Outcome Identification and Planning - Page 388
When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress?
ANS: The pump will deliver a preset amount of medication. Explanation: A client experiencing pain can administer small amounts of medication directly into the IV, subcutaneous, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The client should not wait until the pain is severe to push the button. Even if the client pushes the button multiple times in rapid succession, no additional doses are released because of the preset lock-out time. Sedation can occur with the use of the PCA pump. Assessment of respiratory status remains a major nursing role. *Chapter 12: Pain Management - Page 234
Which therapy uses low-level radiofrequencies to produce localized heat that destroys prostate tissue?
ANS: Transurethral needle ablation Explanation: Transurethral needle ablation uses low-level radiofrequencies to produce localized heat that destroys prostate tissue while sparing the urethra, nerves, muscles, and membranes. Sal palmetto is a herbal product used to treat the symptoms associated with benign prostatic hyperplasia. Microwave thermotherapy involves the application of heat to the prostatic tissue. Resection of the prostate can be performed with ultrasound guidance. *Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders - Page 1764
A client is being treated with colchicine for pain in the big right toe. The client begins to complain of severe right flank pain and is diagnosed with kidney stones. Which type of kidney stone does the nurse recognize this client is most likely affected by?
ANS: Uric acid Explanation: Uric acid stones develop in conditions of gout and high concentrations of uric acid in the urine; it accounts for about 7% of all stones. *Chapter 33: Disorders of Renal Function - Page 868
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
ANS: Urine retention Explanation: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus. *Chapter 19: Postoperative Nursing Management - Page 473
Which type of pain arises from an internal organ, such as the kidneys?
ANS: Visceral Explanation: Visceral pain arises from internal organs, such as the heart, kidneys, and intestines, that are diseased or injured. Neuropathic pain is pain that is processed abnormally by the nervous system. Nociceptive pain is the noxious stimuli that are transmitted from the point of cellular injury over peripheral sensory nerves to pathways between the spinal cord and thalamus, and eventually from the thalamus to the cerebral cortex of the brain. *Chapter 12: Pain Management - Page 227
The nurse is caring for a client with kidney stones who is complaining of severe pain. What type of pain does the nurse understand this client is experiencing?
ANS: Visceral Pain Explanation: Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Somatic pain is caused by mechanical, chemical, thermal, or electrical injuries or disorders affecting bones, joints, muscles, skin, or other structures composed of connective tissue. Neuropathic pain is pain that is processed abnormally by the nervous system. Chronic pain is discomfort that lasts longer than 6 months and is almost totally opposite from those of acute pain. *Chapter 12: Pain Management - Page 227
The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents:
ANS: a loss of over half the client's normal kidney function. Explanation: In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. The GFR is not diagnostic for concentrated urine or the need to drink more water. *Chapter 34: Acute Kidney Injury and Chronic Kidney Disease - Page 895
The nurse recognizes the most common cause of acute postinfectious glomerulonephritis as:
ANS: a streptococcal infection 7 to 12 days prior to onset. Explanation: Acute postinfectious glomerulonephritis usually occurs after infection with certain strains of group A beta-hemolytic streptococci and is caused by deposition of immune complexes. It also may occur after infections by other organisms, including staphylococci and a number of viral agents, such as those responsible for mumps, measles, and chickenpox. *Chapter 33: Disorders of Renal Function - Page 878
Regarding tolerance and addiction, the nurse understands that
ANS: although clients may need increasing levels of opioids, they are not addicted. Explanation: Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain. *Chapter 12: Pain Management, p. 238-239.
According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment?
ANS: location, onset, alleviating factors, and aggravating factors Explanation: Location, onset, alleviating factors, and aggravating factors are all essential components of a comprehensive pain assessment according to The Joint Commission's standards. Family history is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Nutritional deficiencies are not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Range of motion is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. *Chapter 12: Pain Management - Page 230
A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified?
ANS: neuropathic and chronic Explanation: When classified according to its source, pain can be categorized as nociceptive or neuropathic. When classified according to its onset, intensity, and duration, pain can be categorized as either acute or chronic. Because the client is without breakthrough pain at this time, he has no acute pain. Nociceptive pain is transmitted from a point of cellular injury to the brain. This is not the type of pain related to long-term diabetes mellitus. Neuropathic pain sustained by injury or dysfunction of the peripheral or central nervous systems. This type of pain is related to long-term diabetes mellitus. Acute pain is pain or discomfort of short duration: from a few seconds to less than 6 months. This is not the type of pain related to long-term diabetes mellitus. *Chapter 12: Pain Management - Page 229
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for
ANS: recent foods ingested. Explanation: The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. Ingestion of bismuth can turn the stool black and, when occult blood is present, the stool can appear to be tarry black. *Chapter 43: Assessment of Digestive and Gastrointestinal Function - Page 1230
The nurse is working with a child diagnosed with encopresis. After a complete medical workup has been done, no organic cause has been found for the disorder. What follow-up will the nurse expect?
ANS: referred for counseling Explanation: Encopresis is the repeated involuntary passage of feces of normal or near-normal stool in places not appropriate for that purpose. If no organic causes (e.g., worms, megacolon) exist, encopresis indicates a serious emotional problem and a need for counseling for the child and the family caregivers. Medications such as methylphenidate are used for hyperactivity. The diet needs to be high fiber. Antidiarrheals are contraindicated because they can cause more constipation. Lubricant laxatives should be used. *Chapter 50: Nursing Care of the Child With an Alteration in Behavior, Cognition, Development, or Mental Health/Cognitive or Mental Health Disorder - Page 1971
A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about?
ANS: the limits on dose and frequency that are programmed into the PCA Explanation: Patient-controlled analgesia (PCA) devices allow clients to self-administer their own narcotic analgesic using an intravenous pump system and pressing a handheld button. The dose and time intervals between doses are programmed into the device to prevent accidental overdose. Dosing may or may not be more than twice per hour. Naloxone treats overdoses, but this will not likely alleviate the client's concerns about overdosing in the first place. The client may benefit from non-pharmacologic pain measures, but should not be encouraged to minimize the use of the PCA or to endure pain. *Chapter 12: Pain Management - Page 234
A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing?
ANS: visceral Explanation: Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Visceral pain usually is diffuse, poorly localized, and accompanied by autonomic nervous system symptoms such as nausea, vomiting, pallor, hypotension, and sweating. Neuropathic pain is pain that is processed abnormally by the nervous system. Deeper somatic pain such as that caused by trauma produces localized sensations that are sharp, throbbing, and intense. Chronic pain has a duration longer than 6 months. * Chapter 12: Pain Management - Page 227
