Fundamentals Final

visceral pain

arising from organs (arm pain with heart attack)

perception

brain

addication

chroinic relapsing treatable disease influenced by ginestic psychosocial and enviromental factors

Tylenol #3 is a combo of

codeine/ acetaminophen

opioid side effect

constipation n/v sedation respiratory depression pruritus urinary retention

visceral pain is deep or superficial

deep

modulation

descending system

NSAIDS can cause

gastric ulcers, increased bleeding time, renal insufficiencys

acetaminophen can cause

hepatotoxicity

hyperalgesia/ hyperpathia

highted responses to painful stimuli

vicodin is combination of

hydrocodone/acetaminophen

Acute pain causes the body to

increase hr/ rr/ bp diaphoresis dilated pupils

sensitization

increased sensitivity to the environment following the presentation of a strong stimulus

pain threshold

least amount of stimuli needed for a pain sensation

pain tolerance

maximum amount of pain a person is willing to withstand

coanalgesic treat

mogulation

alllodynia

non painful stimuli produces pain

percocet is a combo of

oxycodone/acetaminophen

transduction

peripheral nervous system

example of peripheral neuropathic pain

phantom limb

nociception

process of pain

windup

progressive increase in pain leading to persistent, increased pain

transmission

spinal cord

radiate

spread other areas

somatic pain is deep or superficial

superficial

gate-control theory

the theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small nerve fibers and is closed by activity in larger fibers or by information coming from the brain.

nonopoids treat

transduction

steps of nociception

transduction transmission perception modulation

opiods treat

transmission

The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records? 1. A firewall to protect the server from unauthorized access 2. One unit password to protect the units information 3. Expectation to log off a terminal after using it 4. Expectation to turn the monitor away from view when unattended 5. Requirement to shred all computer-generated worksheets

1. A firewall to protect the server from unauthorized access 3. Expectation to log off a terminal after using it 5. Requirement to shred all computer-generated worksheets

The nurse observes during a dressing change that the clients wound has become infected. When asked by the client how the wound looks, the nurse says it looks fine but the nurses facial expression doesnt support the response. Which aspect of communication should this nurse improve? 1. Adaptability 2. Credibility 3. Timing and relevance 4. Clarity and brevity

1. Adaptability

A nurse must perform a catheterization on a male client. Which zone of proximity should the nurse use for this intervention? 1. Personal distance 2. Intimate distance 3. Social distance 4. Public distance

2. Intimate distance

A group of older clients is interested in living options available in the community when they may need some assistance with their daily needs. What should the nurse suggest as possibilities to meet these needs? 1. Adult foster care 2. Group homes 3. Retirement villages 4. Long-term care facilities 5. Adult day-care centers

1. Adult foster care 2. Group homes 5. Adult day-care centers

The nurse is determining a clients risk for injury. What should the nurse assess in this client? Standard Text: Select all that apply. 1. Age 2. Mobility 3. Hearing 4. Vision 5. Dietary intake

1. Age 2. Mobility 3. Hearing 4. Vision

The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? 1. Always pull a plug at the plug-in from the wall outlet. 2. Keep plants in the home. 3. Use overloaded outlets when necessary. 4. Remove labels from containers and refill for recycling.

1. Always pull a plug at the plug-in from the wall outlet.

While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. What should the nurse do first? 1. Ask the customer if he is choking. 2. Attempt to give five back blows. 3. Perform the Heimlich maneuver. 4. Start chest compressions.

1. Ask the customer if he is choking.

The nurse is communicating with an older client. Which actions demonstrate that the nurse understands the best approaches to communicate with this client? Standard Text: Select all that apply. 1. Asking, What can I do to make you feel safe? 2. Observed intently listening to the client describe how being alone makes her feel 3. Offering to take the client out for a walk 4. Consistently arranging for the client to have her hair done 5. Managing to get a copy of the clients favorite magazine

1. Asking, What can I do to make you feel safe? 2. Observed intently listening to the client describe how being alone makes her feel 5. Managing to get a copy of the clients favorite magazine

The nurse is beginning a helping relationship with a newly admitted client. Which behaviors should the nurse demonstrate that support this type of relationship? Standard Text: Select all that apply. 1. Becoming familiar with the clients social history by reading the admission interview 2. Orienting the client to the physical layout of the facility as well as to the facilitys policies 3. Gaining the clients trust by consistently keeping promises to return and visit 4. Respecting the clients wish to be alone after hearing about the loss of a family friend 5. Asking to remain with the client when he is experiencing symptoms of the flu

1. Becoming familiar with the clients social history by reading the admission interview 3. Gaining the clients trust by consistently keeping promises to return and visit 4. Respecting the clients wish to be alone after hearing about the loss of a family friend 5. Asking to remain with the client when he is experiencing symptoms of the flu

The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? 1. Burns 2. Drowning 3. Poisoning 4. Suffocation

1. Burns

During an interaction between a nurse and client, the nurse conveys respect and an attitude that shows the nurse takes the clients opinions seriously. In which stage of the working relationship are the nurse and client engaged? 1. Exploring and understanding thoughts and feelings 2. Facilitating and taking action 3. Confrontation 4. Concreteness

1. Exploring and understanding thoughts and feelings

A nurse is working with an elderly male client on a medical unit. Which statement demonstrates elderspeak by the nurse? 1. Its time for us to go to physical therapy. 2. I think it would be better if you were planning to go to a nursing home after discharge. 3. Your children must really love their dad. 4. Your wife must be having trouble adjusting to your illness.

1. Its time for us to go to physical therapy.

The nurse is appointed to be a member of committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? Standard Text: Select all that apply. 1. Lifting clients 2. Inadequate lighting 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications

1. Lifting clients 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications

The nurse is engaging a client in the introductory phase of the helping relationship. Which stages will be completed during this phase? Standard Text: Select all that apply. 1. Opening the relationship 2. Clarifying the problem 3. Structuring and formulating the contract 4. Planning before the interview 5. Understanding thoughts and feelings

1. Opening the relationship 2. Clarifying the problem 3. Structuring and formulating the contract

The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? 1. Place the leg band on the client with the leg in a straight horizontal position. 2. Place the sensor under the mattress near the shoulder region. 3. Set a time delay for 30 seconds. 4. Connect the sensor pad to the control unit.

1. Place the leg band on the client with the leg in a straight horizontal position.

An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety? Standard Text: Select all that apply. 1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate 4. Ability to stand in place for a minute before ambulating 5. Alcohol use with prescribed medications

1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate

The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching has been effective? 1. Smoke alarm functioning with new batteries installed 2. Scatter rugs located in the kitchen and bathroom only 3. Cord for a space heater stretched across a hallway 4. Light bulbs burned out in the bathroom and living room

1. Smoke alarm functioning with new batteries installed

A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the clients room for what reason? 1. Suctioning might be needed to prevent the aspiration of oral secretions. 2. The client has difficulty swallowing liquids. 3. There was a spare oral suction set up, and the nurse did not want to return it to the engineering department. 4. It helps when the client is brushing her teeth.

1. Suctioning might be needed to prevent the aspiration of oral secretions.

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? 1. The clients record contained an incorrect DRG. 2. The client was charged for an ECG. 3. A code cart was opened and the client was charged for medications opened but not used. 4. The physician made a diagnostic mistake.

1. The clients record contained an incorrect DRG.

During a home visit, the nurse determines that a toddler is at risk for injury. What did the nurse assess to identify this clients risk? Standard Text: Select all that apply. 1. Unscreened windows 2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Cleaning solution in the bottom cabinet 5. Pots on stove with handles turned inward

1. Unscreened windows 2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Cleaning solution in the bottom cabinet

The nurse is identifying communication strategies for a client unable to speak. What would be appropriate for the client in this situation? 1. Using a picture board to facilitate communication 2. Facing the client when speaking 3. Employing an interpreter 4. Making sure that the language spoken is the clients dominant language

1. Using a picture board to facilitate communication

The nurse wants to gain information about a clients situation. Which question should the nurse use to maximize communication with this patient? 1. What brings you to the hospital? 2. Are you having pain? 3. Does your pain feel better or worse today? 4. Is there anything I can do for you?

1. What brings you to the hospital?

A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. Standard Text: Click and drag the options below to move them up or down. Choice 1. Pad bony prominences on the wrist. Choice 2. Apply the padded portion of the restraint around the wrist. Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

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A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as its his record. How should the nurse respond to this clients request? 1. Youll have to ask your doctor for permission to do that. 2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records. 3. Well make sure that all of your records are sent ahead to the rehab hospital, so you dont really have to worry about those details. 4. Theres a new law that protects your records, so youre not going to be able to have access to them.

2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records.

The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. 3. Client needed to use the bathroom and waited for help but didnt want to soil the bed and fell while attempting to walk to the bathroom. 4. Client does not want to stay in bed but wants to sit in the lounge with others.

2. Client is picking at the access site for intravenous infusion of chemotherapy.

The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. 4. Turn the light on after getting out of bed.

2. Exercise regularly.

A nurse is working in a pediatric clinic and has to explain a nebulizer treatment to a child. Which approach should the nurse use? 1. Give the childs parent a full explanation, but make sure the child hears what is said. 2. Let the child handle the equipment first, then demonstrate on the childs doll. 3. Start the treatment, but make sure that the parent is there to comfort the child if she becomes afraid. 4. Make sure that the physician is available for questions.

2. Let the child handle the equipment first, then demonstrate on the childs doll.

A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this clients documentation? Standard Text: Select all that apply. 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client

2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen

While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client? 1. Insert a tongue blade into the clients mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position if possible.

2. Loosen any clothing around the neck and chest.

The nurse is applying restraints to a client. After securing a health care providers order, what should the nurse do? 1. Assess the restraints every 10 minutes. 2. Pad bony prominences. 3. Secure the restraint to the side rail. 4. Tie the restraint with a square knot.

2. Pad bony prominences.

A client is prescribed seizure precautions. What can the nurse safely delegate to UAP to complete when implementing the precautions? 1. Placing a tongue blade at the head of the bed 2. Padding the clients bed 3. Installing oxygen 4. Checking the oral suction apparatus

2. Padding the clients bed

An older client diagnosed with Alzheimers disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client? 1. Explain all procedures and treatments. 2. Place a bed safety monitoring device on the bed. 3. Orient the client to surroundings. 4. Use relaxation techniques.

2. Place a bed safety monitoring device on the bed.

The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. Restrain the child if he gets up more than once.

2. Place a crib net over the top of the crib.

The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? 1. Assign this client to the farthest room from the nurses station. 2. Place a rocking chair in the clients room. 3. Pull up all of the side rails on the bed. 4. Wedge pillows against the side rails on the bed.

2. Place a rocking chair in the clients room.

A client has specific cultural needs that affect the plan of care. In which part of the clients problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes

2. Problem list

A nurse needs to evaluate the effectiveness of a teaching session with a client. Which approach would provide the best feedback? 1. Client communication 2. Process recording 3. Therapeutic communication 4. Verbal communication

2. Process recording

The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client? 1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation

2. Risk for Injury

Several nurses have been assigned to develop a rotation schedule that provides adequate staffing of all shifts. In which type of group are these nurses functioning? 1. Self-help group 2. Task group 3. Teaching group 4. Therapy group

2. Task group

The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? 1. The client will demonstrate an understanding of all limitations. 2. The client will establish a buddy system. 3. The client will make uninformed choices when addressing health issues. 4. The client will take his medication as desired.

2. The client will establish a buddy system.

A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The clients spouse is in the room when the code team arrives. Which statement by the nurse to the spouse is the best in this situation? 1. I know youre worried about your loved one. Im sure this is a difficult situation for you. Do you have any questions right now? 2. Your spouses heart stopped. All these people are here to help get it started. 3. Your spouses physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now. 4. Is there someone you would like to call? Im sure this is a scary situation and you may feel more comfortable if someone were with you during this time.

2. Your spouses heart stopped. All these people are here to help get it started.

FLACC scale used for; looks at

2m-7y facial expressions,leg movement, activity, cry, consolability

The nurse is identifying activities and skills to delegate to unlicensed assistive personnel (UAP). Which action can the nurse safely delegate? 1. Provide oral fluids to a newly extubated client. 2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery. 3. Apply a wrist restraint to a client. 4. Administer oral pain medication to a client before the client attends physical therapy.

3. Apply a wrist restraint to a client.

A client has just lost her second baby to preterm complications. Which statement demonstrates the best therapeutic response for the nurse to make? 1. Dont be so sad. You can always try again. 2. Didnt your doctor advise you about genetic counseling? 3. I know how you feel. I have children of my own. 4. I am so sad for you. Ill stay with you for a while if you need to talk.

4. I am so sad for you. Ill stay with you for a while if you need to talk.

The graduate nurse is thinking about leaving a new job because of actions demonstrated by the nurse manager. Which actions should the graduate nurse identify as bullying? Standard Text: Select all that apply. 1. Pairing the graduate with a seasoned nurse to assist with learning new skills 2. Asking the graduate to participate in client rounds with the new interns on the care area 3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing

3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing

A nurse enters a clients room and asks about his level of pain. The client, grimacing, says Its fine. Which communication factor is the client struggling with? 1. Territoriality 2. Environment 3. Congruence 4. Attitude

3. Congruence

As a member of the safety committee, the nurses task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions.

3. Keep the environment tidy.

The nurse makes chronological entries in a clients chart that include documentation about the routine care provided, assessment findings, and client problems during a 12hour shift. Which type of charting is this nurse completing? 1. Problem-oriented recording 2. Source-oriented recording 3. Narrative charting 4. Plan of care

3. Narrative charting

The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this clients risk for injury? Standard Text: Select all that apply. 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Health status

3. Nursing history 4. Physical examination

The nurse is reviewing a clients chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? 1. Database 2. Problem list 3. Plan of care 4. Progress notes

3. Plan of care

The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? 1. Keep clutter to a minimum in the clients room. 2. Have the client wear terry-cloth slippers. 3. Provide adequate lighting. 4. Turn off alarms to reduce noise.

3. Provide adequate lighting.

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why its permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? 1. Confidentiality and privacy laws dont apply to students. 2. Most students review so many records and charts that they could not possibly remember details from any one of them. 3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence. 4. As long as the clinical instructor is in the area, accessing client records is part of the education process.

3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence

The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 National Patient Safety Goals to achieve this objective? 1. Review a list of look-alike/sound-alike drugs used in the organization. 2. Use a verification process to confirm the correct procedure. 3. Report critical results of tests and diagnostic procedures on a timely basis.. 4. Use the clients room number as an identifier.

3. Report critical results of tests and diagnostic procedures on a timely basis..

A nurse explains to a client that he will need to have a bowel prep before going to his esophagogastroscopy. On what should the nurse focus to improve communication skills? 1. Pace 2. Intonation 3. Simplicity 4. Clarity

3. Simplicity

A nurse is giving a demonstration of new equipment to the rest of the nursing unit. Which level of proxemics should the nurse use? 1. Intimate 2. Personal 3. Social 4. Public

3. Social

A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower. Which comment by the nurse is the most appropriate? 1. If you look better, you might feel better. 2. Taking a shower might wash away some of that gloom and doom. 3. This is a positive sign. Ill be right back with your supplies. 4. Your spouse will be glad to see that youre feeling better.

3. This is a positive sign. Ill be right back with your supplies.

The nurse is conducting an admission interview. Which response indicates that the nurse is attentively listening to the clients explanations? 1. Can you explain what your symptoms are like? 2. When was the last time you saw a doctor for this? 3. Uh-huh, while nodding the head 4. Im sorry, say that again?

3. Uh-huh, while nodding the head

After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the clients bed safety-monitoring device, and the client fell out of bed. What should the nurse document? 1. Client fell out of bed; bed safety-monitoring device malfunctioning. 2. Client fell out of bed; client removed leg band of bed safety-monitoring device. 3. Client fell out of bed; no observable injuries. 4. Client fell out of bed; bed safety-monitoring device not activated.

4. Client fell out of bed; bed safety-monitoring device not activated.

The nurse needs to communicate information about a clients status to a physician. Which approach demonstrates assertive communication by the nurse? 1. You need to check the laboratory results of the client in room 423. 2. You should visit with the clients family about the upcoming procedure. 3. We need to be more aware of the situation among the client and the clients family. 4. I am concerned that the client does not have adequate pain management.

4. I am concerned that the client does not have adequate pain management.

A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the clients medications? 1. Nothing, as the medications all need to be reordered at the long-term care facility. 2. Have the clients medication prescriptions filled before going to long-term care facility. 3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. 4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client? 1. Assess the clients mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury.

4. Remain free from injury.

The nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for homeland security? 1. Cancer 2. Seasonal flu 3. Tuberculosis 4. Smallpox

4. Smallpox

The nurse is preparing materials to instruct the parents of a newborn. What should the nurse identify as a safety hazard in an infant? 1. Exposure to alcohol consumption 2. Drowning 3. Pedestrian accidents 4. Suffocation in the crib

4. Suffocation in the crib

During a health history, a client admits to taking nutritional supplements instead of prescribed medication. Which responses by the nurse indicate effective communication? Standard Text: Select all that apply. 1. What you did was wrong. 2. Who do you think you are? 3. You shouldnt have done that. 4. Tell me more about the supplements. 5. Explain the reasoning behind your decision.

4. Tell me more about the supplements. 5. Explain the reasoning behind your decision.

The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus? 1. Banging into objects 2. Bicycle rides 3. Recreational activities 4. X-rays

4. X-rays

The nurse enters a clients room and finds that the telephone is lying in the clients lap, tissues are wadded up on the bed, and the clients eyes are red and watery. What is the best response by the nurse? 1. Can I hang that phone up for you? 2. Well, its a beautiful day outside. Lets open the blinds. 3. Has your doctor been in to talk to you yet? 4. You look upset. Is there anything youd like to talk about?

4. You look upset. Is there anything youd like to talk about?

central neuropathic pain is located

all over the body

PAINAD scale used for; looks at

Dementia breathing vocalization facial expression body language consolability

dyesthesia

an unpleasant abnormal sensation (pins and needles)

coanalgesics examples

antidepressants anticonvulsants anesthetic

pseudoaddiction

Patient behaviors (drug seeking) that may occur when pain is undertreated.

referred pain

appear to arise in different areas