PrepU Ch.36; Fundamentals

The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain? a. "Have you had this pain before?" b. "When did your pain begin?" c. "Could you please rate your pain on a 1-10 scale?" d. "How long have you experienced this pain?"

d. "How long have you experienced this pain?"

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what? a. "I may need fewer pain medications with the TENS unit in place." b. "One advantage of the TENS unit is it increases blood flow." c. "Wearing the TENS unit should not interfere with my daily activities." d. "I could use the TENS unit if I feel pain somewhere else on my body."

d. "I could use the TENS unit if I feel pain somewhere else on my body."

The nurse is developing a discharge teaching plan for clients taking opioid pain medication. Which of the following should the nurse include? Select all that apply. 1. Do not drive while taking pain medication. 2. Avoid dairy products. 3. Take medication on an empty stomach. 4. Do not smoke without someone else present. 5. Avoid alcohol.

1. Do not drive while taking pain medication. 4. Do not smoke without someone else present. 5. Avoid alcohol.

The nurse is conducting a pain assessment with an older adult client. The nurse notices that the client grimaces when the nurse asks the client to lean forward. The client, however, rates pain as 3 out of 10 on the numerical pain rating scale. The nurse recognizes that the client may be reporting pain inaccurately for which reason(s)? Select all that apply. 1. The client believes that pain is a normal part of the aging process. 2. The client is doubtful that any interventions will be helpful. 3. The client has a fear of becoming addicted to pain medications. 4. The client is concerned about being perceived as weak or bothersome. 5. The client misunderstands the rating scale

1. The client believes that pain is a normal part of the aging process. 2. The client is doubtful that any interventions will be helpful. 3. The client has a fear of becoming addicted to pain medications. 4. The client is concerned about being perceived as weak or bothersome. 5. The client misunderstands the rating scale

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) 1. Encourage the use of a sitter. 2. Play the client's favorite music. 3. Promote a restful environment. 4. Encourage deep breathing. 5. Encourage increased protein.

2. Play the client's favorite music. 3. Promote a restful environment. 4. Encourage deep breathing.

The nurse is providing care to multiple clients. During which client interaction(s) will the nurse ask about the level of pain the client is experiencing? Select all that apply. 1. The nurse views a client, who previously denied pain, sitting in a chair visiting with family. 2. The nurse is making rounds and taking a client's vital signs at the scheduled time. 3. The nurse is assisting a client to a supine position following a lumbar puncture. 4. The nurse had administered an oral analgesic 5 minutes ago for the client's report of pain. 5. The nurse is completing the admission database with a newly admitted client.

2. The nurse is making rounds and taking a client's vital signs at the scheduled time. 3. The nurse is assisting a client to a supine position following a lumbar puncture. 5. The nurse is completing the admission database with a newly admitted client.

The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply. 1. You may smoke cigarettes during the day but not at night. 2. You must check with your primary care provider before breast-feeding your infant. 3. Client is allowed to have one drink of alcohol each day. 4. Do not drive a vehicle while taking this medication. 5. Keep a diary to record level of pain and time medication is taken. 6. For better absorption, take your pain medication on an empty stomach.

2. You must check with your primary care provider before breast-feeding your infant. 4. Do not drive a vehicle while taking this medication. 5. Keep a diary to record level of pain and time medication is taken.

The nurse is assessing a client who is experiencing pain. The nurse notes the client is experiencing acute rather than chronic pain when the client makes which statement? a. "The pain is really sharp in this one spot." b. "No amount of medication seems to relieve the pain completely." c. "I cannot recall when this pain started." d. "I am experiencing a very low mood right now."

a. "The pain is really sharp in this one spot."

A client has been reluctant to ask for breakthrough doses of the opioid prescribed, despite showing signs of pain. The client states to the nurse, "I don't want to become addicted to the medication." How should the nurse respond to the client's statement? a. "There's only an extremely small chance that you will become addicted to this drug." b. "If you start needing more doses to control your pain, then we'll address the question of addiction." c. "It's best to focus on controlling your pain and not worry about issues like addiction." d. "You could become addicted, but there are excellent resources available in the hospital to deal with that development."

a. "There's only an extremely small chance that you will become addicted to this drug."

The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief? a. Acknowledge the pain as the client reports it and administer pain medication as prescribed. b. Observe the client's behavior when the nurse is not with the client. c. Report the client to the health care provider for seeking drugs. d. Take the client's vital signs often to observe for changes that may indicate pain.

a. Acknowledge the pain as the client reports it and administer pain medication as prescribed.

The nurse is caring for a client with chronic back pain due to inoperable spinal stenosis. Which strategies, suggested by the nurse, may help to decrease the client's back pain? a. Adding the use of hot or cold packs for pain control b. Requesting an increased opioid prescription from the health care provider c. Maintaiing partial bed rest to relieve pain d. Teaching the client to perform stretching exercises

a. Adding the use of hot or cold packs for pain control

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse? a. Administer the pain medication. b. Reassess the client's pain in 30 minutes. c. Contact the client's health care provider. d. Hold the pain medication.

a. Administer the pain medication.

The nurse is caring for a client who frequently comes to the emergency department (ED) reporting a headache that is an 8 or 9 on a pain scale of 1 to 10. The client is noted to be laughing while on the phone and chatting with staff after reporting a headache that is a 10. Which action will the nurse perform prior to initiating treatment? a. Assess for nonverbal cues to pain b. Discuss observations with the client c. Contact the pain clinic for further assessment d. Request a lower dose of medication from the health care provider

a. Assess for nonverbal cues to pain

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action? a. Avoid massaging this area and report the finding to the health care provider. b. Gently massage the region, document the finding, and verbally report it to the health care provider. c. Avoid massaging the area and apply a thin layer of a topical antibiotic ointment. d. Massage the area in an attempt to restore adequate circulation.

a. Avoid massaging this area and report the finding to the health care provider.

The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action is an example of this type of intervention? a. Closing the client's room door to reduce unnecessary noises b. Smoothing out the wrinkles in the client's bed linen c. Offering the client an appropriate book to read or music to listen to d. Assisting the client to change positions to maintain body alignment

a. Closing the client's room door to reduce unnecessary noises

How should the nurse position the head of the bed for a client receiving epidural opioids? a. Elevated 30 degrees b. Flat c. Trendelenburg d. Reverse Trendelenburg

a. Elevated 30 degrees

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant? a. FLACC scale b. Apgar score c. Braden scale d. FACES scale

a. FLACC scale

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate? a. The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. b. The nurse should expect slight resistance during the removal of the epidural catheter. c. If the client develops a headache, an opioid analgesic may be administered along with the epidural analgesia. d. If a client is experiencing adverse effects, a peripheral IV line should be inserted to allow immediate administration of emergency drugs, if warranted.

a. The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Gate Control Theory? a. providing temple massage when head hurts b. asking if pain is produced by smells or sounds c. teaching the client to remove items from the home that remind them of work d. contacting the health care provider to prescribe opioid medication

a. providing temple massage when head hurts

A nurse is caring for a client who was administered an opioid. The client reports constipation. What is another potential side effect of opioid use? a. sedation b. insomnia c. anxiety d. diarrhea

a. sedation

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain? a. "When did your pain begin?" b. "Can you describe the type of pain you are having?" c. "Could you please rate your pain on a 1-10 scale?" d. "How long have you experienced this pain?"

b. "Can you describe the type of pain you are having?"

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse? a. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to prevent accidental dislodgement of the catheter." b. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." c. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to decrease the risk of severe migraine headaches." d. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to increase the effectiveness of the spinal analgesia."

b. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

The nurse is caring for a client utilizing a Patient Controlled Analgesia (PCA) pump that is programmed to allow a bolus dose every 10 minutes. The client is sleeping with visitors at the bedside. Which of the following instructions should the nurse give the client's visitors? a. "Push the button on the pump every 10 minutes." b. "Only the client should push the pump button." c. "Remind the client to push the button more often than every 10 minutes." d. "Push the pump button when you think the client is in pain."

b. "Only the client should push the pump button."

A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse? a. Administer the medication when the client's heart rate is < 90. b. Administer the medication if respiratory rate is > 9. c. Administer the medication when the client's blood pressure is > 140/90. d. Administer the medication when the client's heart rate is > 80.

b. Administer the medication if respiratory rate is > 9.

The health care provider has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? a. Client has a right shoulder immobilizer in place b. Client is disoriented to time and place c. Blood pressure 178/92 mmHg and pulse 118 beats per minute d. Client rates pain an 8 on a 0 to 10 scale

b. Client is disoriented to time and place

The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit? a. Furosemide b. Naloxone c. Digoxin d. Lisinopril

b. Naloxone

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care? a. Observing for bowel incontinence b. Preventing constipation c. Assessing for impaired urinary elimination d. Observing for diarrhea

b. Preventing constipation

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? a. The client requires less nursing care. b. The client is actively involved in pain management. c. The client obtains pain relief slowly and steadily. d. The client is able to have long hours of rest.

b. The client is actively involved in pain management.

The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate? a. They occupy cell receptors for neurotransmitters. b. They bind to opioid receptor sites throughout the CNS. c. They react with acetylcholine and serotonin. d. They block glutamate receptors and peptides.

b. They bind to opioid receptor sites throughout the CNS.

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain? a. acute pain b. limited pain c. referred pain d. chronic pain

c. referred pain

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing: a. somatic pain. b. cutaneous pain. c. visceral pain. d. neuropathic pain.

c. visceral pain.

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement? a. "This will allow me to control my own pain medication." b. "The pump is programmed to limit the chance of overmedicating." c. "I should only take medication when my pain is intense." d. "I give myself the pain medication by pushing the button."

c. "I should only take medication when my pain is intense."

A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is somewhat drowsy but is easily aroused by voice. The nurse would assign which rating? a. 1 b. 3 c. 2 d. S

c. 2

Which medical client is most likely to be experiencing diffuse pain? a. A client who has been prescribed antibiotics for the treatment of strep throat b. A client who is undergoing diagnostic testing for appendicitis c. A client with shingles affecting her entire torso d. A client who has presented to the emergency department with a stab wound

c. A client with shingles affecting her entire torso

The nurse is caring for a client on their first postoperative day after chest surgery. The client appears stoic and does not request analgesia, The nurse should perform what action? a. Ask the client's family if they ever use analgesics b. Document the fact that the client does not need medication c. Actively solicit information about the client's pain level d. Document the client's lack of pain

c. Actively solicit information about the client's pain level

What will the nurse place at the bedside of a client receiving epidural analgesia? a. An extra chest drainage system b. Bottle of sterile saline c. Ampule of 0.4 mg naloxone d. Ampule of 0.4 mg epinephrine

c. Ampule of 0.4 mg naloxone

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse? a. Administer the next dose of the pain medication. b. Assess the client for signs of opioid addiction. c. Assess for medication prescription for breakthrough pain. d. Tell the client he or she will have to wait for 1 hour.

c. Assess for medication prescription for breakthrough pain.

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? a. Compare the client's current assessment with previous admission assessment b. Assess the client's serum albumin level c. Examine the effectiveness of the current pain regimen d. Educate the client/caregiver about signs of impending death

c. Examine the effectiveness of the current pain regimen

A 77-year-old woman is on the nurse's unit s/p left knee replacement. The client typically stools every morning but has not had a bowel movement in 3 days. The nurse knows that which medication places the client at increased risk for constipation? a. Furosemide b. Psyllium c. Hydromorphone d. Acetaminophen

c. Hydromorphone

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? a. Neuromuscular b. Peripheral Vascular c. Respiratory d. Cardiovascular

c. Respiratory

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? a. Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. b. An antidote is automatically delivered if the client exceeds the recommended dose. c. The dose that is delivered when the client activates the machine is preset. d. Thorough client education is necessary to prevent overdoses.

c. The dose that is delivered when the client activates the machine is preset.

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain? a. PAINAD Scale b. FLACC Scale c. Wong-Baker d. CRIES Pain Scale

d. CRIES Pain Scale

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate? a. Stop the back massage immediately. b. Apply a warm compress to the area. c. Massage the area using lotion. d. Document the finding.

d. Document the finding.

The nurse is teaching a novice nurse about the therapeutic effects of laughter. Which example correctly identifies one of these effects? a. It causes shallow breathing. b. It decreases the pain threshold. c. It decreases heart rate. d. It activates the immune system.

d. It activates the immune system.

A client is experiencing pain at a surgical incision site. During transmission of the pain signal, what event will occur? a. Histamine release from damaged tissues activates nociceptors at the incision site b. Release of electrons cause a neuron to be activated c. The thalamus generates a pain signal which is distributed peripherally d. Movement of ions propels the pain signal along a nerve fiber

d. Movement of ions propels the pain signal along a nerve fiber

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered? a. one-time order b. standing order c. stat order d. PRN order

d. PRN order

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action? a. Discontinue the client's pain medication until his or her level of consciousness improves. b. Increase the frequency of the client's vital signs assessment to every 2 hours for the next 6 hours. c. Administer a dose of naloxone and report this finding to the primary care provider. d. Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.

d. Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment? a. Temperature, pedal pulses, and assessment of cranial nerves b. Heart rate, capillary refill, bowel sounds and pedal pulses c. Gastrointestinal status, bowel movements, and urine output d. Respiratory status, oxygen saturation, pain, and sedation level

d. Respiratory status, oxygen saturation, pain, and sedation level

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as: a. transcutaneous electrical nerve stimulation (TENS). b. Therapeutic Touch (TT). c. hypnosis. d. biofeedback.

d. biofeedback.

Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy? a. lorazepam b. morphine c. hydromorphone d. gabapentin

d. gabapentin

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point? a. administering a placebo and performing a reassessment of the pain b. beginning pain medications before the pain is too severe c. judging whether the client is in pain or is just depressed d. reviewing and revising the pain management treatment plan

d. reviewing and revising the pain management treatment plan