PrepU Comfort

The nurse concludes that teaching about pain management was effective when the client states:

"I will support my incision with my hands when I do my coughing and deep breathing exercises."

The nurse is helping with the health assessment of a school-age client with special needs for attendance at summer camp. The mother tears up, saying that she wishes the child would not attend. What is the best response by the nurse?

"It is not unusual for you to have strong feelings about this."

A client with a moderate level of anxiety is pacing quickly in the hall and tells the nurse, "Help me. I cannot take it anymore." What would be the best initial response?

"Let us go to a quieter area where we can talk if you want."

A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the client

"Only you are to push the button for medication."

The physician tells a client, "You are lucky. This episode of chest pain is a warning sign." How can the the nurse explain to the client what the physician means?

A decrease in blood supply to the heart causes stress to cells through the perception of pain.

The nurse assessed a patient's pain subsequent to a broken ankle. The nurse documented that the patient's pain was categorized as:

Acute

Two days after surgery to amputate his left lower leg, a client states that he has pain in the missing extremity. Which action by the nurse is most appropriate?

Administer medication, as ordered, for the reported discomfort.

A client returns from the first session of scheduled physical therapy following total knee replacement surgery. The nurse assesses that the client's knee is swollen, slightly erythematous, and painful. The client rates the pain as 7 out of 10 and has not had any scheduled or PRN pain medication today. What should the nurse do? Select all that apply.

Administer pain medication as prescribed. Elevate the leg and apply a cold pack. It is anticipated that there might be some swelling, redness, and discomfort immediately after activity, including physical therapy. Ideally, pain medication could be offered or given prior to therapy to reduce posttreatment pain, but should be administered now. Elevation and cold packs can also reduce swelling and decrease pain. It is not appropriate to notify the HCP as pain and swelling are normal after therapy. It is also not appropriate to massage the area. This will increase circulation and therefore increase swelling and pain.

The nurse is caring for a burn client with orders for oral ibuprofen and morphine PRN to control pain. Which nursing interaction is the most beneficial for the nurse to implement for pain management?

Alternate these medications around the clock to diminish peaks and valleys in pain control.

The nurse is preparing to send a child with cancer for a radiation treatment. Which medication should the nurse provide to premedicate the child for this procedure?

Antiemetic

The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse?

Clamp the tubing and give the patient a rest period.

A 4-year-old child is scheduled for an MRI. The child's mother is informed that the child will be free of pain but sedated to ensure stillness during the procedure. Which type of anesthesia does the nurse expect this child to have?

Conscious sedation

A client comes into the emergency department with severe back pain radiating to the left lower groin region. Morphine sulfate 10 mg IV is administered as ordered. One hour later the client states that the pain is still at 8 of 10. Which actions would the nurse take?

Contact the physician and explain that the pain is still at 8 of 10 one hour after the morphine has been administered and request a higher dosage.

The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?

Continuous labor support

A client is withdrawing from heroin and is experiencing muscle aches. Which approach by the nurse would be most effective?

Encourage the client to take warm baths.

A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?

Ensure the client knows to taper down the dose if it is discontinued by the care provider.

The nurse needs to carefully monitor a client with traumatic injuries. How often should the nurse check and document the client's pain?

Every time the client's vital signs are assessed

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client?

Explaining hospice care and services

The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering?

Fentanyl

The nurse is assessing a patient for the chronology of the pain she is experiencing. Which is an example of an appropriate interview question to obtain this data?

How does the pain develop and progress?

The nurse is working with a 5-year-old boy who must receive repeated intravenous injections as part of his treatment. He hates the injections, however, and is frightened whenever he sees the syringe and needle. In an attempt to overcome this fear, the nurse holds the syringe up for him to see and tells him, "This looks kind of like a space rocket, don't you think? Here comes the space rocket—it needs to refuel." Which pain management technique is the nurse using here?

Imagery

The nurse is administering an oral liquid medication to a 5-year-old child. What would be the most appropriate for the nurse to do when administering this medication?

Let the child hold the medication cup.

An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery?

Place the client in semi-Fowler's position with the knees to the chest. Appendicitis typically begins with periumbilical pain followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney point (located halfway between the umbilicus and the right iliac crest). To relieve pain prior to surgery, the nurse assists the client to a comfortable position with the knees drawn to the chest and the head of the bed slightly elevated. The nurse may also administer analgesics and ice packs, if prescribed; heat is avoided as heat may precipitate rupture of the appendix. The abdomen is not palpated or massaged more than necessary to avoid increasing the pain. Distraction with music may be helpful, but positioning, using ice packs, and analgesics are most effective.

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client?

Refer the client to her health care provider for evaluation and treatment of the pain.

A parent brings a teenaged child, who is complaining of having a severe headache, to the clinic. The teenager is groaning with pain. During assessment, the client asks the nurse for a note to excuse the absence from school. After further assessment, the nurse suspects that the client is malingering. What leads the nurse to come to this conclusion? Choose the best answer.

The client's symptoms disappeared after getting the medical note.

When describing the role of a doula to a group of pregnant women, the nurse would include which information?

The doula primarily focuses on providing continuous labor support.

The postoperative patient's plan of care contains an intervention to ambulate twice a day 200 feet with assistance of one member of the healthcare team. The intervention was not completed one morning due to his pain. Which of the following would be the appropriate way to document the missed event?

The patient reported his pain at a level of 8/10 at 30 minutes after dosing. The patient was returned to bed and the physician was notified of the uncontrolled pain level with the current medication order.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back.

A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do?

Use constant, gentle touch. Neonates that are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands.

A postmenopausal patient is experiencing dyspareunia. What methods can the nurse recommend she use to diminish the discomfort?

Water-based lubricant

To which client would the nurse be most likely to administer a prn medication?

a client who is reporting pain near the surgical site

A woman in her second trimester of pregnancy is beginning to experience more headaches. In addition to suggesting holding an ice pack to the forehead, the health care provider recomends which medication to provide some relief from the pain?

acetaminophen

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:

instruct the client or her partner to perform light fingertip repetitive abdominal massage.

Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

keep the client warm. The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.

The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use?

light stroking of the skin surface

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?

neuropathic and chronic

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?

reviewing and revising the pain management treatment plan

When using a Z-track injection technique, the nurse holds the gauze pledget against an IM injection site while removing the needle from the muscle. This technique helps to:

seal off the track left by the needle in the tissue.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to:

take NSAIDs with food.

A nurse observes that a client who underwent knee surgery 2 weeks ago needs progressively larger doses of analgesics to get relief from pain. The nurse interprets this as:

tolerance

A client with chronic cancer pain has been receiving opiates for 4 months. She rated the pain as an 8 on a 10-point scale before starting the opioid medication. Following a thorough examination, there is no new evidence of increased disease, yet the pain is close to 8 again. The most likely explanation for the increasing pain is:

tolerance to the opioid.

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?

visceral 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.

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:

"Effleurage is light abdominal massage used to displace pain."

A 9-year-old has suffered a severe anaphylactic reaction and dies. The nurse is providing support for the grieving parents. Which of the following comments would best help them cope?

"How can I help you get through this?"

The nurse understands the definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Which of the following comments by a client confirm the client's understanding of the fundamental concepts of pain? Select all that apply.

"I am tired of living with this nagging pain; I'm not sure how much longer I can go on." "I would love to go to church, but my back pain is too uncomfortable to make it through the service." "I used to walk every day for exercise; pain in my knee made me stop walking."

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?

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

The nurse has completed a preoperative education session with a client who will receive morphine via a patient-controlled analgesia pump (PCA) after surgery. Which statements by the client indicates the need for further education?

"I will remind my family member to push the PCA pump button for me if I doze off during the day."

The nurse has entered the room of a client who is postoperative day 1 and finds the client grimacing and guarding her incision. The client refuses the nurse's offer of p.r.n. analgesia and, on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client's concerns?

"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery."

A client receiving an antipsychotic agent develops acute extrapyramidal symptoms. Which response by the nurse would be most appropriate?

"These are the results of the drug and can be treated; your illness is not getting worse."

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."

A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an example of skin traction?

Buck's

A client who recently immigrated from Korea to the U.S. or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?

Checking vital signs and assessing for nonverbal indications of pain

Which condition is a downward displacement of the bladder toward the vaginal orifice?

Cystocele

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?

Effleurage

A client in labor is given 25 mg of intravenous (IV) meperidine for labor pain. The nurse should monitor the client for which adverse effects of the drug? Select all that apply.

Nausea and vomiting Respiratory depression Tachycardia

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient?

Respiratory assessment related to increased thoracic pressure

A client complains of severe low back pain that began shortly after the death of the client's mother 2 years ago. No physical cause has been found to account for the pain. The client has been largely responsible for the care of four younger siblings because the client's father spends much of the week out of town on work-related business. Based on the client's symptoms, which nursing diagnosis is most appropriate for the client at this time?

Somatic complaints due to anxiety related to life stressors

Which would not be an initial intervention for the client with acute anxiety?

Touching the client in an attempt to comfort the client

A client asks the nurse which vitamins should be taken daily for feelings of fatigue, anxiety, and depression 1 week before menses. Which of the following is the correct response by the nurse?

Vitamin B6

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:

effleurage.