Quiz 14- pain & wound care

Increased pulse rate

A nurse is collecting data from a client who has severe dementia and a fractured femur due to a fall. Which of the following manifestations should the nurse understand is a physical finding in acute pain?

The client's self-report of pain

A nurse is collecting data from a client who reports pain. Which of the following client findings should the nurse consider as the most reliable indicator of pain

Granulation tissue

A nurse is collecting data on the client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize tis is a manifestation of which of the following?

Acupuncture

A nurse is explaining different types of complementary and alternative healing modalities to a client who has chronic pain. Which of the following healing modalities should the nurse describe as the use of needles to stimulate specific points on the body to relieve discomfort, promote health & cure disease?

Endorphins

A nurse is giving an in-service on pain management and includes information about the body's production of substances that attach to opioid receptor sites and prevent the release of neurotransmitters inhibiting the transmission of pain impulses. These substances are called (1 word)

-Grimacing -Restlessness -Clenching _moaning

A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain?

Serosanguineous

A nurse is performing a dressing change on a 2-day post-surgical client. Which terms should the nurse document to describe a pale, red, watery drainage

Don CLEAN gloves and then remove the dressing

A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take

"I should tell the nurse if I cannot control my pain with this device"

A nurse is reinforcing teaching a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following statements by the client indicates an understanding of the teaching?

"I will call for more pain medication before the previous dose wears off"

A nurse is reinforcing teaching about pain control with a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control

Referred pain

A patient has pain in the left arm secondary to coronary insufficiency. This is an example of what type of pain

Pain is subjective for the patient

A patient reports to the nurse that he is experiencing a moderate amount of back pain rated 6/10 on the pain scale. What should the nurse recognize about this assessment

Edema

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following finding is an indication of an wound infection

Client's self-report of pain

A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?

Perform hand hygiene before dressing changes

A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection

Distraction

A client is about to undergo a closed reduction of a fracture. In addition to analgesia, the nurse suggests that the client listen to an audiotape of music. Which of the following nonpharmacologic interventions for pain management is the nurse using?

Asking the client to rate their pain

A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?

Fully collapse the reservoir after emptying it

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

Vitamin C

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

Granulation tissue on the surface of the wound

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device place over it. Which of the following findings by the nurse indicates healing of the wound

Purulent

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the types of drainage found?

Cover the area with saline-soaked sterile dressing

A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds evisceration. Which of the following interventions is appropriate?

Perform hand hygiene prior to any wound care

A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent incisional infection?

30 minutes prior to the dressing change

In an attempt to keep the client comfortable during a dressing change, the nurse may administer analgesic:

warning

Pain serves as a ____________ to the body: it often occurs with ACTUAL or POTENTIAL tissue damage.

Collagen

The nurse assures a patient that the purple, raised, immature scare of a wound (FITB)

300 mL

The nurse carefully measures drainage during the first 24 hours post-surgery. The nurse is aware that it is considered abnormal if the drainage exceeds

Blocks pain impulses

The nurse explains that transcutaneous electric nerve stimulation (TENS) provides are continuous mild electric current to the skin. How does the TENS unit act to reduce pain

Respiratory depression

The nurse is caring for a client that had extensive abdominal surgery and has morphine ordered for pain control. The nurse knows that one of the major complications of using this medication is that it can cause

Gate control

The nurse is giving a backrub to relieve pain. What pain theory is the nurse using

Tertiary intention

The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal

Ensure that it is not restricting chest wall expansion

The nurse is reapplying a chest binder for a client with fractured ribs. What precaution should the nurse take during this procedure?

Subjective data

The nurse obtains info from a patient about the site, severity and duration of the pain. What type of data is this considered

Less than 6 months

The nurse reassures a patient that most acute pain is intense and of short duration, usually lasting:

It has the most minimal scarring results

The nurse reminds the client that primary intention has a marked advantage over other phases of wound healing in that:

Quicker

The nurse reminds the client who is using patient-controlled analgesia that the major advantage to this method is that it is

St. John's Wart

What herbal supplement is popularly used by clients to fight signs and symptoms of depression

The brain does not have the capacity to acknowledge the pain while it is interpreting another source of stimuli

What is a description of gate control theory?

To decrease edema at the site

What is the primary reason for patient using cold compress

-Increased pulse rate -Diaphoresis -Increased respiratory depth & rate -Increased blood pressure

Which of the following are objective signs of pain? (SATA)

-Fast recovery time -Fewer readmissions -Improved quality of life -Shorter hospital stays

Which of the following are the advantages of a client receiving proper pain management during their hospital stay? (SATA)

It is much easier to PREVENT severe pain than to RELIEVE it

Which of the following is a general guideline of pain management

-Increased blood pressure -Increased pulse rate -Increased depth and frequency of respirations -Diaphoresis

Which of the following objective symptoms of the pain would the nurse observe and document?

-Clean from least contaminated to most contaminated -Cleanse the area around the skin with antiseptic swabs first -Instill solution into wound by inserting syringe tip into the wound

Which of the following principles is correct during wound irrigation? (SATA)

-Mood swings -Disorientation -Fatigue _irritability

Which of the following signs and symptoms can a nurse assess in a client with sleep deprivation?

Open drainage

Which of the following types of draining systems describes an open-ended tube that drains into a receptacle or out into the dressing?