Tech Skills Exam 5

The nurse in the intensive care unit (ICU) is concerned about the lack of restorative sleep for patients. For which reasons does the nurse recognize the need for restorative sleep? Select all that apply. 1. The healing process is faster and complete. 2. Cognitive functions are impaired. 3. Immunity decreases 4. Pain tolerance decreases 5. Accidents are more likely to occur.

Option 1: Without restorative sleep, healing is slow and incomplete.

The nurse is aware that cold therapy is sometimes ordered for the numbing effect. Which situation is best suited for numbing with cold therapy? 1. For relief from a severe sunburn 2. To stop the stinging from a bug bite 3. To interrupt the development of a rash 4. To suture a laceration

Option 2: Cold therapy is an effective way to decrease the stinging from a bug bite.

The nurse is preparing to use electrical equipment for the delivery of heat therapy. Which assessment of the equipment is unnecessary? 1. Check the cord for the presence of fraying. 2. The date when the equipment was manufactured. 3. Determine if the plug is attached firmly to the cord. 4. Look for scratches in the insulation layer of the cord.

Option 2: When the equipment was manufactured is unimportant.

The nurse is working in a pain management clinic. Which type of pain will the nurse identify as nociceptive pain? Select all that apply. 1. Cutaneous pain. 2. Phantom pain. 3. Osteogenic pain. 4. Soft tissue pain. 5. Psychosocial pain.

Option 1: Cutaneous pain is classified as nociceptive pain. It is more superficial and pertains to the skin and subcutaneous tissue, such as a minor cut or burn. Option 3: Osteogenic pain, or deep somatic pain, is nociceptive pain arising from bone, ligament, tendon, and blood vessel pain. Option 4: Soft tissue pain, also known as visceral pain, arises from the stimulation of deep internal pain receptors. This is a type of nociceptive pain.

The nurse is preparing to apply ice therapy to a patient after surgery to the scrotum. Which method of ice application will work best? 1. A disposable glove filled with ice and tied shut. 2. An ice bag filled half full of ice with some water added. 3. A half cup of ice wrapped in a clean washcloth. 4. A cooling pad with circulating cold water.

Option 1: It is difficult to apply ice to a scrotum because of the location and the irregularity of the skin surface. A disposable glove can be partially filled with ice, tied shut like a balloon, and covered with a washcloth. The glove is moldable and provides for effective therapy.

The nurse understands that a variety of pharmacological methods of pain management exists. Which types of medications are available to help control pain? Select all that apply. 1. Nonopioid analgesics. 2. Ajuvant analgesics. 3. Patient-controlled analgesia (PCA). 4. Opiate/opioid medications. 5. Nonsteroidal antiflammatory drugs (NSAIDs).

Option 1: Nonopioid analgesics include medications such as acetaminophen. Option 2: Adjuvant drugs will produce pain relief either through a mechanism different from traditional analgesics, or by potentiating or increasing the effects of opioids or nonopioid drugs. Option 4: Opiate/opioid medication are narcotics that are effective in relieving mild to severe pain that is classified as visceral or deep somatic pain. Option 5: NSAIDs affect inflammation and pain by preventing the release of inflammation mediators such as, histamine, serotonin, prostaglandins, and leukotrienes.

The nurse works in an acute care setting with patients who have had surgery. Which factors does the nurse identify as affecting how patients respond to or express pain? Select all that apply. 1. Previous pain experiences. 2. Personal support systems. 3. Ethnic and cultural beliefs. 4. Current developmental stage. 5. Emotional responses.

Option 1: Previous pain experiences will affect how patients respond to pain. Patients who have never experienced pain may not have good coping skills. Option 2: Personal support systems will affect how patients respond to pain. Most patients do better if they have a good support system. Option 3: Ethnic and cultural beliefs will affect how patients respond to pain. Some cultures are stoic while others are more verbal. Option 4: Current stage of development will affect how patients respond to pain. Younger and older patients may handle pain differently than adults. Option 5: How a patient handles emotional situation will affect how the patient responds to pain. Patients may become angry, sad, or depressed.

The nurse is reviewing a pain assessment for a patient experiencing pain. Which areas of information are important? Select all that apply. 1. The specific location of the pain 2. A pain level using a 0-10 scale 3. The effectiveness of medication 4. A description of the pain 5. Actions that cause the pain

Option 1: The site of the pain needs to be specific; "it hurts in my belly" provides little information about the location. Option 2: The intensity of the pain is important during assessment as baseline information. Option 4: A description of pain characteristics can vary with different conditions. The meaning of sharp chest pain is different than chest pressure pain. Option 5: Actions or conditions that elicit pain are important in pain management. Pain with breathing is handled differently than pain with urination.

The nurse is caring for a pediatric patient after a tonsillectomy. For which primary reason will the nurse expect cold therapy to be ordered? 1. To decrease pain. 2. To increase healing. 3. To promote hemostasis. 4. To eliminate swelling.

Option 3: The primary reason for cold therapy after a tonsillectomy is to control bleeding and promote hemostasis.

The nurse placed a cold pack on a patient's knee for 30 min. When the cold pack is removed, the skin is bright pink in color. The nurse recognizes that the patient is having a rebound effect. Which cause does the nurse understand? 1. The time exposure to cold therapy was too long. 2. The skin beneath the cold pack was not protected. 3. The area has vasodilation to prevent tissue damage. 4. The skin color indicates normal response to cold.

Option 3: When the skin temperature reaches 60°F, vasodilation will occur to prevent tissue damage. The increased circulation will cause the skin color to change to a pink or red.

The nurse is caring for an adult patient recently diagnosed with cancer who is scheduled for surgery. The patient tells the nurse, "I have been sleeping for seven hours and I still feel tired." Which reason can the nurse identify as most likely for the patient's statement? 1. The patient is actually sleeping too long for an adult. 2. The patient's anxiety over surgery is preventing restorative sleep. 3. The patient is experiencing depression about the recent medical diagnosis. 4. The patient is receiving antianxiety and sleep-promotion medications.

Option 4: It would not be unusual for this patient to be ordered on antianxiety and sleep-promotion medications. The nurse is aware that these medications can interfere with (rapid eye movement) REM sleep, which prevents the patient from feeling rested.

The nurse is caring for multiple patients. Which patients will the nurse identify as being contraindicated for heat therapy? Select all that apply. 1. A patient just admitted for multiple contusions 2. A patient experiencing serious muscle spasms 3. A patient who is hypothermic from exposure 4. A patient who has edema from a joint replacement performed two days prior 5. A patient who has abdominal swelling after surgery

Option 1: A patient with multiple contusions will not receive heat therapy, which can increase bleeding in recent injuries. Option 5: A patient with a fresh wound from trauma of surgery is not a candidate for heat therapy until they are 48 to 72 hr past the surgery.

The nurse is caring for a patient who is experiencing a pain level of 4 on a scale of 0-10 after the administration of pain medication. Before seeking an increase in the patient's medication order, the nurse decides to try distraction. Which activities are considered to be distractions for pain management? Select all that apply. 1. Turning on the television 2. Attempting to nap 3. Receiving a back rub 4. Working on word puzzles 5. Drinking a warm beverage

Option 1: Turning on the television is an effective form of visual and/or auditory distraction; another form is reading a book. Option 3: Receiving a back rub is an effective form of tactile distraction; other examples are rocking, brushing the hair, or taking a warm bath. Option 4: Working on word puzzles is an effective form of intellectual distraction; other examples are talking with another person or playing games.

The nurse works in acute care. In which situation is the nurse most likely able to independently apply heat therapy? 1. A patient who expresses extremely cold feet. 2. A patient with inflammation at an IV site. 3. A patient with anal edema from hemorrhoids. 4. A patient who prefers heat therapy over cold therapy.

Option 2: An IV site with inflammation is referred to as phlebitis. In many institutions nurses can apply heat to the inflamed area. However, the facility policy should always be followed.

The nurse is caring for a patient who is hypothermic from exposure. The health-care provider diagnoses the patient's hypothermia as being extreme. Which order does the nurse expect due to the patient's condition? 1. Placement of warming blankets 2. Warm packs applied to the axilla and groin 3. IV infusion of warm normal saline 4. Oral intake of warm fluids

Option 3: In cases of extreme hypothermia, the nurse will expect an order for the IV infusion of warm, normal saline.

The nurse is providing care to a patient diagnosed with bone cancer. The nurse is aware that the patient is experiencing which type of pain? 1. Phantom pain 2. Neuropathic pain 3. Nociceptive pain 4. Chronic pain

Option 3: Nociceptive pain is also referred to as deep somatic pain or osteogenic pain. Nociceptive is used to describe bone, ligament, tendon, and blood vessel pain. This is the type of pain a patient with bone cancer will experience.

The nurse works night shift in a long-term care facility. Which measure by the nurse is important to provide an environment conducive for sleep? 1. Leaving a bathroom light on for safety 2. Setting the room temperature slight cooler at night 3. Closing the door to reduce noises from outside the room 4. Promoting warmth with pajamas and a lightweight blanket

Option 3: Noise from outside the room can prevent the patient from sleeping, or wake the patient during the sleep cycle.

The nurse is applying heat to a patient's swollen ankle. The patient states that the cold therapy makes the ankle less painful. Which purpose does the nurse recognize as the purpose of the heat therapy? 1. The counteractive therapy allows treatment on a more frequent basis. 2. Heat therapy helps to restore circulation to damaged tissues. 3. The resulting vasodilation will help carry away the excess fluid and reduce edema. 4. Heat therapy is designed to increase joint and muscle movement.

Option 3: The purpose of heat circulation, applied after 48 to 72 hr of the injury, is to help carry away excess fluid and reduce edema. Pain is reduced as edema resolves.

The nurse is caring for a school-age patient who has a chronic condition that requires frequent hospitalization and causes severe pain. The nurse, who is familiar with the patient, notices that the patient has been crying throughout the evening. Which factor does the nurse recognize as a likely cause for the crying? 1. The patient is young and pain is difficult to manage at this stage of development. 2. The patient's tolerance for pain becomes more difficult with each hospitalization. 3. The patient is overly fatigued because of the inability to sleep. 4. The patient's parents visited for a short time and had to leave.

Option 4: Given the patient's medical history and the duration of the crying, the patient is likely dealing with emotions. The patient's parents are a large part of the patient's support system; a short visit may not have met the patient's needs.

The nurse is preparing to apply heat therapy to the arm of an older adult patient. Which factor related to the patient's age is inappropriate? 1. Lower heat application temperature to between 95°F to 100°F. 2. Assess skin condition at the site being treated every 5 to 10 min. 3. Stay with the patient during therapy if the patient is cognitively impaired. 4. Assess the patient's level of tactile sensation with a pointed object.

Option 4: One of the expected changes with aging is decreased tactile sensation. There is no need for the nurse to check the sense of touch. The use of a pointed object could cause pain or injury.