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A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? Select all that apply. 1. Cleaning the skin surrounding the gastrostomy tube stoma 2. Crushing and administering metoprolol through the gastrostomy tube 3. Programming the feeding pump to administer a prescribed bolus feeding 4. Teaching the client about home enteral feeding and gastrostomy tube care 5. Weighing the client using the bed scale
1 2 3
When caring for an adult client who is in soft wrist restraints, what is the appropriate nursing action to prevent interference with medical treatment?
Clients in medical-surgical restraints used to prevent interference with medical treatment are monitored and assessed according to federal, state, and regulatory agency guidelines. Guidelines include client observation and assessment of skin integrity and neurovascular status every hour; restraint release and ROM exercises every 2 hours; and offering fluids, nutrition, and toileting every 2 hours.
Fondaparinux (Arixtra),
Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place (Option 2). Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis.
Isoniazid (INH)
Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following: Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1) Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH Report changes in vision (eg, blurred vision, vision loss) Report signs/symptoms of severe adverse effects such as: Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) (Option 3) Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4)
In addition to standard precautions, the client infected with multidrug-resistant organisms (eg, vancomycin-resistant enterococci [VRE] or methicillin-resistant Staphylococcus aureus [MRSA]), Clostridium difficile, and scabies will require contact precautions that include the following:
Place client in a private room (preferred) or semi-private room with another client with the same infection Dedicate equipment for client (must be kept in the client's room and disinfected when removed from room) (Option 1) Wear gloves when entering the room Perform excellent hand hygiene before exiting the room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) (Option 2) Wear gown with client contact and remove it before leaving the room (Option 5) Place door notice for visitors Ensure client leaves the room only for essential clinical reasons (ie, tests, procedures)
amikacin, an aminoglycoside antibiotic
Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include ototoxicity and nephrotoxicity. Age, renal function, and drug dose affect the occurrence of these adverse reactions. Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity. The nurse should carefully assess for changes in the client's hearing, balance, and urinary output.
serum lab results
Serum laboratory test Normal values (adult male) Blood urea nitrogen 6-20 mg/dL (2.1-7.1 mmol/L) Creatinine 0.6-1.3 mg/dL (53-115 µmol/L) Hematocrit 39%-50% (0.39-0.50) Hemoglobin 13.2-17.3 g/dL (132-173 g/L) Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L)
The nurse provides an in-service for hospital staff on how to prevent pressure ulcers in clients with limited mobility. Which instructions are appropriate for the nurse to include?
Skin assessment, proper skin care, repositioning every 2 hours, adequate nutrition, and proper support surfaces are effective in helping prevent pressure ulcers. Massage over the bony prominences is not recommended for pressure ulcer prevention.
acetaminophen Gabapentin (Neurontin) Phenytoin (Dilantin)
The recommended dose for acetaminophen should not exceed 4 g in 24 hours, as it can lead to liver injury. The client is already receiving acetaminophen 1000 mg IV every 6 hours (4,000 mg). If the client needed and received the maximum possible dose of 6 tablets of hydrocodone/acetaminophen (5 mg/325 mg), the total dose of acetaminophen (4,000 mg + 1,950 mg [6 tablets] = 5,950 mg) would exceed the recommended daily dose. Gabapentin (Neurontin) is an analgesic adjunct and anticonvulsant drug prescribed to promote comfort and decrease the incidence of seizures. Phenytoin (Dilantin) is an anticonvulsant prescribed to prevent and/or treat post-traumatic seizure activity in clients following a head injury. The nurse would not question this prescription.
The nurse is reviewing prescriptions for the assigned clients. Which prescriptions should the nurse question? Select all that apply. 1. Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia 2. Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus 3. IV morphine for a client with severe acute renal colic pain who is scheduled for a percutaneous nephrolithotripsy 4. Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs 5. Simvastatin for a client with hypercholesterolemia who is reporting generalized muscle aches and weakness
2 5 The nurse should question these prescriptions and contact the health care provider: Dicyclomine, an anticholinergic/antispasmodic drug prescribed to manage irritable bowel syndrome, is contraindicated with paralytic ileus, as it decreases intestinal motility and would exacerbate the condition (Option 2). Statins (eg, atorvastatin, simvastatin) lower LDL cholesterol. Myopathy, a possible adverse effect, may lead to life-threatening rhabdomyolysis (Option 5). (Option 1) Tumor lysis syndrome is due to rapid lysis of cells and the resulting release of intracellular ions potassium and phosphorous into serum. Phosphorus binds calcium and causes hypocalcemia. Metabolism (catabolism) of released cellular nucleic acids leads to severe hyperuricemia. IV hydration and hypouricemic medications (eg, allopurinol) are usually prescribed to promote excretion of purines and prevent acute kidney injury. (Option 3) IV opioids (eg, morphine) or nonsteroidal anti-inflammatory agents (eg, ketorolac) are used to treat severe renal colic pain. Percutaneous nephrolithotripsy breaks and removes stones and can lead to severe pain. Therefore, pain medications are appropriate. (Option 4) Levofloxacin, a fluoroquinolone antibiotic prescribed to treat urinary tract infections, has no known cross-sensitivity to penicillin. However, cross-sensitivity with other fluoroquinolones can occur.
Clostridium difficile requires contact precautions
Place the client in single-room isolation (preferred) or cohort with other C difficile-infected clients All surfaces within 3 feet of the bed are considered contaminated Personal protective equipment (gown and gloves) must be discarded before leaving the room Hand hygiene must be performed with soap and water Alcohol-based hand sanitizers do not kill C difficile spores (Option 1) Dedicated medical equipment (stethoscope, blood pressure cuff) should remain in the room
Good Samaritan laws prevent civil action against nurses who stop to help of their own accord (eg, not part of the job duties). The nurse cannot receive payment for any care given (Option 2). It is essential for the nurse to perform in the same manner as an ordinary, reasonable, and prudent medical professional would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an arterial bleed
1 3 4 5 The following statements are most appropriate to include in the hand-off change-of-shift report: "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports a 3 on a pain scale of 0-10." This statement communicates exact information about medication dose, time, and measurable outcomes, and the oncoming nurse can anticipate when the client can be remedicated. "The continuous heparin infusion bag needs to be replaced at 2100." This statement communicates information about care that is due after the next shift begins and helps to organize and prioritize care. "The last potassium level was 3.2 mEq/L, and potassium chloride was prescribed 30 minutes ago but has not yet arrived from the pharmacy." This statement communicates a critical laboratory result and the time medication was prescribed, and alerts the oncoming nurse to follow up with the delivery of medication from the pharmacy. "The social worker is scheduled to speak with the spouse about home care at 0900 tomorrow." This communicates exact information regarding a social service consult with a family member about discharge.
The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? 1. Abrupt-onset hypertension and headache 2. Blue and cold fingertips 3. Dry cough and exertional dyspnea 4. Heartburn and difficulty swallowing
1. Abrupt-onset hypertension and headache Scleroderma is an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal. (Option 2) Raynaud phenomenon can develop secondary to scleroderma. It is characterized by vasospasm-induced color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in warm water) but is not life-threatening. (Option 3) Pulmonary fibrosis is a progressive complication of scleroderma that is defined as scarring of lung tissue, which then causes reduced function, dry cough, and dyspnea. Some clients may be placed on oxygen. This is not immediately life-threatening. (Option 4) Heartburn and dysphagia (difficulty swallowing) are common symptoms associated with scleroderma. This is due to the disease process of internal scarring, and it is not life-threatening.
The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood 2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off 3. Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site 4. Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter
1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood The nurse should assess the postoperative client first by monitoring vital signs, examining the dressing and amount and appearance of the drainage, and performing a neurovascular assessment (eg, pulses, skin color and temperature, sensation, movement). Serosanguineous (pink) drainage would be expected 2 hours after surgery, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. A pressure dressing may be required to provide wound hemostasis, or the client may need to return to the operating room for cauterization of a bleeding vessel. This client is at highest risk for morbidity and mortality (Option 1). (Option 2) The dressing on an infected foot ulcer is usually removed before the foot is placed in a whirlpool bath (hydrotherapy). The nurse can apply a new dressing or cover and wrap the foot using a sterile towel or gauze bandage to protect it from microorganisms. This client is not the priority. (Option 3) Dialysis grafts are prone to infection. This client needs to be assessed for erythema, graft tenderness, fever, and tachycardia. These are not immediately life-threatening conditions. (Option 4) Infection can cause delirium (altered mental status). This client needs one-to-one observation and repeated reorientation while antibiotics take effect. However, this client is not a priority over a client who is actively bleeding.
The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an appropriate understanding of the study and reason for participation? 1. "I changed my mind, but once in you're stuck." 2. "I hope others will be helped through my involvement." 3. "I know I will get new medication by being in this study." 4. "If I don't participate, my health care provider (HCP) will be upset."
2. "I hope others will be helped through my involvement." Research with human subjects is reviewed by institutional research boards to ensure ethical principles are followed. The research participant cannot be deceived and must participate voluntarily knowing the risks and purpose of the study; confidentiality must be maintained. Clients in research studies often have altruistic motives. They know they may achieve no personal gain, but others could benefit from their participation. (Option 1) A basic tenet of any research study is that the client has the right to autonomy and to withdraw at any time. (Option 3) All clients should receive safe, quality care whether they participate in the study or not. Due to randomization, the client has no guarantee of receiving a medication that is more effective rather than the placebo. This misconception should be clarified. (Option 4) Clients should not be coerced in any way, including withdrawal of approval or affection. The client may have misperceived the HCP's potential response, but this stated reason for participation needs further exploration.
The nurse receives a report on 4 clients. Which client should the nurse assess first? 1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless 2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% 3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago is confused 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to time and place
2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% A fat embolism is life-threatening; therefore, the client with the femur fracture is the priority. There is a risk for the formation of fat emboli following certain fractures, typically those of the long bones and pelvis. Globules of fat leave the bone and travel through the bloodstream to the lungs, skin, and brain where they cause damage by occluding small vessels. Altered mental status will result from blocked blood vessels in the brain. An embolism to the lung would result in respiratory distress. A hallmark sign of fat emboli is the presence of petechiae (pin-sized red/purple spots) that result from small-vessel clotting and appear across the chest, in the axillae, and in the soft palate.
A float nurse is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse? 1. Client 3 days following a myocardial infarction who reports chest pain that increases on inspiration 2. Client admitted for hypertensive emergency who now has a blood pressure of 136/86 mm Hg on amlodipine PO 3. Client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min 4. Client with unstable angina admitted last night who had negative troponin levels and nonspecific ECG changes
2. Client admitted for hypertensive emergency who now has a blood pressure of 136/86 mm Hg on amlodipine PO A hypertensive emergency is an elevation in blood pressure (BP) >180 mm Hg systolic and/or >120 mm Hg diastolic with evidence of target organ damage (eg, kidneys). The goal of treatment is to slowly lower BP using IV antihypertensive medications (eg, vasodilators); a rapid drop in BP may cause decreased perfusion to vital organs. Once the client's condition is stabilized, oral antihypertensives are prescribed and IV medications are titrated off. The float nurse can be safely assigned to the client whose BP is controlled on oral medication and whose condition is considered stable. The float nurse has the knowledge/skills to assess vital signs and administer oral medications within prescribed parameters.
A nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question? 1. Amlodipine 2. Codeine 3. Ipratropium 4. Methylprednisolone
2. Codeine Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD). (Option 1) Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol). (Option 3) Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm. (Option 4) Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD.
The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? 1. 1-day postoperative client with lower abdominal pain and no urine output for 6 hours 2. An elderly client with blood pressure 190/88 mm Hg who is asymptomatic 3. Client with hepatitis C virus who has alanine aminotransferase/aspartate aminotransferase (ALT/AST) values 4 times the normal value 4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign
4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign The prioritization principle is that systemic symptoms are more important than local symptoms. Trousseau's sign (carpal spasm with blood pressure cuff inflation) indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size. Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias. Assessing this client is a priority over pain or expected findings. (Option 1) This client likely has postoperative urinary retention and needs to be evaluated as soon as possible (second in priority). Although, this condition is painful and could result in kidney injury, it is not immediately life-threatening. (Option 2) This client has isolated systolic hypertension, which is common in elderly clients and they are often asymptomatic. Systolic blood pressure is usually >160 mm Hg but diastolic blood pressure is <90 mm Hg. Treatment might benefit these clients, but this is not a priority. (Option 3) ALT and AST are enzymes released when hepatocytes are destroyed as part of the hepatitis pathology. Hepatitis is diagnosed when these enzymes are ≥2-3 times the normal value. The hepatitis C virus usually causes chronic infection. The client's acuity is not directly related to the level of enzymes; this client is not more seriously ill because the enzymes are higher than a client whose labs results are twice the normal value. This is an expected finding and is not a priority.
Which client is most appropriate for the 7:00 AM-7:00 PM charge nurse on a cardiac step-down unit to assign to a float registered nurse from a medical-surgical unit? 1. Client who just returned to the unit after coronary angioplasty and placement of a stent 2. Client with atrial fibrillation scheduled for electrical cardioversion this afternoon 3. Client with heart block scheduled for pacemaker placement this afternoon 4. Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin
4. Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin The most appropriate assignment for the float nurse is the client with heart failure and IV heparin. The nurse from a general medical-surgical unit should be familiar with the assessment, nursing care, nursing diagnoses, and medications administered to clients with heart failure and with the facility's protocol for administration of a continual IV heparin infusion. (Option 1) This client should be assigned to an experienced nurse who regularly works on the unit. The nurse would be familiar with monitoring for bleeding at the femoral access site, post-procedure angina (eg, coronary vasospasm, acute thrombosis), and alterations in peripheral pulses. The experienced nurse would be better able to provide education as most clients are discharged 24 hours after stent placement. (Option 2) This client's nurse should be familiar with cardioversion. The nurse could explain the procedure to the client, assist if the procedure is done on the unit, and monitor the client for post-procedure complications (eg, cardiac dysrhythmias). (Option 3) This client's nurse should be familiar with monitoring for heart block until a pacemaker is placed, pacemaker placement, and postprocedure complications.
Four clients come to the emergency department (ED). Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment? 1. Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an oxygen saturation of 91% 2. Healthy child with new-onset fiery-red rash on cheeks and the "flu" 3. Middle-aged client with vaginal itching and white, curdlike discharge 4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face
4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face Although this elderly client may be unconscious due to intoxication, vomit and decreased level of consciousness place this client at risk for airway obstruction. Treatment of this client is a priority, and measures must be taken to protect the airway (eg, rescue position, head of bed elevation, intubation). (Option 1) Bacterial infection is the most common cause of COPD exacerbation. Although clients with COPD usually have cough and sputum, it becomes a concern when the sputum changes in color, consistency, or volume. This client needs antibiotics. The goal pulse oximetry reading for COPD is typically 90%-93% as many clients with COPD rely on their hypoxemic drive to breathe. Therefore, this client is stable and can wait until the unconscious elderly client is treated. (Option 2) This child has fifth disease ("slapped-cheek," erythema infectiosum), which is caused by parvovirus B19. Symptoms, in addition to a bright-red facial rash, include fever and general flulike symptoms. It is harmless unless the client has a hemolytic/immunodeficient condition. Pregnant women should avoid contact with infected individuals as the virus can be transmitted to the fetus and cause anemia. Prioritization is determined by acuity, and therefore children do not automatically receive higher priority. However, due to the potential exposure of this child to a pregnant client in the ED, the triage RN should prioritize this client ahead of the one with vaginal infection. (Option 3) This client is exhibiting a classic sign of the common Candida vaginitis (yeast) infection. Classic signs and symptoms include itching and irritation in the vulva or vagina, white cheesy vaginal discharge, and low vaginal pH. Although uncomfortable, this client is stable and can safely wait up to 2 hours for treatment.
Aspirin
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastrointestinal (GI) bleeding by decreasing the production of prostaglandins, which protect the lining of the stomach and intestines from digestive acids. NSAIDs (especially aspirin) also decrease platelet aggregation and thereby inhibit blood clotting. Coffee-ground emesis and black tarry stools (melena) are signs of GI bleeding. Bruising can occur due to the decreased platelet aggregation. Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity.
Good Samaritan laws
Good Samaritan laws prevent civil action against nurses who stop to help of their own accord (eg, not part of the job duties). The nurse cannot receive payment for any care given (Option 2). It is essential for the nurse to perform in the same manner as an ordinary, reasonable, and prudent medical professional would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an arterial bleed
The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent botulism?
discard canned food with a bulging end Botulism is caused by the gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis. The organism is found in the soil and can grow in any food contaminated with the spores. Manifestations include descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth muscle paralysis). The main source is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw (wild) honey. The immature gut system in these children makes them more susceptible. (Option 1) Contaminated water is boiled to prevent infestation with Giardia, which can cause gastrointestinal disease but is not related to botulism. (Option 3) Keeping dairy at room temperature can cause it to spoil, which would then cause gastroenteritis if ingested. Most serious illnesses are prevented through pasteurization. This is not related to botulism. (Option 4) Escherichia coli infections result from ingestion of food or water that is contaminated by feces. This can be related to improper handwashing or undercooking meat and is not related to botulism.
A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection?
dorsal surface of hand Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed. (Option 1) The antecubital fossa is commonly selected in emergency situations due to its size and ease of cannulation but is problem prone for longer-term needs as it is in the bend of the elbow. Bending of the arm can move the catheter, causing irritation at the insertion site and increasing infection risk. (Option 3) The foot is not typically accessed in adults without a specific health care provider prescription. It is occasionally used in emergency situations; however, veins in the legs and feet may have decreased venous return, and complications can lead to thrombophlebitis or deep vein thrombosis. (Option 4) The radial vein is present on the lateral side of the wrist but is in close proximity to several nerves, which could cause severe pain or nerve damage.
