Advanced Skills II Unit II Exam

What questions does a nurse ask a patient about their pain on a pain assessment? The best answer.

Nature, Intensity, location, onset.

A nurse is instructing a patient about relaxation techniques for pain management. The patient should...

tense and relax individual muscle groups. Starting with the toes and feet.

Nurse caring for a patient with a stage I pressure ulcer would most appropriately select a ______dressing

thin film

A nurse is caring for a new patient admitted for electrolyte imbalance who has been practicing Ayurveda. The nurse immediately notified the physician because...

uses purgatives as part of the treatment.

Patient complains he feels he is getting worse because of increased swelling @ wound site, nurse best response of swelling...

vessels have dilated and allowed plasma to leak into the wound site.

The nurse caring for a 25yo ake without any religious affiliation who was admitted last week with severe gastrointestinal infection encounters the hospital chaplain who wants to pray with the patient. The most appropriate response would be...

"before you do that, we need to get the patient's permission."

Karen's patient is prescribed a COX-2 inhibitor for her pain. Which of the following is an example of a COX-2 inhibitor?

-Antiinflammatory

Pain is transmitted through the circulatory system.

-False

Pain receptors may be stimulated by chemical, electrical, mechanical agents and transduction.

-False

There is no way to determine if a dementia patient is in pain.

-False

Which of these answers are not non-pharmaceutical treatment of pain?

-Fentanyl

A 70 yo male patient with chronic pain says he doesn't want any techniques that involve machinery. This patient would be more likely to use a nontraditional method of pain control such as...

-Hypnosis

There are several different types of pain. Which type of pain occurs after the loss of a body part from an amputation?

-Phantom

A nurse has reinforced instruction with a lenient who has an arterial ischemic leg ulcer about wound care and self-management of the health problem. Which statement by the client indicates a need for further instructions?

I should elevate my legs above heart level at least 1 hour each day.

A nurse is assessing her patient for pain. What theory would she use?

Pain viewed as being controlled by a gate mechanism in the central nervous system.

A client has undergone laser surgery to remove two nevi. The nurse includes which of the following statements when reinforcing discharge instructions to the client?

Protect the areas from direct sunlight for at least 3 months.

A nurse is taking care of a patient with a laceration with edges that do not approximate. What intention of healing is the wound?

Second intention.

A nurse goes in to do an assessment on the patient and she observes the patient having periodic pauses in breathing, then starts to breathe again. This is considered a sleep disorder called.

Sleep apnea.

An adult client is brought into the emergency room by ambulance after being hit by a car. The client is unconscious and is in shock. A perforated spleen is suspected and emergency surgery is required immediately to save the client's life. There are no family members present but the nurse finds identification on the client. In regard to informed consent for the surgical procedure, the nurse understands which of the following is the best nursing action?

Transport the client to the operating room immediately.

A nurse knows that when assessing her patient there are 5 types of pain that it can be. Name them

acute, neuropathic, nociceptive, phantom, and chronic.

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fraction. The nurse determines that the client is using the walker incorrectly if the client...

advances the walker to reciprocal motion.

A nurse has a 76 you that had a wound requiring a nonadherent dressing to apply because...

allows drainage to seep through the barrier and be absorbed on the other side.

Relaxation helps pain?

decrease in severity

An elderly hispanic male was admitted with a severe headache and is anxious. The patient tells the nurse that he was given the mal de ojo. The culturally competent nurse understands the mal de ojo means that the patient believes that he...

was given the evil eye, which is thought to cause weeping and headache.

PCA pumps are controlled by?

-patient

A nurse teaches a client with a rib fracture to cough and deep breathe. The client resists direction by the nurse because of the pain. The nurse most appropriately:

-premedicates the client and assists the client to splint the area during these exercises.

Nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by _______b/p

-restlessness, rising pulse and falling.

A 5 yo hospitalized patient is having difficulty falling asleep. Which action is most likely to be helpful?

have parents bring a favorite blanket or pillow from home.

A nurse is taking care of a patient that has an abdominal surgical wound. What would be signs of possible dehiscence?

increased serosanguineous drainage from the wound.

Nurse is alert to the possible dehiscence of an abdominal surgical wound. Which is evidenced by?

increased serosanguineous drainage from the wound.

The nurse gives an example of a wound that heals by second intention as a:

laceration with edges that do not approximate.

A nurse is caring for a patient with an order for an Aquamatic K-pad as an application of local heat to the leg. The patient has the least risk for injury caused by possible burns if the patient has...

leg muscle cramps.

atient asks nurse about difference between manipulative & body based methods & mind body therapies. Nurse correct response is that:

manipulative. Body-based methods involve teaching or manipulation & mind body therapies deal with the mind's ability to affect the body

Nurse chooses a nonadherent dressing to apply to a wound because the non adherent dressing:

allows drainage to seep through the barrier and be absorbed on the other side.

patient is seen by an alternative medicine practitioner for menopausal symptoms. Most popular and elective herbal remedy that the alternative medicine practitioner would suggest...

black cohosh.

A nurse is assessing the status of a patient who is sleeping. Which assessment data indicated that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?

decreased respirations, slow heart rate.

A nurse is assisting in preparing to admit a client from a post-anesthesia care unit who has had microvascular decompression of the trigeminal nerve. The nurse plans to ensure that which of the following equipment is at the bedside when the client arrives?

flashlight and pulse oximeter

A patient is due for a wound dressing change for a horizontal lower abdominal incision. In which direction should the nurse pull to remove the tape from the old dressing?

from each of the four sides toward the wound.

A nurse is reinforcing instructions with a client about the use of crutches and is teaching the client the method for ascending and descending stairs. When instructing the client about ascending the stairs, the nurse tells the client to do which of the following?

move the unaffected leg up first, followed by the affected leg and crutches.

A 28 yo male has a new order for Codeine. The nurse must teach the patient that this medication is a...

narcotic analgesic

Nurse explains that the major purpose of the use of a hydrocolloid dressing is to?

occlude air and promote breakdown of necrotic tissue.

Fifth Vital Sign:

pain

A patient is newly admitted to the med-surg unit. The doctor has ordered vital signs q2h. Which assessment of vital signs, the nurse should include...

pain level.

A nurse is discharging her patient and needs to teach discharge pain control measures. Check all that apply...

physical exercise routine sleeping hours Fentanyl patches moist heat and cold

Nurse removing wound staples wound engage the staple puller and squeeze the handles completely and

pull outward

A nurse is assisting in developing a plan of care for the child returning from the operating room after a tonsillectomy. The nurse avoids placing which intervention in the plan of care?

suction whenever necessary.

A nurse is asked by a patient what is meant by doing complementary therapies, the nurse would give an example as...

using imagery along with pain medication to increase comfort.

Severe pain may cause shock and even death

-True

As a nurse taking care of an asian patient the nurse should...

-ask the patient feelings about hearing a joke or funny story.

A 58 yo female is experiencing pain because of severe rheumatoid arthritis. The nurse knows that this type of pain is considered.

-chronic

Patient has a pooling of blood under unbroken skin of the hip after a fall. Nurse to document this as?

-hematoma

A nurse is asking the doctor to clarify the first stage of wound healing is...

-inflammation

The nurse clarifies that the first stage of wound healing is

-inflammation

Giving pain medication to numerous patients, the nurse expects the patient who will have the shortest analgesic effect will be the patient receiving medication...

-intravenously

An older client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. The nurse obtains which of the following as a priority item to manage this problem.

-Sheepskin

Pain is defined as a feeling of distress or suffering caused by the stimulation of nerve endings

-True

Pain is whatever the patient says it is.

-True