Basic Patient Care Med/Surg Chapters 7 & 9

Arrange the sequence of nociceptive pain in the order in which the process occurs.

1) Transduction, 2) Transmission, 3) Perception, and 4) Modulation.

Which role may the LPN/LVN perform in a long-term care facility?

Charge nurse, Administrator of medications, Administrator of wound care, Assignment delegator.

The nurse is instructing a family about chair selection for an older adult with Parkinsons disease. Which information is most important for the nurse to include?

Choose a chair with sturdy arms to aid in rising.

A resident with advanced Parkinson disease stays in his wheelchair all day. He reports that he is too tired to walk and is fearful of falling. Which intervention to increase the patients mobility should the nurse add to the patients care plan?

Assist the resident with ambulating in the hallway with a gait belt.

The nurse is caring for an 85-year-old patient who has been on bed rest for a fractured hip. The nurse finds that the patient is flushed, has a temperature off 100F, a pulse of 100, and a respiratory rate of 24. What assessment should the nurse perform next?

Auscultate breath sounds

The charge nurse instructs the nursing assistants about the policy concerning call lights. The nurse teaches that patients taking which type of medication require especially prompt call light attention?

Diuretics.

When the confused resident pours his cereal in a cup and "drinks" it, how should the nurse best respond?

Do nothing to interrupt the behavior.

While bathing a patient, the nurse notes that a transdermal patch that was meant to be on the patient for 3 days now is now gone on the second day. What action should the nurse take?

Document the loss and apply a fresh patch to be replaced in 3 days.

After assessing reddened heels on a bed bound patient with a history of stroke, which intervention should the nurse add to the care plan?

Elevate feet on pillows.

The nurse is caring for a patient who is having constant nociceptor pain. Which intervention best addresses the patient's pain during the perception phase of pain?

Engage the patient in conversation regarding his family, hobbies, and plans following discharge from the facility.

The nurse is caring for a disoriented resident. Which intervention is most appropriate for the nurse to include when planning care for this patient?

Ensure that activities are scheduled for the same time each day.

The nurse is educating a 70-year-old patient who just had a cast removed from a broken arm. The nurse should teach the patient about which potential effect of immobility related to casting?

Frozen shoulder

Which statements describe an impact of disability?

Life patterns centered around treatment or rehabilitation, Grief over what has been lost, Spiritual distress, and Sense of powerlessness/

The nurse is using the gate theory as a guide to pain management. which interventions should the nurse plan to offer?

Massage, Social activities, and Interactive distraction.

The nurse explains that acupressure and acupuncture are effective pain relief modalities that focus on specific body areas. Which term best describes these therapies?

Meridians.

The patient is experiencing phantom pain following the amputation of her foot. which type of pain is most associated with phantom pain?

Neuropathic.

Pain receptors in the skin, connective tissue, bone, joints, and muscles are classified as

Nociceptors.

Which treatment resource focuses on restorative care for people with chronic illness and disabilities?

Out-patient clinics, Long-term health care facilities, Home care, and Rehabilitation agencies.

The nurse explains that the pain threshold and pain tolerance are different. Which statement about the pain threshold is true?

Pain threshold is the point at which pain is perceived.

In order to provide the optimum nursing care, It is important for the nurse to know that the standard of pain and pain control is best described by which person?

Patient.

Long-term health care facilities are the center of treatment for which type of patients?

Patients who are recovering after the most acute phase of their illness is over, Patients who are receiving rehabilitation after a joint replacement, Patients who are too weak from primary illness to care for themselves presently, and Patients who are in need of a permanent home because of effects of a chronic condition.

The nurse clarifies the basics of the gate theory of pain control. Which information should the nurse include?

The "gate" can be closed to pain by the use of non-painful stimuli.

The patient who had abdominal surgery this morning refuses the opioid pain medication for fear of addiction. How should the nurse respond?

"Fewer then 3% of people become addicted to drugs used for pain relief."

Which student nurse's note in the patients record features proper documentation of a pain assessment?

"Pt. complains of local sharp pain (4/5) in lower abdomen upon standing."

The hospitalized post surgical is reluctant to take the opioid pain medication because of drowsiness. Which response is most informative for the nurse to make?

"Sleep and pain relief promote helping."

The nurse educates the nursing assistant about the importance of locking the wheels of a wheelchair, Which statement indicates that the nursing assistant understands the nurses teaching?

"The locks help to prevent falls"

The nurse is planning care plans for multiple patients. Which patient does the nurse anticipate will experience the highest level of pain?

79-year-old experiencing pain related to osteoarthritis

The LPN/LVN making care assignments to nursing assistants would not assign a patient who has which problem?

An unstable condition

The nurse is caring for the patient with nueropathic pain. Which agents will most effectively control this patients pain?

Antidepressants, Anti-inflammatory agents, and anticonvulsants.

The home health nurse educates the 75-year-old patient about the warm compresses he is using on his swollen elbow. Which information is most important to include in the teaching plan?

Allow the compress to remain in place for 15 to 20 minutes.

The nurse is seeking to motivate a frustrated patient who is learning to walk again after a stroke. Which intervention would be most effective?

Arrange a visit with another stroke victim who has learned to ambulate.

The nurse is caring for an obese resident with a pressure ulcer on her coccyx. The patient frequently lies on her back because it is difficult to turn due to her weight. Which intervention most effectively encourages independence?

Arrange for a trapeze so that the patient can assist with positioning.

The nurse assess a bed bound resident, a reddened area over the coccyx that does not blanch is discovered. Which is the best intervention to prevent further skin damage?

Cover the site with a transparent film dressing.

Which action should the LPN/LVN take when delegating to a nursing assistant?

Give specific instructions as to what is to be done, Instruct how the task is to be done, List information that needs to be reported, and Be aware that nurse is responsible for outcome of delegated care.

When can the LPN/LVN apply a physical restraint to a resident in a long-term care facility?

If all other measures have been attempted and failed, If documentation is made on all failed attempts, If the family is unable to stay with the resident or calm them down, If the least restrictive device is chosen.

The rehabilitation nurse describes a patient who is blind, works a full time job as a Spanish interpreter, and lives with his wife in a downtown apartment. How should the nurse classify this person?

Impaired.

The rehabilitation nurse makes the point that a dysfunction of a specific body part is termed

Impairment

The patient on frequent doses of merperidine (Demerol) complains of constipation. Which initial intervention is best?

Increase oral fluid intake.

The student nurse is becoming familiar with Healthy People 2020 goals related to rehabilitation. The student nurse demonstrates understanding when identifying which goals?

Increase the proportion of adults with disabilities who participate in social activities, Increase the proportion of adults who report satisfaction with life, Reduce the proportion of adults with disabilities who report feelings such as sadness, unhappiness, or depression that prevent them from being active, and Reduce the proportion of people with disabilities who report environmental barriers to participation in home, school, work, or community activities.

Although the patient with a kidney stone denies pain, the nurse assess cues that indicate that pain is perceived. Which assessments indicate that pain may be present?

Increased pulse rate, Diaphoresis, Muscle tension. Nausea.

What are the functions of endorphins?

Inhibition of unpleasant stimuli, diminished anxiety, and feelings of euphoria.

The nurse is caring for a 76-year-old patient in a long term care facility who sent his food tray back to the kitchen untouched for the second time today. Which intervention is most effective to increase nutrition?

Offer the patient a high protein drink.

The patient who has been in traction for bilateral femur fractures complains of constipation. Which actions should the nurse take?

Provide prune juice from the snack cart, Encourage increased fluid intake, Arrange for high-fiber foods such as cauliflower and broccoli, Administer stool softeners.

The nurse is caring for a patient who is 1 day postoperative following a colon resection The patient has degenerative joint disease and uses a pain medication patch to control this chronic pain. Which consideration is most important when planning care for this patient?

Realize that this patient will most likely require more pain medication than most patients undergoing a colon resection.

The nurse is caring for a resident who has a security device for safety purposes. What interventions should the nurse include in the plan of care?

Reassess the need for security devices every 4 to 8 hours.

The long term care facility nurse is discussing fall prevention measures with the charge nurse. Which replacement should the nurse suggest?

Replacing area rugs with a non-slip pad.

The nurse is caring for a patient that is receiving intravenous morphine sulfate. The patient breaks out in hives and begins to itch. What should the nurse do first?

Stop the infusion.

The nurse is educating the home health patient about indications for acetaminophen. Which information should the nurse include in the teaching plan?

Take acetaminophen before pain becomes severe.

The nurse is caring for a 45-year-old male Arab patient who is in pain. Which action can most likely be attributed to the patients's cultural belief about pain?

The patient asks for pain relief to control pain.

When giving care to a 30-year-old Hispanic male, which action can most likely be attributed to the patients cultural beliefs about pain?

The patient maintains a stoic affect about pain.

A patient reports pain relief after having received a placebo. Which conclusion is most accurate for the nurse to determine?

The patient was relieved of the anxiety that there is no ready source of pain remedy.

To help with pain control, how should the nurse time the distraction activities for a patient?

To bridge the time between administration and onset.

Which statement describes the chief goal of a long term care facility?

To promote individual independence.

Which statement expresses a multi-focused goal of rehabilitation?

To promote new coping skills, To teach adaptive living skills, To focus on self-care for increased independence, To improve quality of life.

Because of the threat of lowering the seizure threshold, the home health nurse would suggest that the 85 year old patient limit the use of which pain medicine?

Tramadol (Ultram)

The nurse is planning a group TV activity in a long term care facility. The nurse should select a channel that offers which type of program?

Travel documentaries.

The nurse is planning to teach a family member about effective massage techniques. Which information is most important to include in the teaching plan?

Use long, firm strokes while avoiding areas of inflammation.