Cancer, Older adults, Pain, ED, Cultural

A client with a pressure ulcer has the following laboratory values: white blood count 8000/mm3, prealbumin 15.2 mg/dL, albumin 4.2 mg/dL, and lymphocyte count 2000/mm3. Which action by the nurse is most appropriate? A) Request a dietary consult. B) Assess the client's vital signs. C) Document the findings. D) Place the client in isolation.

A Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The albumin and lymphocyte counts given are normal. The white blood cell count is not directly related to nutritional status. The prealbumin count is low and is a more specific indicator of nutritional status than is the albumin count. This puts the client at risk for impaired wound healing, so the nurse should request a dietary consult.

What statement indicates that the client understands teaching about neutropenia? A) "I will call my doctor if I have an increase in temperature." B) "My grandchildren may get an infection from me." C) "I need to use a soft toothbrush." D) "I have to wear a mask at all times."

A Bone marrow suppression leads to neutropenia and increases the client's risk for infection. Decreased numbers of neutrophils and other white blood cells can minimize the clinical manifestations of infection. For this reason, the client may not develop a high temperature, even with severe infection, and any elevation of temperature should be reported immediately to the health care provider. The client does not need to wear a mask or use a soft toothbrush (although if the client has low platelets, he or she should use a soft toothbrush to avoid causing trauma). The client is not contagious.

Which nursing intervention best assists a bedridden client to keep skin intact? A) Use a lift sheet to move the client in bed. B) Turn the client every 2 to 4 hours. C) Use a foam mattress pad. D) Apply talcum powder to the perineal area.

A Friction forces are generated when the client is dragged or pulled across bed linen; this often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin clean and dry is an important intervention, but powders should not be used in the perineal area. To minimize vasoconstriction and possible pressure ulcer development from dependency, the client should be turned at a minimum of every 2 hours. A foam mattress will not significantly decrease pressure to an area.

The nurse is caring for an older postoperative client. Which assessment finding causes the nurse to assess further for a wound infection? A) The client is now confused but was not confused previously. B) Moderate serosanguineous drainage is seen on the dressing. C) The white blood cell count is 8000/mm3. D) The white blood cell differential indicates a right shift.

A Older adult clients often do not demonstrate typical signs and symptoms of infection because of the diminished immune function seen with aging. Often, the first sign of infection is mental status changes. Any change in mental status in the older postoperative client should lead the nurse to assess for a wound infection.

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system wide. b. decreased tumor growth and longevity c. large tidal volumes and decreased lung capacity d. decreased carbohydrate, protein, and fat destruction

A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with pain or stress response.

When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain? a. inability to concentrate b. expressed hopelessness c. psychosocial withdrawal d. anger and hostility

A The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred.

What interrelated constructs facilitate a nurse to become culturally competent? A) Cultural desire, self-awareness, cultural knowledge, and cultural skill B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity C) Cultural desire, self-awareness, cultural knowledge, and cultural identity D) Cultural diversity, self-awareness, cultural skill, and cultural knowledge

A The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

Which is most indicative of pain in an older client who is confused? (Select all that apply). A) Screaming B) Decreased blood pressure C) Crying D) Decreased respirations E) Facial grimace F) Restlessness

A,C,E,F No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations.

The nurse is caring for four clients. Which client assessment is the most indicative of having pain? A) Client stating that he is "anxious" B) Heart rate of 105 beats/min and restlessness C) Blood pressure 150/70 mm Hg and sleeping D) Postoperative client with a neck incision

B At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.

A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse's first action when the client reports burning at the site? A) Apply a cold compress. B) Discontinue the infusion. C) Slow the rate of infusion. D) Check for a blood return.

B Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she should immediately stop the infusion. Even if the IV has a good blood return, some of the chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the correct action, depending on the specific agent. However, the compress would be applied only after the infusion has been discontinued.

Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting? A) Cutaneous skin stimulation B) Imagery C) Radiofrequency ablation D) Hypnosis

B Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stimuli.

The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission's main objective? A) Performing range-of-motion exercises on the client three times each day B) Assessing the client's respirations when administering opioids C) Delegating to the nursing assistant to give the client a complete bath daily D) Ensuring that the client is eating 100% of the meals served to him or her

B It is important for the nurse to assess respirations of the client when administering opioids because of the possibility of respiratory depression. The other interventions may or may not be necessary in the care of the client and do not focus on safety.

Why does the nurse always ask the client his or her pain level after taking routine vital signs? A) To follow McCaffery's guidelines on pain management B) To ensure that pain assessment occurs on a regular basis C) To determine the need for more frequent vital sign measurement D) To determine whether pain is influencing blood pressure and heart rate

B Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management.

A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which intervention will the nurse prepare for this client FIRST? A) Continuous arteriovenous rewarming B) Dry clothing and warm blankets C) Peritoneal lavage with warmed normal saline D) Administration of warmed IV fluids

B Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia.

A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response? A) "I am preventing the spread of infection from you to me or any other client here." B) "The clothing protects me from accidentally absorbing these drugs." C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask." D) "These coverings protect you from getting an infection from me."

B Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing protective clothing whenever preparing, giving, or disposing of chemotherapy drugs.

The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem? A) Middle-aged woman with a fractured arm B) Client with expressive aphasia C) Younger adult with metastatic cancer D) Client who has undergone an appendectomy

B Populations at highest risk for inadequate pain treatment include older adults, minorities, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting.

The priority nursing intervention for a patient suspected to be hypothermic would be to: A) hydrate with intravenous (IV) fluids. B) remove wet clothes. C) assess vital signs. D) provide a warm blanket.

B The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates: A) slow capillary refill. B) red, sweaty skin. C) low pulse rate. D) decreased respirations.

B With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

An older client just returned from surgery and is rating pain as "8" on a 0 to 10 scale. Which medications are unsafe choices for treatment of severe pain in this older adult? (Select all that apply.) A) Morphine (Durmorph) B) Meperidine (Demerol) C) Propoxyphene (Darvocet) D) Methadone (Dolophine) E) Codeine

B,C,D,E Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the gold standard and may be used in the older adult while monitoring for sedation and respiratory depression is conducted.

Which finding puts a client at greatest risk for wound infection? A) Presence of a deep wound B) Coexisting medical conditions C) Immune compromised status D) Severely reddened skin

C A compromised immune system puts a client at greatest risk for infection. Although all the other options might increase the client's susceptibility, the one with the greatest potential impact is being immune compromised.

The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pressure medication. B) Administer a drug to lower the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medication.

C Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out.

The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? A) Healthy individual, college educated, travels frequently, can balance a checkbook B) Healthy individual, works out, reads well, cooks and cleans house C) Healthy individual, volunteers at church, works part time, takes care of family and house D) Healthy individual, works outside the home, uses a cane, well groomed

C Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.

The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse's first action? A) Administering oxygen by nasal cannula B) Documenting the findings and continuing to monitor C) Arousing the client by calling his or her name D) Administering naloxone (Narcan) IV push

C Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and the rate of respiration is increased spontaneously, no further intervention is required.

Which statement indicates that the client needs more teaching about mucositis? A) "I will use a soft-bristled toothbrush to prevent trauma." B) "I will rinse my mouth with water after every meal." C) "I should use an alcohol-based mouth rinse to kill bacteria." D) "I cannot use floss because it may irritate my gums."

C Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation associated with mucositis.

Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? A) Documenting all changes observed in the client and maintaining a postoperative flow sheet B) Monitoring the client for changes in postoperative status such as wound infection C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic D) Notifying the physician of the client's increase in restlessness after medication change

C The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-point drop in blood pressure. Monitoring the client's postoperative status, maintaining a postoperative flow sheet, and notifying the physician of a change in the client's status after a medication change would not be considered activities of the Rapid Response Team.

The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? A) Prescribe aspirin for a client who presents with an acute myocardial infarction B) Insert a central line to give intravenous fluid to a dehydrated client. C) Use sterile technique when changing dressings on a new surgical site. D) Intubate a client whose oxygen saturation is 92%.

C The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician.

The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse? a. admin tylenol 650 mg orally b. encourage rest, and reassess in 15 minutes c. sponge the victim with cool water and remove his shirt d. encourage drinking of cool water or sports drink

C The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment

The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take? A) Assist with intubation. B) Monitor pain level. C) Administer oxygen. D) Administer naloxone (Narcan).

D A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.

What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases? A) Requesting that a family member remain with the client to assist in ambulation B) Keeping all four siderails up while the client is in bed C) Placing the client in restraints to prevent movement without assistance D) Providing assistance to the client in getting out of the bed or chair

D Advanced age and multiple illnesses, particularly those that result in alterations in sensation, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to prevent falls. The client should not be restrained or maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point.

An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 99.2° F (37.3° C), blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate? A) Document the findings and continue to monitor. B) Assess the client's pain level and treat if needed. C) Perform a Mini-Mental Status Examination. D) Assess the client for other signs of infection.

D Because of an age-related decline in immune function, an older adult's normal temperature may be 1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection.

The emphasis on understanding cultural influence on health care is important because of: A) disability entitlements. B) HIPAA requirements. C) litigious society. D) increasing global diversity.

D Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of: A) mixed pain syndrome. B) chronic pain. C) neuropathic pain. D) nociceptive pain.

D Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

A nurse is caring for an older adult client who lives alone. Which economic situation presents the most serious problem for this client? a. costs of creating a living will b. stock market fluctuations c. increased provider benefits d. social security as the basis of income

D Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs

While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? A) Completing all nursing care in the evening when the patient is more rested B) Completing all nursing care in the morning so the patient can rest the remainder of the day C) Limiting visitors, thus promoting the maximal amount of hours for sleep D) Prioritization and administration of nursing care throughout the day

D Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? A) Temperature extremes B) Occupational exposure C) Impaired cognition D) Physical agility

D Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? A) Examine dependent body areas. B) Notify the physician. C) Document the finding and continue to monitor. D) Assess turgor on the client's forehead.

D Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

The new nurse is caring for a client with a high temperature. Which action should the nurse perform FIRST? A) Obtaining a fan from central supply for the client's room B) Monitoring the client's temperature more often than ordered C) Sponging the client while monitoring for shivering D) Apply cool packs to the client's axillae and groin

D The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate.

Which statement made by a nurse represents the need for further education regarding pain management in older adult clients? a. older adults tend to report pain less often than younger adults b. older clients usually have more experience with pain than younger clients c. older adults are at greatest risk for under treated pain d. older clients have a different pain mechanism and do not feel it as much

D There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients. The other statements are accurate regarding older clients and pain.