Comfort EAQ

Which herbal medication would the nurse suggest to a client to reduce premenstrual discomfort?

Black cohosh root

When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include?

Comfort reason: Because pain is an all-encompassing and often demoralizing experience, the nurse would want to keep the client as pain-free as possible. Surgery corrects deformities and facilitates movement, which is not an immediate need. Concentration and motivation are difficult when a client is in severe pain.

Which pain scale is used to measure the intensity of pain in preschoolers?

FACES scale

Which action puts a client at risk for low back injury and pain?

Smoking tobacco Reason: Smoking is a risk factor for low back pain and injury because it causes constriction of blood flow. Regular swimming exercise helps strengthen the back. Vitamin D supplementation works with calcium to strengthen the musculoskeletal system. Prolonged sitting can be augmented with a foot stool and ergonomic chair to support the back.

Which herbal therapies would be beneficial to a client with menstrual cramping? Select all that apply. One, some, or all responses may be correct.

Catnip, Fennel, Black haw reason: Herbal therapies such as catnip, fennel, and black haw are used to treat menstrual cramping and dysmenorrhea. Bugleweed and chamomile are used to treat breast pain.

Which herbal therapies can be recommended to a client with breast pain? Select all that apply. One, some, or all responses may be correct.

Chaste tree fruit, Bugleweed, Chamomile Reason: Herbal therapies for breast pain include chamomile, bugleweed, and chaste tree fruit. Dong quai is recommended for menstrual cramping and dysmenorrhea. Black cohosh root eases premenstrual discomfort and tension.

A client is receiving patient-controlled analgesia (PCA) after surgery. Which benefit would this type of therapy provide? Select all that apply. One, some, or all responses may be correct.

Client is able to self-administer pain-relieving medications as necessary, Decreases client dependency, Increases client sense of autonomy

A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the medication, the client complains of feeling dizzy. Which action will the nurse take?

Place the client in the supine position and take the vital signs. Reason: Dizziness is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, cardiac output, and blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.

Which pain scale would the nurse use when assessing a 4-year-old child?

Wong-Baker

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct.

Apply for 30-minute time intervals. reason: To prevent skin damage, ice and heat should only be applied for 20- to 30-minute intervals. Clients should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue. The client can take ibuprofen if approved by the health care provider.

Which is a sign of a ruptured ectopic pregnancy in an adolescent?

Abdominal pain and hypotension reason: An ectopic pregnancy occurs when a fertilized egg implants outside the uterus. Hypotension and abdominal pain indicates that the ectopic pregnancy might have ruptured. Ectopic pregnancy would elicit tachycardia related to subsequent shock. Ectopic pregnancy is ruled out if abdominal pain is associated with bleeding or hypertension.

Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster? Select all that apply. One, some, or all responses may be correct.

Contact isolation, Wet compresses, Gabapentin, Silvadene, Acyclovir reason: A client with herpes zoster would receive antiviral medications such as acyclovir. Silvadene can be applied to open vesicles. Gabapentin can be used to treat the nerve pain associated with herpes zoster. Wet compresses can be applied to the vesicles to relieve discomfort. Herpes zoster is highly contagious, and the client would be placed in contact isolation precautions.

Which finding in a newborn is a behavioral response to pain? Select all that apply. One, some, or all responses may be correct.

Crying

Which medication is used in the treatment of a client with intervertebral disc disease?

Cyclobenzaprine Reason: Intervertebral disc disease often causes myalgia. Muscle relaxants, such as cyclobenzaprine, are used in its treatment. Etidronate, zoledronic acid, and salmon calcitonin are effective in the treatment of osteoporosis.

After abdominal surgery, a client reports pain. Which action would the nurse take first?

Determine the characteristics of the pain. Reason: he exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.

Which condition would the nurse document to describe a client presenting with the loss of the ability to taste after cancer treatment has affected the client's ability to eat food?

Dysgeusia reason: Dysgeusia is the loss of the ability to taste, which can occur after treatment for cancer. Mucositis is the inflammation and irritation of the mucosa in the mouth or throat. Dysphagia is difficulty in swallowing or an inability to swallow. Xerostomia is dry mouth. All four of these complaints are common side effects of chemotherapy or radiation treatment.

Which pain scale would the nurse use to measure the intensity of pain in toddlers?

FACES scale

Which client assessment finding would the nurse document as subjective data?

Pain rating of 5 Reason: Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.

Which statement is an accurate description of dysmenorrhea?

Pain with menses. Reason: Dysmenorrhea is defined as pain with menses. Endometrial hyperplasia results from anovulation and persistent estrogen stimulation. Bleeding between menses is metrorrhagia. Heavy bleeding with menses is menorrhagia.

Which would the nurse consider the most significant influence on a client's perception of pain when interpreting findings from a pain assessment?

Previous experience and cultural values

A client in active labor becomes very uncomfortable and asks the nurse for pain medication. Nalbuphine is prescribed. The nurse understands that this medication relieves pain by which mechanism?

By acting on opioid receptors to reduce pain reason: Nalbuphine is classified as an opioid analgesic and is effective in relieving pain; it induces little or no newborn respiratory depression. Nalbuphine does not induce amnesia, act as an anesthetic, or induce sleep.

When the nurse is analyzing an electrocardiogram (ECG), which waveform illustrates atrial depolarization?

a Reason: Option a reflects the P wave; it represents the electrical impulse starting at the sinus node and spreading throughout the atria (atrial depolarization). Waveform b reflects the QRS complex; it represents depolarization of the ventricles. Option c reflects the T wave; it represents repolarization of the ventricles. Waveform d reflects the U wave; it is believed to reflect late ventricular repolarization or repolarization of the Purkinje fibers; it is sometimes identified in clients with hypokalemia.

A client has an intravenous (IV) solution of 5% dextrose in water (DW) 250 mL to which 100 mg of morphine is added. The health care provider prescribes 14 mg of morphine per hour for end-of-life palliative treatment of a client. At how many milliliters per hour will the nurse set the IV pump?___ mL/h

35 reason: The prescribed rate is 14 mg/h. The available concentration is 100 mg/250 mL. Use dimensional analysis to determine the appropriate rate.

Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the medication is being used primarily for which property?

Anti-inflammatory reason: The anti-inflammatory action of aspirin reduces joint inflammation. Aspirin reduces fever, but this is not the rationale for prescribing it for clients with rheumatoid arthritis. It can relieve pain and prevent abnormal clotting; however, although these effects can be beneficial, these are not the primary reasons that it is prescribed for rheumatoid arthritis.

On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. Which action would the nurse perform first?

Obtain the client's vital signs. reason: Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis; vital signs provide supporting data. The nurse assists the client to ambulate if pain was the result of flatulence; however, rigidity is associated with bleeding or peritonitis, and the nurse needs additional data. An analgesic may mask the symptoms, thereby delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to the symptoms presented.

A client who is 29 weeks pregnant reports a dull backache and abdominal cramps. Which condition would the nurse suspect?

Preterm labor Reason: A client in the 29th week of gestation who reports a dull backache and abdominal cramps is experiencing preterm labor. Uterine atony causes postpartum hemorrhage after delivery. Uterine fibroids have the same symptoms, but they may occur in nonpregnant women. Pelvic inflammatory disease may lead to an ectopic pregnancy.

A client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. Which action would the nurse implement?

Placing the prescribed as-needed warm, wet compress on the elbow reason: Vasodilation should help reduce pain from cellular clumping; applying a warm, wet compress will address the pain until the pump can be activated. Television may be an adequate distractor for mild pain, not moderate or severe pain. Nursing measures should be attempted first to relieve the pain before the primary health care provider is called. Telling the adolescent to wait provides no comfort.

Which interventions would the nurse perform while caring for an actively dying client? Select all that apply. One, some, or all responses may be correct.

Provide client and family reassurance, Perform symptom management for the client. reason: The nurse would provide comfort care in an actively dying client. In comfort care, the nurse would reassure the client and family to reduce their emotional anxiety. The nurse would perform symptom management to improve the client's quality of life. The client should not be admitted into hospice care if he or she is actively dying. A client is admitted to hospice care if death is expected within 6 months. The client may not require aggressive laboratory tests when death is imminent. He or she should be repositioned as needed for comfort.

A pain scale of 1 to 10 is used by the nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. Which conclusion would the nurse make regarding the client's response to pain medication?

The medication is not adequately effective. reason: The expected effect should be more than a 1-point decrease in the pain level. Whether a client has a low pain tolerance cannot be determined with the data available. The medication has not achieved an adequate response; pain generally is considered to be tolerable if it is 4 or below on a pain scale of 1 to 10. There is not sufficient data to determine whether the client needs more education about the use of the pain scale.

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen?

To increase oxygen concentration to heart cells Reason: Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.

The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience?

Visceral pain reason: Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable. View Topics

Which alternative treatments would a nurse recommend to help ease a young child's pain at home? Select all that apply. One, some, or all responses may be correct.

Yoga, Biofeedback, Guided imagery reason: Yoga, biofeedback, and guided imagery are all very well researched and are low-risk for young children. Spinal manipulation carries the risk of potentially serious complications and should not be performed at home. Young children are at higher risk of complications resulting from supplement use.

Which rational supports administering the medication pregabalin to a client with acquired immunodeficiency syndrome (AIDS)?

To reduce neuropathic pain

A client presents to the health care facility with abdominal pain. Which question would the nurse ask the client to obtain information about concomitant symptoms?

"What other discomfort do you experience?" Reason: Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain. The nurse assesses the quality of the pain by asking the client to describe it. The nurse gathers information about the location of the illness by asking the client to identify the exact location. The nurse tries to understand the precipitating factors by asking the client about the activities that aggravate the pain

Which describes the role of the nurse in this situation when he or she informs the health care provider the client is requesting pain medication after surgery?

Advocate Reason: The nurse acts as a client advocate by speaking to the primary health care provider on behalf of the client. The nurse acts as an educator while teaching the client facts about health and the need for routine care activities. The nurse manager uses appropriate leadership styles to create a nursing environment for client-centered care. The nurse administrator manages client care and delivery of specific nursing services within a health care agency.

Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)? Select all that apply. One, some, or all responses may be correct.

Back and shoulder pain, Nausea and vomiting, Rigid abdomen, Hypotension, Tachycardia Reason: Perforation of an ulcer can cause tachycardia and hypotension (both caused by fluid volume shifts from the vascular compartment to the abdominal cavity). A client with a perforated ulcer would have a hard, rigid abdomen (caused by tensed muscles) and nausea and vomiting. Back and shoulder pain can occur as a result of irritation of the phrenic nerve.

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How would the nurse respond to complaints of pain?

By acknowledging that the pain is real and administering medication to relieve it Reason: Pain medication is required, along with intensive supportive nursing care. To the client the pain is real, requiring pain medication; addiction is not a concern at this time. Explaining that the pain is psychological in origin does not help relieve the pain; medication and emotional support are required. The pain may not recede within a few days; pain medication should be administered.

Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction?

Effleurage reason: Effleurage is the gentle stroking of the abdomen in rhythm with her breathing during a contraction. Massage is the application of therapeutic touch and pressure on the body. Acupressure is the application of pressure along special acupressure points. Counterpressure is the application of pressure to the sacrum during a contraction.

The nurse understands which anesthetic medication is commonly used for short procedures on pediatric clients?

Fentanyl reason: Fentanyl is recommended for short procedures on pediatric clients. For long procedures in which pain is anticipated even after the procedure, morphine should be administered. Meperidine and hydromorphone are used to achieve mild to moderate sedation in pediatric clients.

When a client is experiencing acute coronary syndrome, which factor would the nurse identify as the cause of the pain experienced by a client?

Heart muscle ischemia reason: Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial aneurysms are not a common cause of myocardial ischemia or infarction. Arteries, not veins, are involved in the pathology of an acute coronary syndrome. Tissue injury and pain occur in the myocardium, not the cardiac plexus.

A client describes abdominal discomfort after ingestion of milk. Which enzyme, as a result of a genetic deficiency, would the nurse consider to be the cause of the client's discomfort?

Lactase reason: Milk and milk products are not tolerated well because they contain lactose, a sugar that is converted to galactose by lactase. Sucrase assists in the digestion of sucrose, which is not a milk sugar. Maltase assists in the digestion of maltose, which is not a milk sugar. Amylase assists in the digestion of starch, which is not a milk sugar.

A client receives intrathecal morphine to control severe postoperative pain. Which action will the nurse include as part of the client's initial 24-hour postoperative care plan?

Monitoring of respiratory rate hourly Reason: Intrathecal morphine can depress respiratory function depending on the level it reaches within the spinal column; hourly assessments during the first 12 to 24 hours will allow for early intervention with an antidote if respiratory depression needs to be corrected. Bradycardia, not tachycardia, and hypotension occur. Administering naloxone every 3 to 4 hours is too infrequent if the client's respirations are depressed. The recommended adult dosage usually is 0.4 to 2 mg every 2 to 3 minutes, if indicated. CNS depression occurs secondary to hypoxia.

The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation?

Pain Reason: Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. A neurological check is not necessary unless the client's neurological status has worsened since the stroke. Both skin and wound checks can be assessed once client comfort has been determined and handled.

The nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis?

Pain in right lower quadrant reason: Pain shifting to the right lower quadrant between the anterior iliac crest and the umbilicus is McBurney point and is indicative of appendicitis. The client may also have fever, nausea, and vomiting, but these can occur with other infectious processes. Absolute constipation occurs with many bowel obstructions.

Which factor may cause neck pain in a client?

Poor posture reason: Poor posture may affect the nerves innervating the neck, thereby causing pain in the neck. Headache may be associated with neck pain, but it does not precipitate neck pain. Low body weight and sedentary lifestyle may cause osteoporosis.

Which parameters would the nurse consider for proper rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse? Select all that apply. One, some, or all responses may be correct.

Reaction to pain, Response to voice Reason: The disability examination provides a rapid baseline assessment of neurological status. It helps evaluate level of consciousness by the AVPU mnemonic, which also helps assess the responsiveness to pain and voice. Level of anxiety is not assessed by a disability mnemonic. Body temperature and evidence of assault are assessed in a primary survey of exposure.

When providing postoperative teaching, which rationale would the nurse give to explain the purpose of administering an opioid analgesic via epidural catheter?

Relieves abdominal pain Reason: Analgesics alleviate pain by binding with opioid receptors in the brain, thus altering the perception of and response to pain; patient-controlled analgesia (PCA) via an epidural catheter gives the client control over medication administration and usually results in the client using less medication. Opioids do not facilitate oxygen use; they decrease the respiratory rate, and less oxygen is used; the client should be monitored. Although decreasing anxiety and restlessness may be responses to an opioid, they are not the primary reason why opioids are used after abdominal surgery. Opioids are not given to dilate blood vessels; antianginal medications and vasodilators are used for this purpose

Which caring intervention helps provide comfort, dignity, respect, and peace to a client?

Relieving pain and suffering

Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain?

Repositioning. Reason: Acute postoperative pain always requires the use of analgesics, but nonpharmacological interventions such as repositioning the client can help relieve pain. Ambulation is not specifically used to decrease postoperative pain. Purse-lipped breathing is primarily used to improve ventilation. Deep breathing and coughing are used to clear the respiratory tract.

Which is a sensory simulation strategy a laboring client can use as a nonpharmacological strategy for pain management?

Selecting a focal point and beginning breathing techniques reason: Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.

Which is the most important topic to include in teaching to promote the comfort of a client with a pruritic skin disease?

Sleep reason: Pruritic skin diseases often interfere with sleep. Adequate rest increases the client's ability to tolerate the itching, thereby decreasing the damage to the skin. Exercise and elimination are not specifically associated with the discomfort of a client with a pruritic skin disease. Hand hygiene is an infection control measure.

Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer?

The pain occurs 1 to 2 hours after having a meal. Reason: Pain occurs after the stomach empties; eating stimulates gastric secretions, which act on the gastric mucosa of an empty stomach, causing gnawing pain. Vomiting temporarily alleviates pain because acid secretions are removed. There is no intolerance of fats, and eating generally alleviates pain. Pain associated with the ingestion of fatty foods is associated with cholecystitis. Pain is localized in the epigastrium; however, it only radiates to the abdomen if the ulcer has perforated

An adult client with low-functioning Down syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining this client's level of pain?

Using the Wong-Baker FACES Pain Rating Scale reason: An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; the Wong-Baker FACES Pain Rating Scale uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

Which intervention would the nurse recommend for post-cesarean gas pain?

Walking around the room Reason: Walking around as much as possible can help expel excess gas after a cesarean birth. The client also may be advised to lie on the left (not right) side and rock in a rocking chair. The client should avoid using a straw when drinking water or other fluids. Supporting the incision when moving relieves incisional pain, but does not promote expulsion of gas.