Comfort- PrepU
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? a) Administering ordered analgesics and monitoring their effects b) Performing meticulous skin care c) Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes d) Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware
a) Administering ordered analgesics and monitoring their effects
The nurse is instructing a client about skin care while receiving radiation therapy to the chest. What should the nurse instruct the client to do? a) Keep the area covered with a non-adherent dressing between treatments. b) Wash the area with tepid water and mild soap. c) Apply lotion if the skin becomes dry. d) Shave the chest to prevent contamination from chest hair.
b) wash the area with tepid water and mild soap
The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply. a) "I'll eat food that is very hot." b) "I'll try to chew my food on the unaffected side." c) "If brushing my teeth is too painful, I'll try to rinse my mouth instead." d) "Drinking fluids at room temperature should reduce pain." e) "I can wash my face with cold water."
B, C, D
A pregnant client's labor is progressing, but her cervix is still only 5 cm dilated and 100% effaced. Although she appears relaxed, she is aware of labor contractions. At this time, which suggestion would be most helpful for the client's partner? a) "Encourage her to rest between contractions." b) "Have her practice rapid, shallow breathing." c) "Keep a record of her contraction pattern." d) "Suggest that she receive an epidural anesthetic."
a) "Encourage her to rest between contractions."
While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which of the following statements is the most therapeutic response by the nurse? a) "Do you want me to call the doctor now and explain that you are concerned?" b) "You don't need to worry at this point about too much pain medication." c) "I am sure the doctor has ordered the appropriate amount of narcotic." d) "You are concerned that the client is receiving too much narcotic medication?"
d) "You are concerned that the client is receiving too much narcotic medication?"
Which is the most appropriate nursing intervention for a client with pruritus caused by medications used to treat cancer? a) administration of antihistamines b) steroids c) silk sheets d) medicated cool baths
d) medicated cool baths
The nurse is assisting in the birthing room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate childbirth. Which interventions should the nurse perform when caring for the client after this procedure? Select all that apply. a) Apply ice to the perineum. b) Administer pain medication, as prescribed. c) Check the episiotomy repair site. d) Explain perineal care to the client when she can focus on the instructions. e) Change the dressings every shift.
A, B, C, D
The nurse is assessing a client who is reporting having a pain in the lower part of the leg. In order to differentiate bone pain from pain from trauma, the nurse should ask the client if the pain is: (Select all that apply.) a) throbbing b) sharp c) increases with movement d) aching e) dull
A, B, E
The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which statement by the client indicates that the client understands the teaching? a) "It is safe to apply a nonperfumed lotion to my skin." b) "I can apply an over-the-counter cortisone ointment to relieve the dryness." c) "A heating pad, set on the lowest setting, will help decrease my discomfort." d) "I should take antihistamines to decrease the itching I am experiencing.
a) "It is sage to apply a non perfumed lotion to my skin."
A client on heparin for a deep vein thrombosis reports an aching pain in the back and finds it difficult to get comfortable when lying in that position. The client refuses to take any medications for pain. What actions would the nurse take to alleviate the back pain? a) Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain. b) Suggest alternating side-lying positions to lessen the back pain. c) Reinforce the importance of changing positions and the possibility of pressure ulcer formation. d) Encourage the client to take the medications to provide optimal rest
a) Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain.
The nurse is developing a care plan for a client with cancer receiving hospice home care. Which would be the most appropriate action for managing the client's chronic pain? a) Administer analgesics when vital signs indicate increased pain severity. b) Avoid intravenous pain medication until the client is terminal. c) Sedate the client with tranquilizers. d) Administer analgesics regularly and additionally as needed for break-through pain.
a) administer analgesics regulär and additionally as needed for break-through pain
The nurse is managing care of a primigrada at full term who is in active labor. What should be included in developing the plan of care for this client? a) anesthesia/pain level assessment every 30 minutes b) oxygen saturation monitoring every half hour c) vaginal bleeding, rupture of membrane assessment every shift d) supine positioning on back, if it is comfortable
a) anesthesia/ pain level assessment every 30 minutes
Acetaminophen was given to an adolescent for headache. Which of the following parameters would indicate the effectiveness of the medication? a) Change in behavior b) Intermittent sleeping c) No change in behavior d) No change in vital signs
a) change in behavior
An 18-month-old child is admitted to the pediatric unit. Which of the following can the nurse do to reduce the stress on the client during this hospitalization? a) Encourage the client's caregivers to be with the client as much as possible b) Minimize needle sticks to the client c) Allow the child to explore the environment d) Encourage play times with other children on the unit
a) encourage the clients caregivers to be with the client as much as possible
A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should: a) gently but firmly set limits on how much time the client spends in bed during the day. b) encourage the client to take an antianxiety agent as needed at bedtime. c) encourage environmental stimulation during the evening. d) talk with the client for a long time at night to reduce his anxiety
a) gently but firmly set limits on how much time the client spends in bed during the day
An adolescent in the terminal stage of leukemia cries out for more pain medicine. What is the best action for a nurse to take in caring for this dying adolescent? a) Give him more pain medication to control his pain and suffering. b) Maintain a strict medication administration schedule. c) Withhold medication because the adolescent has a low pain threshold. d) Withhold pain medication because he may become addicted to it.
a) give him more pain medication to control his pain and suffering
The nurse discovers that a young client has been given a dose of morphine four times the ordered dose. Which of the following is the immediate priority action for the nurse to take? a) Obtain an order for naloxone and administer it promptly. b) Notify the parents of the medication error. c) Bring emergency resuscitation equipment to the child's room. d) Ensure that the error is corrected on the medication record.
a) obtain and order for naloxone and administer it promptly
A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? a) Obtain vital signs. b) Insert an NG tube and connect to suction. c) Document history of the symptoms. d) Assess bowel sounds and abdominal tenderness.
a) obtain vital signs
A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse? a) Refuse to administer the placebo to the client. b) Give the placebo but do not tell the client it is a stronger medication. c) Give the placebo as ordered by the physician. d) Consult with the pharmacist to discuss the dosage of the placebo.
a) refuse to administer the placebo to the client
A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping the client cope with these cramps? a) Teaching her to dorsiflex her foot during the cramp b) Advising her to take over-the-counter calcium supplements twice per day c) Suggesting that she walk for 1 hour twice per day d) Instructing her to increase milk and cheese intake to 8 to 10 servings per day
a) teaching her to dorsiflex her foot during the cramp
A nurse is caring for a child with intussusception. Which of the following is an expected client outcome related to the nursing diagnosis Acute pain related to cramping, which might be made for this child? a) The child exhibits no manifestations of discomfort. b) The child is very still. c) The child has a normal bowel movement. d) The child has not vomited in 3 hours.
a) the child exhibits no manifestations of discomfort
Lower back pain is a common concern among pregnant clients. Which comfort measure should a nurse include in her teaching plan for a pregnant client? a) Use an ergonomically correct desk chair. b) Avoid tilting the pelvis forward. c) Wear high-heeled shoes. d) Bend at the waist, not at the knees.
a) use an ergonomically correct desk chair
A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? a) Use constant, gentle touch. b) Bring in toys for distraction. c) Stroke the neonate's back. d) Place a musical mobile over the crib.
a) use constant, gentle touch
A client is being admitted to the hospital following an inadvertent overdose with oxycodone. He reveals that he has chronic back pain that resulted from an injury on a construction site. He states, "I know I took too much oxycodone at once, but I cannot live with this pain without them. You cannot take them away from me." Which response by the nurse is most appropriate? a) Your pain will be controlled by tapering doses of oxyocodone with other pain management strategies and medicines. b) "You are going to be switched from the oxyocodone to methadone for long-term pain management. c) "Once you are tapered off the oxyocodone, you will find that non-addictive pain medicines will be enough to control your pain." d) The oxyocodone will be stopped tomorrow, but you will have lorazepam to help you with the withdrawal symptoms.
a) your pain will be controlled by tapering doses of oxyocodone with other pain management strategies and medicines
A nurse is caring for a client diagnosed with ovarian cancer. Diagnostic testing reveals that the cancer has spread outside the pelvis. The client has previously undergone a right oophorectomy and received chemotherapy. The client now wants palliative care instead of aggressive therapy. The nurse determines that the care plan's priority nursing diagnosis should be: a) Knowledge deficit: Chemotherapy. b) Acute pain. c) Impaired home maintenance. d) Noncompliance.
b) acute pain
Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? a) teaching about planned diagnostic tests b) administering pain medication. c) maintaining hydration d) completing the admission history
b) administering pain medication
A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to: a) decrease the perception of pain. b) escape the source of pain. c) tolerate the pain. d) divert attention from the source of pain.
b) escape the source of pain
A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: a) shave the affected leg in anticipation of surgery. b) keep the affected leg level or slightly dependent. c) elevate the affected leg as high as possible. d) place a heating pad around the affected calf.
b) keep the affected leg level or slightly dependent
A frail elderly client with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is assisting the client's family to place the mattress (see image). What should the nurse instruct the family to do? a) Turn the mattress over so the air cells face the mattress of the bed, and cover the mattress with a bed sheet. b) Make the bed with the bed sheet on top of the pressure mattress. c) Put a thick pad over the pressure mattress to prevent soiling, and place the bed sheet on top of the pad. d) Make the bed, and then remove the pillow to allow full use of the mattress on the neck
b) make the bed with the bed sheet on top of the pressure mattress
A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen? a) Skeletal muscle hyperactivity secondary to cerebral palsy b) Muscle spasms with paraplegia or quadriplegia from spinal cord lesions c) Spasticity related to stroke d) Acute, painful musculoskeletal conditions
b) muscles spasms with paraplegia or quadriplegia from spinal cord lesions
Which of the following would be most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with severe diarrhea to help her comfort her infant who is fussy? a) placing a mobile above the crib b) offering a pacifier c) sitting at crib side talking to the infant d) turning the television on to cartoons
b) offering a pacifier
Which night clothes would the nurse recommend for an infant with atopic dermatitis? a) a diaper and short-sleeved shirt b) one-piece cotton pajamas with long sleeves c) a woolen sleeper with feet and mittens d) two-piece flannel pajamas with short sleeves
b) one-piece cotton pajamas with long sleeves
Following nasal surgery, the client has packing in the nose. The nurse should: a) instill normal saline nose drops. b) perform frequent mouth care. c) monitor temperature every 4 hours. d) examine the nares for ulcerations.
b) perform frequent mouth care
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a) avoid naps during the day. b) rest in an air-conditioned room. c) increase the dose of muscle relaxants. d) take a hot bath.
b) rest in an air-conditioned room
The parents of a school-age child with a brain tumor have elected to have only comfort measures instituted for their dying child. The child has been experiencing significant discomfort and has been receiving pain medication. A nurse knows that the pain-management principle most effective in controlling the child's pain is: a) alternating stronger opioid pain medications with nonopioid agents. b) striving to prevent pain by routine administration of pain medication. c) using an age-appropriate tool for effectively assessing pain. d) administering pain medication promptly when the child requests it.
b) striving to prevent pain by routine administration of pain medication
A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer? a) "If the baby's diaper is dry when she's crying, leave her alone and she'll fall asleep." b) "Leave your baby alone for 10 minutes. If she hasn't stopped crying by then, pick her up." c) "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." d) "Crying at this age indicates hunger. Try feeding her when she cries."
c) "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs."
After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which client statement indicates the need for additional teaching? a) "I will drink adequate fluids separate from my meals or snacks." b) "I will snack on a small amount of carbohydrates throughout the day." c) "I will eat two large meals daily with frequent protein snacks." d) "I will eat dry crackers or toast before arising in the morning.
c) "I will eat two large meals daily with frequent protein snacks."
A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? a) Drink plenty of fluids. b) Take a sitz bath. c) Apply an ice pack to her perineum. d) Perform perineal care after voiding or a bowel movement
c) apply an ice pack to her perineum
A client who had a colectomy 8½ hours ago and has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next? a) Check that the family is comfortable. b) Assess vital signs following the use of morphine. c) Dim the lights in the room. d) Increase nasal oxygen from 2 to 3 L.
c) dim the lights in the room
A 7-year-old child is brought to the clinic by a parent for a school physical. When the child is prepared for examination, which of the following interventions should the nurse provide to ensure the the child's comfort? a) Offer the option of the parent staying or remaining in the waiting room b) Have the child take off all of their clothing and put on a client gown c) Explain the purpose of the equipment being used during the examination d) Distract the child with bright colors
c) explain the purpose of the equipment being used during the examination
Which relaxation strategy would be effective for a school-age child to use during a painful procedure? a) Having the child keep his eyes shut at all times b) Having the child hold his breath and not yell c) Having the child take a deep breath and blow it out until told to stop d) Being honest with the child and telling him the procedure will hurt a lot
c) have the child take a deep breath and blow it out until told to stop
The nurse is performing effleurage (massaging) for a primigravida client in early labor. Which technique should the nurse use? a) deep kneading of superficial muscles b) secure grasping of muscular tissues c) light stroking of the skin surface d) prolonged pressure on specific sites
c) light stroking of the skin surface
A 10-year-old boy is 24 hours post appendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN for pain. What is the priority nursing action in managing the child's pain? a) Perform a head-to-toe assessment. b) Administer 1 mg morphine as prescribed. c) Obtain vital signs with a pain score. d) Change the child's position in bed.
c) obtain vital signs with a pain score
A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate? a) Offer ice chips every hour to decrease thirst. b) Divert the client's attention by turning on the television. c) Offer the client frequent oral hygiene care. d) Reexplain to the client why she cannot drink.
c) offer the client frequent hygiene care
A dehydrated infant is receiving I.V. therapy. The mother tells the nurse she wants to hold her infant but is afraid this might cause the I.V. line to become dislodged. What should the nurse do? a) Inform the mother that only a nurse should hold the infant during I.V. therapy. b) Advise the mother to let the infant lie quietly in bed. c) Show the mother how to hold the infant properly. d) Tell the mother it's best not to move the infant now
c) show the mother how to hold the infant properly
A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The mother questions pain medication for home. Which response by the nurse is most appropriate? a) "Maybe the health care provider will prescribe aspirin for the head pain." b) "Pain medication is avoided after a head injury to avoid hiding a worsening condition." c) "Opioid medications may lead to vomiting, which increases the intracranial pressure (ICP)." d) "Your child has a mild concussion; acetaminophen can be given."
d) "Your child has a mild concussion; acetaminophen can be given."
The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse? a) "Children don't experience as much pain after surgery as adults." b) "The child's activity level is the best indicator of pain." c) "A child who resumes usual play is not experiencing pain." d) "Some children distract themselves with play while in pain."
d) "some children distract themselves with play while in pain
Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which body system? a) pulmonary b) cardiac c) renal d) gastrointestinal
d) gastrointestinal
A 52-year-old male was discharged from the hospital for cancer-related pain. His pain appeared to be well controlled on the IV morphine. He was switched to oral morphine when discharged 2 days ago. He now reports his pain as an 8 on a 10-point scale and wants the IV morphine. Which explanation is the most likely for the client's reports of inadequate pain control? a) He is addicted to the IV morphine. b) He is physically dependent on the IV morphine. c) He is going through withdrawal from the IV opioid. d) He is undermedicated on the oral opioid.
d) he is undereducated on the oral opioid
The nurse is caring for a client in labor who is receiving epidural anesthesia. The nurse assesses a blood pressure of 80/40 mm Hg. Which of the following interventions will the nurse include in the client's plan of care? a) Monitor the fetal heart rate b) Turn off the client's epidural infusion c) Increase the epidural infusion rate d) Increase the client's fluid rate
d) increase the clients fluid rate
The clients has a palpable but faint right radial pulse. Capillary refill on all five digits <8 s. No observable swelling. The client is reporting numbness in the tips of all five digits. The skin is warm, dry, and red. A nurse assesses a 40-year-old female client with Raynaud's phenomenon involving her right hand. The nurse notes the information in the progress notes, as shown. From these findings, the nurse should develop a plan with the client to first manage: a) acute pain. b) lack of circulation. c) potential for skin breakdown. d) numbness.
d) numbness
A primipara calls the birthing unit 3 days after a vaginal birth. She tells the nurse that she is bottle-feeding and her breasts are swollen and painful. Which instructions would be appropriate? a) Wear a tight breast binder for the next 24 hours. b) Avoid wearing a bra to allow the engorgement to subside. c) Refrain from taking a shower with the water on the breasts. d) Use ice packs for 20 minutes every 3 to 4 hours.
d) use ice packs for 20 minutes every 3 to 4 hours