EAQ 7
A client with a MI is admitted to the cardiac intensive unit. Which pain relief medication would the nurse expect to find on the plan of care for this client?
morphine- it relieves pain quickly and reduces anxiety, also decreases cardiac workload; diazepam is a muscle relaxant used for sedative effect, midazolam is a hypnotic that may be used to reduce fear and restlessness, oxycodone is orally administered analgesic
Which statement is an accurate description of dysmenorrhea?
pain with menses; endometrial hyperplasia results from anovulation and persistent estrogen stimulation, bleeding between menses is metrorrhagia, heaving bleeding with menses is menorrhagia
Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain?
repositioning; purse-lipped breathing is primarily used to improve ventilation, deep breathing and coughing are used to clear the respiratory tract
The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data?
the client's pain is 7 on a scale of 1 to 10
An endoscopic sphincterotomy is scheduled to remove a gallstone lodged in the common bile duct. The client asks the nurse about pain during the procedure. Which statement would the nurse provide?
an IV sedative usually is administered- usually administered to produce effective sedation (conscious sedation) for the procedure
A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. Which action would the nurse take?
assess the circulatory status of the extremity; loosening the dressing slightly may result in bleeding from the catheter insertion site and is contraindicated; having the client flex the joints of the right leg may result in bleeding from the catheter insertion site and is contraindicated; the leg should remain extended for several hours
A client is receiving patient-controlled analgesia (PCA) after surgery. Which benefit would this type of therapy provide?
client is able to self administer pain relieving medications as necessary, decreases client dependency, increases client sense of autonomy- usually smaller amounts of analgesics are used; amount of analgesics and dosage of the medication are programmed to prevent accidents or abuse, medication levels are kept in a maintenance range, client is't dependent on the nurse availability to administer meds, nurse is still responsible for monitoring client for effectiveness, refilling the apparatus, and charting the amount administered and the client's response
Which intervention is useful in promoting comfort for the client experiencing a headache?
cold therapy; massage can be useful for acute or chronic pain but it not specifically used to treat headaches, heat therapy can be used for superficial or deep tissue pain, relaxation techniques are used to enhance the effectiveness of other pain relief measures
A client who has severe back pain is found to have a vertebral compression fracture. Which cause of fracture would the nurse consider when planning interventions?
collapse of the vertebral bodies- osteoporotic vertebrae collapse under the weight of the upper body or by improper or rapid turning, reaching, or lifting
A client presents to the health care facility with abdominal pain. Which questions would the nurse ask the client to obtain information about concomitant symptoms?
concomitant symptoms- these are symptoms that accompany the primary symptom of the illness and worsen the health conditions (ex. nausea that may accompany the primary symptom of pain); assess quality of pain by asking to describe, gather info about location by asking about location, nurse tries to understand precipitating factors by asking about activities that aggravate pain
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- ischemia causes tissue injury and the release of chemicals such as bradykinin that stimulates sensory nerves and produce pain
Which information would the nurse include when explaining the purpose of a thallium scan to the client who has a history of chest pain?
it assess myocardial ischemia and perfusion- related to angina or MI; action of the heart valve is available from an ECG or from cardiac catheterization with an angiography; visualization of the ventricular systole and diastole is determine by cardiac angiography; identifying the adequate cardiac conduction is determined by an electrocardiogram
Which statement indicates the nurse has a correct understanding about trigeminal autonomic cephalagia (cluster headaches)?
it is caused by an overactive hypothalamus- and it is enlarged; cluster headaches are most commonly seen in men aged 20 to 50 years, and they cause intense unilateral headaches of short duration lasting 30 minutes to 2 hours
A client described 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
The postoperative prescriptions for a client who had repair of an inguinal hernia include docusate sodium daily. Before discharge, the nurse instructs the client about which potential side effect?
mild abdominal cramping - the only side effect, this emollient laxative permits water and fatty substances to penetrate and mix with fecal material; rectal bleeding, nausea, and vomiting are more likely to occur with a saline-osmotic laxative,
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
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 clients vital signs- rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis; nurse would ambulate if pain was the result of flatulence, analgesics may mask the symptoms thereby delaying diagnosis
A client who had a MI receives 15mg 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- 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
Which condition would the nurse suspect in the client who reports a burning sensation and sharp pain on the sole of a foot?
plantar fasciitis- caused by chronic degeneration and inflammation; torticollis is the twisting of the neck to one side to an unusual position; per planus is the abnormal flatness of the sole and arch of the foot; crepitation is a frequent, audible crackling sound with a palpable grating that accompanies movement
Which factor may cause neck pain in a client?
poor posture- may affect the nerves innervating 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
A client who is 29 weeks pregnant reports a dull backache and abdominal cramps. Which condition would the nurse suspect?
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
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
Which intervention would the nurse perform while caring for an actively dying client?
provide client and family reassurance and perform symptom management for the client; client is admitted to hospice care if death is expected within 6 months
Which parameters would the nurse consider for proper rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse?
reaction of pain, reaction to voice- the disability examination provides a rapid baseline assessment of neurological status, ALERT, VOICE, PAIN, UNRESPONSIVENESS
When providing postoperative teaching, which rationale would the nurse give to explain the purpose of administering an opioid analgesic epidural catheter?
relieves abdominal pain- analgesics alleviate pain by binding with opioid receptors in the brain
Which caring intervention helps provide comfort, dignity, respect, and peace to a client?
relieving pain and suffering; listening helps obtain meaningful interactions with clients, spiritual caring helps clients find balance between their own life and values, goals, and belief symptoms, providing presence helps convey closeness and a sense of caring
Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline?
remove the IV catheter and restart the saline lock in another site- pain indicates that the tip of the catheter is no longer in the vein and the client needs removal of the current catheter and a new IV access site
Three days after a cast is applied to a client's fractured tibia, the client reports burning pain over the ankle that is not relieved by a change of position. The cast over the ankle feels warm to the touch. Which action would the nurse take first?
report the data to the primary health care provider- indicates tissue hypoxia or breakdown; other data, such as elevated temp or increased white blood cells are not present to support the presence of an infection
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- sensory stimulation strategy; heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy
A client with severe abdominal pain is on meperidine treatment and later develops seizures. Which intervention is given highest priority?
stop administration of meperidine- opioid such as meperidine are associated with neurotoxicity and seizures which are caused by accumulation of the its metabolite, normeperidine; transdermal scopolamine helps reduce nausea and vomiting associated with the admin of meperidine; O2 is administered when the client has over sedation and respiratory distress
Ten minutes after the initiation of a blood transfusion, a client reports chills and flank pain. Which nursing action would be performed first?
stop the transfusion- this is a sign of acute hemolytic transfusion reaction, indicating the recipient's blood is incompatible with the transfused blood, pain is caused by hemolysis, agglutination, and capillary plugging in the kidneys
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- pain generally is considered to be tolerable if it is a 4 or below
Which pain related clinical manifestation would the nurse expect in a client who had received a diagnosis of peptic ulcer?
the pain occurs 1 to 3 hours after having a meal- 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 is localized in the epigastrum and only radiates to the abdomen if the ulcer is perforated
A client has an IV solution of 5% dextrose in water 250mL to which 100mg of morphine is added. The health care provider prescribes 14mg of morphine per hour for end of life palliative treatment of a client. At how many mL per hour will the nurse set the IV pump?
35mL/h 100/14 x 250 = 35mL
a pediatric client with a past history of chicken pox reports a fever and headache. Which medication would the nurse avoid giving to the client?
Aspirin- there is a risk of developing Reye syndrome; Tetracycline generally cuases discoloration of teeth, Nalidixic acid sometimes causes cartilage erosion, Chloramphenicol is associated with Gray syndrome in children
A client presents with chief complaints of unexplained weight gain and back pain from a compression fracture of the vertebrae. On assessment, there is truncal obesity with excessively thin extremities, a moon shaped face, a buffalo hump, thin hair, and adult acne. The symptoms described are suggestive of which disease?
Cushing disease- caused by excess cortisol secretion caused by hypersecretion of adrenocorticotropic hormone (ACTH), other characteristics are DM, muscle wasting, osteoporosis, echhymosis, and slow healing of wounds; Addison disease include hypotension, dehydration, hypoglycemia and hyperpigmentation of the skin; MS is a progressive disease involving destruction of the myelin sheath leading to nerve damage; Kaposi sarcoma is a cancer associated AIDS
Which pain scale would the nurse use to measure the intensity of pain in toddlers?
FACES scale
Which pain scale is used to measure the intensity of pain in preschoolers?
FACES scale; visual analog scale, numerical rating scale, and verbal descriptor scale can be used in young children and adults
The nurse understands which anesthetic medication is commonly used for short procedures on pediatric clients?
Fentanyl - 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 the nurse is analyzing an ECG, which waveform illustrates atrial depolarization?
P wave- represents the electrical impulse starting at the sinus node and spreading throughout the atria (atrial depolarization); QRS represents depolarization of the ventricles; T wave represents repolarization of the ventricles; U wave reflects late ventricular repolarization of repolarization of the Purkinje fibers (sometimes identified in clients with hypokalemia
Which medication is used in the treatment of a client with intervertebral disc disease?
cyclobenzaprine- often causes myalgia that is treated with muscle relaxants; etidronate, zoledronic acid, and salmon calcitonin are effective in the treatment of osteoporosis
Which pain scale would the nurse use when assessing a 4 year old child?
Wong- Baker- type of faces scale best used in children as young as 3 or 4 years; CRIES and FLACC are pain scales typically used with young infants who are unable to verbalize pain, the numerical pain scales are best used in older children, teens, or adults who can accurately assign a number to represent pain level
Which is a sign of a ruptured ectopic pregnancy in an adolescent?
abdominal pain and hypotension- ectopic pregnancy occurs when a fertilized egg implants outside the uterus; it would elicit tachycardia related to subsequent shock; ectopic pregnancy is ruled out if abdominal pain is associated with bleeding or hypertension
A client who reports chest pain and difficulty breathing is admitted to the emergency department. A chest x-ray reveals a pneumothorax. Which assessment finding would the nurse expect?
absence of breath sounds over the affected area; distended neck veins are associated with failure fo the right side of the heart and can occur with a mediastinal shift; paradoxical respirations occur with flail chest; purulent sputum is a sign of infection
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- by speaking to the healthcare provider on behalf of the client; acts as an educator while teaching the client facts about health and the need for routine activities, 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 conditions of the clients who are admitted with injuries due to a bus accident are prioritized under the emergent classification?
airway obstruction, shock
Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain?
apply for 30 minute time intervals- to prevent skin damage apply for 20 to 30 mins intervals; shift positions every 2 hours to prevent skin breakdown, ice should be used to the first 24 to 48 hours followed by heat, never apply ice directly to skin
Which herbal medication would the nurse suggest to a client to reduce premenstrual discomfort?
black cohosh root- used to reduce premenstrual discomfort and tension associated with menstrual disorders; fennel is an uterotonic agent that is used to reduce menstrual cramping and dysmenorrhea, bugleweed is an antigonadotropic agent that decreases prolactin levels and reduces breast pain, chamomile is an antispasmodic agent that helps reduce breast pain
An adolescent complains of breast pain. Which antigonadotropic herb may alleviate beast pain by decreasing prolactin levels?
bugleweed; black haw and catnip are herds that act as uterine antispasmodics, chaste tree fruit also decreases breast pain by decreasing prolactin levels, but it is not antigonadotropic
An adolescent who has 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
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- it is classified as an opioid analgesic and is effective in relieving pain, it induces little or no newborn respiratory depression
Which herbal therapies would be beneficial to a client with menstrual cramping?
catnip, fennel, 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?
chamomile, bugleweed, and chaste tree fruit; dong quai is recommended for menstrual cramping and dysmenorrhea, back 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?
client is able to self administer pain relieving medications as necessary, decreases client dependency, increases client sense of autonomy
Which factor would the nurse explain as the likely cause of pain to a client who is diagnosed as having a herniated nucleus pulposus?
compression of the spinal cord by the extruded nucleus pulposus
A client take oxycodone every 3 hours for pain surgery. Which actions would the nurse take before administering each dose of oxycodone?
count the client's respirations, ask the client to rate the level of pain, assess the client's LOC
When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?
decreased sounds - because the right lung is collapsed with a right pneumothorax, the nurse would expect very decreased or absent breath sounds on the right; crackles occur with movement of air through fluid, such as with pulmonary edema; wheezes occur with air movement through narrowed airways and would not be heard when there is no air movement because of lung collapse
Which point would the nurse include in a teaching plan to help manage pain during dressing changes if a client has burns over 18% of body surface>
deep breathing exercises- effective in controlling pain
The nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to a client. Which nursing function does this represent?
delegation
After abdominal surgery, a client reports pain. Which action would the nurse take first?
determine the characteristic of the pain- exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery
Assessment findings of a client who is admitted to the emergency department include cramping pain in the left lower quadrant, weakness, bloating, malaise, and a low grade fever. The nurse suspects which condition?
diverticulitis- can occur anywhere but most common in sigmoid colon in left lower quadrant; pancreatitis is associated with acute epigastric of left upper quadrant pain, appendicitis is associated with lower right quadrant pain and localized McBurney's point; cholecystitis is associated with right upper quadrant pain that may be referred to the right shoulder and scapula
Which condition would the nurse document to prescribe a client presenting with the loss of the ability to taste after cancer treatment has affected the client's ability to eat food?
dysgeusia; mucositis is the inflammation and irritation of the mucosa in the mouth or throat, dysphagia is difficulty swallowing, xerostomia is dry mouth; all of these complaints are common side effects of chemotherapy or radiation treatment
After surgery, a child experiences intense pain and an analgesic is prescribed. Which would the nurse consider when administering the analgesic?
even though children do not like medicine, analgesics will make them more comfortable
Which suggestion would the nurse make regarding what a client would wear to prevent back pain as pregnancy progresses?
low-heeled shoes - helps maintain the body's center of gravity over the hips, limiting arching of the back that compensates for the increased weight in the abdominal area; maternity girdles are no longer recommended, support stocking may be helpful for a woman with varicose veins or ankle edema
One week after the beginning antithyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and a fever. The client is admitted with diagnosis of thyrotoxic crisis. Which intervention is appropriate to implement for this client?
reduce body temperature and heart rate- immediate treatment in this emergency focuses on reduction of oxygen demands and thus cardiac workload to prevent cardiac decompensation; increase fluid to compensate for that loss because of the high metabolic rate, a response to sedatives is not likely because medications are metabolized more rapidly with thyrotoxic crisis (danger of exaggerated effects of the medication with hypothyroidism), clients with thyrotoxic crisis are more apt to develop hypoglycemia from the high metabolic rate
The nurse has administered sublingual nitroglycerin. Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin?
relief of anginal pain- cardiac nitrates relax smooth muscles of the coronary arteries, they dilate and deliver more blood to hart muscle relieving ischemic pain
A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. The nurse would expect to teach the client about which condition?
tinea pedis- it is clinically manifested as interdigital scaling and maceration and a scaly plantar surface, sometimes with erythema and blistering; tinea cruris is a fungal infection that is clinically manifested with well-defined scaly plaque in the groin area, tinea corporis is clinically manifested as an erythematous, annular, ring-like scaly appearance with well- defined margins, tinea unguium or onchomycosis is manifested with scaliness under the distal nail plate
A client with 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- improves cardiac output, which may or may not prevent dyspnea
Which rational supports administering the medication pregablin to a client with AIDS?
to reduce neuropathic pain
Which direction regarding sleeping position would the nurse give to a client who is 8 months' pregnant?
turn from side to side when in bed- will relieve back pressure, promotes uterine perfusion and fetal oxygenation
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- 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 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
Which alternative treatment would a nurse recommend to help ease a young child's pain at home?
yoga, biofeedback, guided imagery- they are 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 is the most important topic to include in teaching to promote the comfort of a client with a pruritic skin disease?
sleep - pruritic skin disease often interfere with sleep, adequate rest increases the client's ability to tolerate the itching, thereby decreasing the damage to the skin
Which action puts a client at risk for low back injury and pain?
smoking tobacco
Which would the nurse recommend to a client who is formula-feeding her infant and complains of discomfort from engorged breasts?
apply cold packs and a snugly fitting bra- cold relieves discomfort, and a snug bra provides support and aids in pressure atrophy of acini cells so that milk production is suppressed; warm moist compresses are suitable for the breast feeding mother experiencing discomfort from engorgement because it promotes comfort and stimulates mild production, expressing milk manually is suitable for breast feeding mother
Which medication would the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with RA?
aspirin- because of it's anti-inflammatory effect; opioids should be avoided because they promote medication dependency and do not affect the inflammatory process, Alprazolam is an antianxiety medication
Which finding in a newborn is a behavioral response to pain?
crying; tachypnea, diaphoresis, tachycardia, and HTN are physiological responses to pain
Which factors can trigger a client's migraine attacks?
fatigue, sleep problems, hormonal fluctuations
The nurse understands which anesthetic medication is commonly used for short procedures on pediatric clients?
fentanyly- recommended for short procedures on pediatric clients; morphine used for long procedures in which pain is anticipated even after the procedure, meperidine and hydromorphone are used to achieve mild to moderate sedation in pediatric clients
Which nursing interventions enhance comfort in a dying client in the hospital?
frequently repositioning the client, maintaining oral hygiene in the client, applying body lotion to the client's skin daily
The overproduction of which hormone is associated with carpal tunnel syndrome in clients?
growth hormone; overproduction of adolsterone hormone is associated with Conn syndrome; antidiuretic hormone overproduction can result in syndrome of inappropriate antidiuretic hormone, overproduction of parathyroid hormone results in hyperparathyroidism
After an amputation of a limb, a client reports extreme discomfort in the area where the limb once was. On which goal would the nurse plan to focus interventions?
identifying actions to decrease pain in the lost limb
A client with a diagnosis of MI asks the nurse "What is causing the pain I am having?" Which explanation would the nurse give?
inadequate oxygenation of the myocardium- cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue; release of myocardial isoenzymes is an indication of myocardial damage
A client is admitted to the hospital after 2 days of painful abdominal spasms and severe diarrhea. Which appropriate sequence does the nurse use to examine the client's abdomen starting with inspection?
inspection, auscultation, percussion, palpation
Which nursing action would be implemented after a client has a lumbar puncture?
maintaining the client in the supine position for several hours
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
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- pain shifting to the right lower quadrant between the iliac crest and the umbilicus is McBurney point and is indicative of appendicitis; client may also have fever, nausea, and vomiting but these can occur with other infectious processes, absolute constipation occurs with many bowel obstructions
Which client assessment finding would the nurse document as subjective data?
pain rating of 5
Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)?
tachycardia, hypotension, rigid abdomen, nausea and vomiting, back and shoulder pain
