Exam #4

A patient with cancer is experiencing increased pain issues. A plan is developed for adding ibuprofen 600mg BID to the medication regimen of narcotics. The patient asks the nurse why he is now expected to take ibuprofen because he does not have arthritis. What is the most appropriate reply by the nurse?

"Ibuprofen increases the effects of your narcotic, providing better pain relief" Nonsteroidal anti-inflammatory drugs potentiate the effects of opiates and, when in combination, are of particular use in cancer patients because of major contributing factor of pain is cell destruction. Narcotic doses may still need to be increased as the disease is progressive. NSAIDS have an anti-inflammatory effect, but the ability to block prostaglandin synthesis promotes their pain-relieving properties. There is no information to support that they act more slowly or extend pain relief.

When assessing chronic pain in the older adult, which question will be most helpful in determining appropriate interventions?

"What treatments have you used and which have been most helful?" Chronic pain may begin insidiously and many remedies may have been tried before seeking treatment.

Three days after undergoing exploratory laparotomy and lysis of adhesions, a patient tells the nurse that his pain is no better than on the first day postop and he fears that he will be unable to return to his work withing the allotted time frame. Which response by the nurse is the most appropriate for the situation?

"You have undergone a major surgery, which is a major stressor to your body. As your body heals, your pain should resolve" Acute pain occurs after surgury and is usually limited and of predictable duration. Increased activity is needed to maintain function, promote healing, and prevent complications of surgery.

The use of percutaneous electrical stimulation as an effective means to control pain is based on which of the following? a. Gate-control theory b. Concept of therapeutic touch c. idea of using distraction d. theory of using heat application

A. Gate-control theory

Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? 1.Activity Intolerance. 2.Risk for Activity Intolerance. 3.Impaired Physical Mobility. 4.Risk for Disuse Syndrome.

1.Activity Intolerance. Rationale: Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not "at risk for," as in option 2. There is no evidence that the client requires assistance (impaired mobility, option 3), or is immobile (disuse syndrome, option 4).

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1. Automobile crashes 2. Drowning and firearms 3. Falls 4. Suicide and homicide

1.Automobile crashes Rationale: When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use. Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents.

Performance of activities of daily living (ADLs) and active range of motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. 1.Elbow flexion with eating and bathing. 2.Elbow extension with shaving and eating. 3.Wrist hyperextension with writing. 4.Thumb ROM with eating and writing. 5.Hip flexion with walking.

1.Elbow flexion with eating and bathing. 4.Thumb ROM with eating and writing. 5.Hip flexion with walking. Rationale: Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension (option 2). Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint (option 3).

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. 1.Increase muscle tone and improve circulation. 2.Increase blood pressure. 3.Increase muscle mass and strength. 4.Decrease heart rate and cardiac output. 5.Maintain joint range of motion.

1.Increase muscle tone and improve circulation. 3.Increase muscle mass and strength. 5.Maintain joint range of motion. Rationale: Isotonic exercise increases muscle tone, mass, and strength, maintains joint flexibility, and improves circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body (option 4). Little or no change in blood pressure occurs (option 2).

When assessing a client's gait, which does the nurse look for and encourage? 1.The spine rotates, initiating locomotion. 2.Gaze is slightly downward. 3.Toes strike the ground before the heel. 4.Arm on the same side as the swing-through foot moves forward at the same time.

1.The spine rotates, initiating locomotion. Rationale: Normal gait involves a level gaze, an initial rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward.

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? 1."Going up, the strong leg goes first, then the weaker leg with both crutches." 2."Going down, the weaker leg goes first with both crutches, then the strong leg." 3."The weaker leg always goes first with both crutches." 4."A cane or single crutch may be used instead of both crutches if held on the weaker side."

3."The weaker leg always goes first with both crutches." Rationale: Although the crutches (or cane) are always used along with the weaker leg, the weaker leg should go down the stairs first. The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct.

When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1.Sports contribute to an adolescent's self-esteem. 2.Sunbathing and tanning beds can be dangerous. 3.Guns are the most frequently used weapon for adolescent suicide. 4. A driver's education course is mandatory for safety.

3.Guns are the most frequently used weapon for adolescent suicide. Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver's education course does not ensure safe practice.

A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? 1.Exercises past the point of resistance. 2.Performs each exercise one time. 3.Performs each series of exercises once a day. 4.Uses the same sequence during each exercise session.

4.Uses the same sequence during each exercise session. Rationale: When the client performs the movements systematically, using the same sequence during each session, the nurse can evaluate that the teaching was understood and is successful. When performing active ROM the client should exercise to the point of slight resistance, but never past that point of resistance in order to prevent further injury (option 1). The client should perform each exercise at least three times, not just once (option 2). The client should perform each series of exercises twice daily, not just once per day (option 3).

Which of the following nurses is most likely to experience the greatest amount of stress related to his or her position as a nurse? a) A graduate nurse working on a telemetry unit b) A nurse with 1 year of experience working on an oncology unit c) A nurse who is an editor of a nursing journal d) A nurse with 10 years of experience working as a nurse educator

A graduate nurse working on a telemetry unit Explanation: Stress is often greater for new graduate nurses and nurses who work in settings such as an intensive care unit and emergency care.

Upon arrival to the emergency room, the mother of a patient involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing? a) Severe anxiety b) A panic attack c) Mild anxiety d) Moderate anxiety

A panic attack Explanation: Panic causes the person to lose control and experience dread and terror. Panic is characterized by a disorganized state, increased physical activity, difficulty communicating, agitation, trembling, dyspnea, palpitations, a choking sensation, and sensations of chest pressure or pain. Severe anxiety creates a narrow focus on specific detail; moderate anxiety leads to a focus on immediate concerns; and mild anxiety is often present in day-to-day living, and it increases alertness and perceptual fields.

An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of a) Valuation b) Adaptation c) Evaluation d) Reaction

Adaptation Explanation: Adaptation is generally considered a person's capacity to flourish and survive, even with diversity.

A nurse is caring for a client who is an investment banker. The client is stressed because of the sudden fall of share prices in the stock exchange. Which of the following stress-reduction techniques should the nurse use with this client? a) Discourage family from interacting with the client. b) Advocate on behalf of the client to others. c) Avoid referring the client to other organizations. d) Avoid discussing the client's condition with client's family.

Advocate on behalf of the client to others. Explanation: The nurse should advocate on behalf of the client to others. If need be, the nurse should refer the client and his family to organizations or people who provide post-discharge assistance. The nurse should keep the client and the client's family informed about the client's condition and encourage the family members to interact with the client.

A terminally ill patient is experiencing chronic pain due to spinal cord tumor and has been admitted on several occasions for pain crises. Which intervention can produce positive outcome for the individual with uncontrolled pain and a short life expectancy?

Analgesic Nerve Blocks Analgesic blocks using neurolytic agents block nerve conductivity and destroys the nerves. Topical anesthesia, local anesthetic agents, and nonnarcotics are not effective for a patient experiencing pain due to cord compression.

When caring for a patient with a suspected viral infection, which medication order would the nurse question?

Aspirin ASA may pose a risk for people of any age when administered to those with viral infections. Adults have experienced Reye's syndrome-like manifestations.

Mr. Xenobia's chronic cancer pain has recently increased and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse? a. "if you take more morphine, it will not change your pain effect" b. "I'll call the physician and ask for an increased dose" c. "the amount you are taking now is all I can give you" d. "I'm worried if we increase your dose that you will stop breathing"

B "I'll call the physician and ask for an increased dose" Rationale: there is no ceiling on the analgesic effect of opioid narcotics. Patients develop a tolerance to the effects, which often necessitates an increase in the dose.

The nurse is assessing the confused client, in trying to determine the client's level of pain, the nurse should: a. be aware that confused clients don't feel as much pain due to their confusion b. observe the client carefully for changes in behavior or vital signs c. ask the client's family how much pain the client normally has d. use only pain scales that feature numbers or "faces" the client can point to.

B. Observe the client carefully for changes in behavior or vital signs Rationale: the nurse should observe the confused client for nonverbal cues to pain

A 73 year old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? a. phantom b. visceral c. deep somatic d. referred

C. Deep somatic Rationale: Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is a pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptions and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site.

When establishing a plan for pain control, what question would the nurse first ask the patient? a. "How long have you been having this pain?" b. "What measures relieve your pain?" c. "How does the presence of this pain affect your life?" d. "Aren't you tired of being in pain?"

C. How does the presence of this pain affect your life? Rationale: Before developing a plan for controlling a patient's pain, the nurse must elicit information about the patient's perception of his pain.

It is most important for the nurse to understand the various ways in which pain is classified. a. so that he can document the client's pain using accurate terms. b. so that he can be clear in his communication with the physician. c. so that he can develop an effective pain management plan. d. So that he can educate the client thoroughly

C. so that he can develop an effective pain management plan Rationale: different modalities are used in the treatment/management of pain and are often based on how the pain is classified.

At 7 months after back injury and lumbar laminectomy, a patient complains of tenderness at the operative site and appearss depressed and unwell. Other symptoms include depression, fatigue, and sleep disturbances. Which nursing diagnosis is a priority for this patient?

Chronic Pain Chronic pain has vague symptoms and few other physical findings and occurs beyond

When admitting a postop patient to the surgical unit, which nursing action is a priority?

Conduct Pain Assessment Assessment is a constant ongoing task for the postop patient

Mr. Mitchell and Mr. Farrell have both had their gallbladders removed laparascopically. Mr. Mitchell is rating his pain at a 5 on a 10-pain scale and states he does not require pain medication. Mr. Farrell is rating his pain a 5 on a 10-pain scale and is demanding something stronger for his pain. This is an example of a difference in which of the following? a. Surgeon's skill b Patient's pain thresholds c. Patient's personalities d. Patient's pain tolerance

D. Patient's pain tolerance Rationale: Both patients would perceive the surgical incision to be painful at about the same point. Mr. Mitchell is able to tolerate his pain when it is rated at a 5, whereas Mr. Farrell is not. The patient's personality is a factor that affects pain tolerance.

Which of the following is a physiological response experienced during the exhaustion stage of general adaptation syndrome? a) Increased mental alertness b) Vasoconstriction c) The initiation of neuroendocrine activity d) Decreased blood pressure

Decreased blood pressure Explanation: The stage of exhaustion is often accompanied by decreased blood pressure and vasodilation. Increased mental alertness and the initiation of neuroendocrine activity are associated with the alarm reaction of the GAS.

A 72 year old patient is hospitalized after a fall at home, is restless, has elevated blood pressure, and moans with turns. When the nurse asks, the patient denies being in pain. What initial interventions should the nurse employ?

Discuss the symptoms and explain how medication will increase comfort and increase healing Older adults are hesitant to express pain becasue they may fear being labeled as a complainer

The children of a 60-year-old woman are distraught at her apparent lack of recovery following a stroke several weeks earlier. The patient's daughter has frequently directed harsh criticism toward the nurses, accusing them of a substandard effort in rehabilitating her mother despite their best efforts. What defense mechanism may the patient's daughter be exhibiting? a) Sublimation b) Regression c) Displacement d) Denial

Displacement Explanation: The daughter may be transferring her feelings about her mother's health status to the care providers, an act that involves the displacement of the emotional reaction to another person. Denial about her mother's potential for recovery may underlie her response, but this is not demonstrated as clearly as displacement.

The nurse would recognize that short-term pharmacological treatment may be appropriate if an anxious patient's nursing diagnoses includes which of the following? a) Social isolation b) Decisional conflict c) Disturbed sleep pattern d) Defensive coping

Disturbed sleep pattern Explanation: The nurse should recognize that diagnoses relating to conflict, coping, and decisional conflict are less amenable to pharmacologic treatment. Disturbances in sleep patterns, however, are often addressed by the appropriate use of hypnotic medications.

While reviewing the medication list for an older client with a history of heart failure, diabetes, and hypertension, which medication might cause concern?

Dolobid 250mg Salicylate salts containing mg or na should be avoided in clients whom excessive amounts of these electrolytes might be harmful

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? a) Secondary stage b) Exhaustion stage c) Alarm stage d) Resistance stage

Exhaustion stage Explanation: The client is in the exhaustion stage when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor; this results in exhaustion. The effects of stress-related neurohormones suppress the immune system and the body is open to various ailments. In the alarm stage, the person is prepared for a fight-or-flight response. In the resistance stage, the client's body is returned to the homeostasis state. Consequently, one or more organs or physiologic processes may eventually lead to increased vulnerability to stress-related disorders or progression to the stage of exhaustion. The secondary stage is not a stage related to stress.

The nurse is interviewing a client with complaints of chronic fatigue. The nurse understands that the client has a sedentary lifestyle and suggests that the client start low-intensity exercise. Which of the following exercises would be appropriate for the nurse to suggest the client engage in initially? a) Brisk walking b) Running c) Cycling d) Gardening

Gardening Explanation: The nurse should suggest that the client start with gardening, which is a low-intensity exercise and is particularly good preparation for sedentary persons before they progress to more vigorous aerobic exercise. Running, cycling, and brisk walking are vigorous aerobic exercises.

The nurse is called to a patients room who complains of pain 9/10 and requests pain medication. He is laughing, watching football, and is in conversation with a visitor. Based on the assessment, what intervention should the nurse employ?

Give the total dose of pain medication Pain is a multidimensional phenomenon that is difficult to define. It is personal and subjective and is whatever the patient says it is.

A non-english speaking hispanic client is moaning and appears to be in pain. How does the nurse intervene to faciliatate adequate pain management?

If an interpreter is available, explain that pain is related to illness and by treating the pain healing will promote wellness Moaning and crying are used to alleviate the pain rather than communicate a need for intervention. If the patient understands that pain is related to illness there is a higher likelihood that the patient will accept treatment.

A nurse is assessing an obese teenager who is unhappy and stressed out because she has not lost weight despite working out at the gym. The physician asks the nurse to try the modeling intervention for stress management for the client. Which of the following actions should the nurse perform when adhering to the modeling intervention? a) Ask the client to undergo liposuction surgery. b) Ask the client to change her exercise regimen. c) Ask the client to cut down on her food intake. d) Introduce the client to someone with a positive attitude.

Introduce the client to someone with a positive attitude. Explanation: The nurse should introduce the client to a person who demonstrates a positive attitude or behavior as this promotes the ability to learn an adaptive response. The nurse should not ask the client to change her exercise regime, cut down on her food intake, or undergo liposuction surgery as that could lead to further medical complications.

Which order would the nurse question when caring for a postop patient receiving epidural morphine infusion?

Lovenox 40mg SC BID Molecular weight heparins have been linked to spinal hematoma in clients with epidurals.

An 80 year old patient who is recovering from a hip fracture with surgical nailing is becoming increasingly confused and unable to participate in care, and has experienced several periods of urinary incontinence. Which orders might the nurse suspect of contributing to the patient's sypmptoms?

Meperidine 25mg Meperidine causes confusion and delerium in the older adult and should be used caustiously in patients with altered renal function.

Two days after undergoing surgery, a patient refuses to get out of bed. What information can the nurse provide that may increase compliance with the treatment plan?

Movement can cause breakthrough pain. We can give you medication to control the pain and help you to increase your activity

A 28 year old quadriplegic complains of burning pain in his lower legs. What type of pain should the nurse suspect?

Neuropathic Pain Nociceptive/neuropathic pain is due to damage to nerve cells or changes in the processing of pain

A client who is a drug addict visits a health care facility for treatment. During counseling, he discloses that he took to drugs because it helped him deal with stressful situations. The nurse explains that he is not using the correct coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case? a) Stress-reduction strategy b) Therapeutic coping strategy c) Antidepressant strategy d) Non-therapeutic coping strategy

Non-therapeutic coping strategy Explanation: The client has used non-therapeutic coping strategies such as mind- and mood-altering substances to cope with stress. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. Also, the client has not used an antidepressant strategy.

What information about pain must the nurse understand when designing a plan of care to manage pain?

Past experience with pain effects the way current pain is perceived Past experience affects the way current pain is perceived, the impact of pain experiences is not predictable, anxiety influences an individuals response to pain, and no matter what the experience is, one never becomes accustomed to pain.

You walk into your patients' room and find her sobbing uncontrollably. When you ask what the problem is your patient responds "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this patient's care plan you note a nursing diagnosis of "Ineffective coping related to stress". What is the best outcome you can expect for this patient? a) Patient will avoid stressful situations. b) Patient will start anti-anxiety agent. c) Patient will adapt relaxation techniques to reduce stress. d) Patient will be stress free.

Patient will adapt relaxation techniques to reduce stress. Explanation: Stress management is directed toward reducing and controlling stress and improving coping. The outcome for this diagnosis is that the patient needs to adopt coping mechanisms that are effective for dealing with stress, such as relaxation techniques. The other options are incorrect because it is unrealistic to expect a patient to be stress free; avoiding stressful situations and starting an anti-anxiety agent are not the best answers as outcomes for ineffective coping.

As an occupational health nurse at an oil refinery on the Gulf coast of Texas you are doing patient education with a man in his mid-forties. The patient is being seen after having been exposed to a chemical spill at the refinery. What type of stressor has this patient been exposed to? a) Psychiatric b) Psychosocial c) Physiologic d) Physical

Physical Explanation: Physical stressors include cold, heat, and chemical agents; physiologic stressors include pain and fatigue. These facts make the other options incorrect.

A high school student comes to the nurse's office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a(an) a) Adjustment b) Concern c) Threat d) Stressor

Stressor Explanation: Stress, coping, and adaptation are interrelated. Survival depends upon successful coping responses to ordinary and sometimes extraordinary circumstances and challenges.

A middle-aged woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are a) Stressors b) Demands c) Illnesses d) Stimuli

Stressors Explanation: Stress is defined as any event or set of events, a stressor, that causes a response. Everyday triggers associated with work or social relationships, and uncommon events such as natural disasters, physical trauma, injuries, illnesses, divorce, death of a loved one, or loss of a job are commonly recognized stressors.

When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem? a) Avoid doing petty jobs. b) Take control of the situation. c) Change jobs. d) Avoid people who dump tasks on him.

Take control of the situation. Explanation: A behavioral technique for modifying stress is to take control rather than become immobilized. This is also known as alternative behavior. Another behavioral approach to reduce stress is to sometimes say "no," in order to avoid becoming overwhelmed and more stressed. Changing jobs or avoiding the person or the petty jobs would not help.

You are the nurse caring for a 72-year-old female who is recovering from abdominal surgery on the Medical Surgical unit. The surgery was very stressful and prolonged and you note on the chart that her blood sugars are elevated yet she in not been diagnosed with diabetes. To what do you attribute this elevation in blood sugars? a) It is a result of antidiuretic hormone. b) She must have had diabetes prior to surgery. c) She has become a diabetic from the abdominal surgery. d) The blood sugars are probably a result of the "fight-or-flight" reaction.

The blood sugars are probably a result of the "fight-or-flight" reaction. Explanation: During stressful situations, ACTH stimulates the release of cortisol from the adrenal gland, which creates protein catabolism releasing amino acids and stimulating the liver to convert amino acids to glucose, the result is elevated blood sugars. Option A is incorrect, antidiuretic hormone is released during stressful situations and stimulates reabsorption of water in the distal and collecting tubules of the kidney. Option B is incorrect; assuming the patient had diabetes prior to surgery demonstrates a lack of understanding of stress induced hyperglycemia. Option C is incorrect, there is no evidence presented in the question other than are elevated blood sugars that would support a diagnosis of diabetes.

A nurse is trying to assess a client's stress type; however, the client is very depressed and quiet and does not reply to the nurse's questions. The nurse is unable to maintain her calm while repeating the questions. Where is the nurse going wrong in assessing the client? a) The nurse should demonstrate confidence and expertise. b) The nurse should take help from the senior physician. c) The nurse should not assess the client's stress type. d) The nurse should calm him first by giving him a sedative.

The nurse should demonstrate confidence and expertise. Explanation: Some general interventions appropriate during the care of the client who is suffering from stress include remaining calm during the discussions with the client, being available to the client, responding promptly to the client's signal for assistance, and encouraging family interaction. However, taking the help of a senior physician or giving the client a sedative would not help in assessing the client. The nurse has to assess the client's type of stress.

Which factor regarding older adults and medication is important for the nurse to understand?

The older adult is more likely to experience drug interactions than the general public

What is a realistic outcome for the patient who is terminally ill with bone cancer and is experiencing uncontrolled pain?

The patient experiences improved quality of life

You are caring for a 72 year old patient with advanced cancer who complains of increased pain and tactile sensitivity over the last several weeks. Which non pharmacological alternative could be added to her plan of care to enhance her comfort?

Therapeutic Touch Therapeutic touch is thought to realign aberrant energy fields through passing hands over the energy fields without actually touching the body and promoting comfort.

A patient with colon cancer is being managed with OxyContin 30mg PO BID and Oxycodone 5mg PO q4h PRN for breakthrough pain. The patiens wife voices her concern that the patient is becoming addicted to the medication and questions whether milder nonnarcotic medications could be used. What is the most appropriate response by the nurse?

With the diagnosis of cancer, there is a need to use regular and strong mediaction for pain control to provide a better quality of life Persistent pain can be managed using long acting medications and narcotics when the condition warrants their use. Addiction is not an issue for the patien with chronic cancer pain. Amount and types of meds are adjusted according to patient status

Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol) a. Hepatitis B b. Occasional alcohol use c. allergy to aspirin d. gastric limitation with bleeding

a. Hepatitis B

Which pain management task can the nurse safely delegate to nursing assistive personnel? a. asking about pain during vital signs b. evaluating the effectiveness of pain medication c. developing a plan of care involving nonpharmacologic interventions d. administering over-the-counter pain medications

a. asking about pain during vital signs Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over-the-counter and prescription medications is the responsibility of the RN or LPN

the school aged hospitalized child is afraid of separation from ______

age group

A client expresses to the nurse that she constantly feels irritated and loses her temper. During the course of the interview, the nurse finds that the client takes care of her mother who was confined to bed following a stroke. The client struggles to balance caring for her family and her mother. Which nrusing diagnosis would the nurse most likely identify for this client? a) Compromised family adjustment b) Caregiver role strain c) Ineffective coping d) Anxiety

b) Caregiver role strain Explanation: The most appropriate nursing diagnosis is caregiver role strain because the client feels tired and fatigued by struggling to care for her mother and fulfilling family needs. Ineffective coping, compromised family adjustment, and anxiety would be inappropriate nursing diagnoses based on the information provided.

Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis a. ibuprofren b celecoxib c aspirin indomethacin

c. Aspirin Rationale: Aspirin is a unique NSAID that inhibits platelet aggregation. Low dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, MI, and stroke. Ibuprofren, celecoxib, and indomethacin are NSAIDS, but they do not inhibit platelet aggregation

Which action should the nurse take before administering morphine 4.0 intravenously to a patient complaining of incisional pain? a. Assess the patient's incision b. Clarify the order with the prescriber c. assess the patient's respiratory status d. monitor the patient's heart rate

c. Assess the patient's respiratory status

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? a.Report the fire. b. Extinguish the fire. c. Protect the clients. d. Contain the fire.

c.Protect the clients. Rationale: In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire

The nurse administers codeine sulfate 30mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? a. Immediately b. in 10 minutes c. in 15 minutes d. in 60 minutes

d. in 60 minutes Rationale: Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore the nurse should reassess the patient's pain 60 min after administering. The nurse should reassess pain after 10 min when administering codeine by IM or SC routes. Drug administered by the IV routes are effective almost immediately; however codeine is NOT recommended for IV administration.

the school aged child perceives the cause of illness to be external or internal?

external- she knows that illness is not a result of bad behavior

the preschooler fears separation as well as ________ when hospitalized

mutilation- remember preschoolers have vivid imaginations... fantasy

the adolescent who is hospitalized fears separation from ___ and loss of _______

peers, loss of independence

The client is a 5-year-old child hospitalized for a surgical procedure. The client is bedwetting. The parents report this is a new behavior and their child is toilet trained. The nurse assesses the client is exhibiting the defense mechanism of a) displacement. b) reaction formation. c) compensation. d) regression.

regression. Explanation: Regression is a maladaptive behavior in which the client returns to an earlier method of behaving as seen in the child who is now bedwetting. Compensation is overcoming a perceived weakness by emphasizing a more desirable trait. Displacement is transferring an emotional reaction from one object or person to another. Reaction formation is exhibiting behaviors that are the opposite of what the client would really like to do.

which age groups are most likely to physically resist the nurse during procedures?

school aged, adolescents

which age group engages in stalling tactics before painful procedures most?

school-aged

the toddler fears _________ most when hospitalized

separation from family

the infant fears _____ most when hospitalized

separation from loved object

the toddler and preschooler will think that illness is caused by ______________

something they did wrong

preschoolers may require physical restraint during painful procedures (t/f)

true

toddlers may require physical restraint for painful procedures (t/f)

true