nurs 101 pain
The nurse understands which anesthetic medication is commonly used for short procedures on pediatric clients? a) fentanyl b) morphone c) meperidine d) hydromorphone
a) fentanyl 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.
Which intervention would the nurse recommend for post-cesarean gas pain? a) lying on right side b) walking around the room c) using a straw when drinking water d) supporting the incision when moving
b) walking around the room
A client has an intravenous (IV) solution of 5% dextrose in water (D5W) 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? Record your answer using a whole number. ___ mL/h
35 mL/h The prescribed rate is 14 mg/h. The available concentration is 100 mg/250 mL. Use dimensional analysis to determine the appropriate rate. 100/14 * 250 = 35
Which describes the focus of hospice care? a) To ease the pain from illness b) To provide curative treatment c) To assist with activities of daily living d) To adapt to the limitations due to an illness
a) To ease the pain from illness The focus of hospice care is palliative care to ease the pain caused by the illness. It is a system of family-centered care that allows clients to live at home with dignity. Hospice care does not provide curative treatment. The health care team follows an individualized plan of care for the client. Assisted living facilities offer long-term care for the older client in settings with a homelike environment. These facilities assist the client with activities of daily living. Rehabilitation facilities provide restorative care that helps the client adapt to the limitations caused by the illness.
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? a) lactase b) sucrase c) maltase d) amylase
a) lactase 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. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function
A client with a myocardial infarction is admitted to the cardiac intensive care unit. Which pain relief medication would the nurse expect to find on the plan of care for this client? a) morphine b) diazepam c) midazolam d) oxycodone
a) morphine Morphine is the medication of choice for a myocardial infarction because it relieves pain quickly and reduces anxiety. It also decreases cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the severe pain associated with a myocardial infarction. Midazolam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the severe pain associated with a myocardial infarction. Oxycodone is an orally administered analgesic; an analgesic that is administered via the intravenous, not the oral, route provides more immediate pain relief.
Which action puts a client at risk for low back injury and pain? a) smoking tobacco b) regular swimming exercise c) vitamin d oral supplementation d) use of a footstool with prolonged sitting
a) smoking tobacco 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. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
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? a) tinea pedis b) tinea cruris c) tinea corporis d) tinea unguium
a) tinea pedia Tinea pedis is a fungal infection with an itching sensation associated with pain. 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 onychomycosis is manifested with scaliness under the distal nail plate. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items with four options. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
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? a) visceral b) somatic c) referred d) intractable
a) visceral 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.
Which nursing action would be implemented after a client has a lumbar puncture? a)Maintaining the client in the supine position for several hours b)Encouraging the client to ambulate every hour for at least 6 hours c)Keeping the client in the Trendelenburg position for at least 2 hours d)Placing the client in the high-Fowler position immediately after the procedure
a)Maintaining the client in the supine position for several hours Staying flat may help prevent spinal fluid leakage and postprocedure headache; this is recommended, even though some people develop a headache despite this precaution. Encouraging the client to ambulate every hour for at least 6 hours may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12 hours. The Trendelenburg position may increase intracranial pressure and is not appropriate. Placing the client in the high-Fowler position immediately after the procedure may predispose to spinal fluid leakage; the client should be kept flat.
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. a) tachycarida b) hypotension c) rigid abdomen d) nausea and vomiting e) back and shoulder pain
all of the above 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.
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. Which action would the nurse take after obtaining the fetal heart rate and maternal vital signs? a) Teach the client how to push with each contraction. b) Provide the client with comfort measures for relaxation. c) Prepare to have the client's blood typed and cross-matched. d) Encourage the client to perform patterned, paced breathing.
b) Provide the client with comfort measures for relaxation. The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation. The client is in early first-stage labor; pushing commences during the second stage. There is no evidence that the client's bleeding is excessive or unexpected and that a transfusion will be needed. Patterned, paced breathing should be used in the transition phase, not the early phase of the first stage of labor. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.
Which herbal therapies can be recommended to a client with breast pain? Select all that apply. One, some, or all responses may be correct. a) dong quai b) chamomile c) bugleweed d) chaste tree fruit e) black cohosh root
b) chamomile c) bugleweed d) chaste tree fruit 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.
When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include? a) surgery b) comfort c) education d) motivation
b) comfort 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 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? a) musositis b) dysgeusia c) dysphagia d) xerostomia
b) dysgeusia 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 client assessment finding would the nurse document as subjective data? a) bp 120/82 beats/min b) pain rating of 5 c) potassium 4.0 mEq d) pulse oximetry reading of 96%
b) pain rating of 5 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. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word "stroke" in relation to rehabilitation, you are safe in identifying this choice as the correct response.
Which factor may cause neck pain in a client? a) headache b) poor posture c) low body weight d) sedentary lifestyle
b) poor posture 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 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? a) Educator b) Manager c) Advocate d) Administrator
c) Advocate 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.
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? a) By withholding the medication to help prevent addiction b) By stating that the limb has been removed and that the pain is psychological c) By acknowledging that the pain is real and administering medication to relieve it d) By explaining that the phantom limb sensation will subside within a few more days
c) By acknowledging that the pain is real and administering medication to relieve it 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.
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? a) Determine if this is an allergic reaction. b) Elevate the client's head and keep the extremities warm. c) Place the client in the supine position and take the vital signs. d) Tell the client that this is not a typical sensation after receiving morphine sulfate.
c) 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. 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. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.
Which is a sign of a ruptured ectopic pregnancy in an adolescent? a) abdominal pain and bradycardia b) abdominal pain and bleeding c) abdominal pain and hypotension d) abdominal pain and hypertension
c) abdominal pain and hypotension 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.
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? a) analgesic b) antipyretic c) anti-inflammatory d) antiplatelet
c) anti-inflammatory 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. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on which you have learned and your best assessment of the question.
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. a)Switch positions every 4 hours. b)Use a heating pad for the first 24 hours. c)Apply for 30-minute time intervals. d)Place the ice pack directly to injury site. e)Take ibuprofen every 4 hours PRN.
c)Apply for 30-minute time intervals. 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.
A client with a diagnosis of myocardial infarction asks the nurse, "What is causing the pain I am having?" Which explanation would the nurse give? a) compression of heart muscle b) release of myocardial isoenzymes c) rapid vasodilation of the coronary arteries d) inadequate oxygenation of the myocardium
d) 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. Myocardial infarction does not involve compression of the heart. The release of myocardial isoenzymes is an indication of myocardial damage; this does not cause myocardial pain. Vasodilation will increase perfusion and contribute to pain relief, not cause myocardial pain.
Which pain scale would the nurse use when assessing a 4-year-old child? a) CRIES b) FLACC c) numerical d) wong-baker
d) wong-baker The Wong-Baker method is a type of faces pain scale best used in children as young as 3 or 4 years. It contains several faces that a child can use to identify his or her pain level. 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.
