Pain Mastery Quiz RNSG 1324

A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which nursing action is most important at this time? 1. Strain the urine carefully. 2. Apply warm compresses to the flank area. 3. Report hematuria to the health care provider (HCP). 4. Administer meperidine every 3 hours

1. Strain the urine carefully. Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to detect passage of the stone. Hematuria is to be expected from the irritation of the stone. Analgesics should be administered when the client needs them, not routinely. Moist heat to the flank area is helpful when renal colic occurs, but it is less necessary as pain is lessened.

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? 1. Change the child's position in bed. 2. Obtain vital signs with a pain score. 3. Administer 1 mg morphine as prescribed. 4. Perform a head-to-toe assessment.

2. Obtain vital signs with a pain score. The child is in pain and needs intervention, but before the nurse can determine how to proceed, it is essential to know the client's pain score to determine the appropriate morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child's position and administering pain medication may be helpful to relieve the child's pain, but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head to toe assessment, but it is not the priority in managing the child's pain.

A client presents to the emergency department complaining of a dull, constant ache along the right costovertebral angle along with nausea and vomiting. The most likely cause of the client's symptoms is: 1. an overdistended bladder. 2. interstitial cystitis. 3. renal calculi. 4. acute prostatitis.

3. renal calculi. Renal calculi usually presents as a dull, constant ache at the costovertebral angle. The client may also present with nausea and vomiting, diaphoresis, and pallor. The client with an overdistended bladder and interstitial cystitis presents with dull, continuous pain at the suprapubic area that's intense with voiding. The client also complains of urinary urgency and straining to void. The client with acute prostatitis presents with a feeling of fullness in the perineum and vague back pain, along with frequency, urgency, and dysuria.

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? 1. Notify the parents of the medication error. 2. Bring emergency resuscitation equipment to the child's room. 3. Ensure that the error is corrected on the medication record. 4. Obtain an order for naloxone and administer it promptly.

4. Obtain an order for naloxone and administer it promptly. Naloxone is an opioid antagonist that is given as an antidote for morphine. An antidote is an agent that neutralizes a poison or counteracts its effects. This should be the immediate priority for the nurse.

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client? 1. Discuss nutritional strategies to decrease the possibility of heartburn. 2. Support the client's use of acetaminophen to relieve pain. 3. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. 4. Refer the client to her health care provider for evaluation and treatment of the pain.

4. Refer the client to her health care provider for evaluation and treatment of the pain. The nurse seeing this client should refer her to a health care provider for further evaluation of the pain. This referral would allow a more definitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symptoms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the influence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major emphasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heartburn are appropriate during pregnancy, but not in this situation. Acetaminophen is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems.

A client is talking with the nurse about unsightly varicose veins and their discomfort. What information should the nurse provide to the client? 1. Contact a surgeon to perform a femoral-popliteal bypass graft. 2. Sclerotherapy can be used for cosmetic improvement. 3. Keep the legs elevated when sitting or lying down. 4. Avoid walking to reduce the discomfort.

3. Keep the legs elevated when sitting or lying down. The nurse instructs the client to elevate the legs to improve venous return and alleviate discomfort. Walking is encouraged to increase venous return. Sclerotherapy or laser treatment is done for cosmetic reasons, but it does not improve circulation. Surgery may be performed for severe venous insufficiency or recurrent thrombophlebitis in the varicosities. Femoral-popliteal bypass graft is a surgical intervention for arterial disease.

A 10-year-old boy falls, injures his left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first? 1. Apply a warm compress to the injured shoulder. 2. Give him a nonopioid analgesic for pain. 3. Ask him to demonstrate full range of motion of his left arm. 4. Keep him in a comfortable position and apply ice to the injured shoulder.

4. Keep him in a comfortable position and apply ice to the injured shoulder. Ice should be applied first to reduce swelling and pain. The client should also be helped into a comfortable position. The nurse shouldn't apply warm compresses because it may increase swelling and cause bleeding into the injured tissue. Demonstrating full range of motion of the left arm may cause further damage to the injured area. In the emergency department, the nurse must have a physician's order to administer an analgesic.

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. 1. "I'll try to chew my food on the unaffected side." 2. "I'll eat food that is very hot." 3. "If brushing my teeth is too painful, I'll try to rinse my mouth instead." 4. "Drinking fluids at room temperature should reduce pain." 5. "I can wash my face with cold water."

1. "I'll try to chew my food on the unaffected side." 3. "If brushing my teeth is too painful, I'll try to rinse my mouth instead." 4. "Drinking fluids at room temperature should reduce pain." Mechanical or thermal stimuli trigger the facial pain of trigeminal neuralgia. Chewing food on the unaffected side and rinsing the mouth rather than brushing teeth reduce mechanical stimulation. Drinking fluids at room temperature reduces thermal stimulation. Eating hot food and washing the face with cold water are likely to trigger pain.

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? 1. Acute pain 2. Risk for infection 3. Impaired urinary elimination 4. Imbalanced nutrition: Less than body requirements

1. Acute pain Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time.

The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse should tell them? 1. Dehydration is expected during the dying process. 2. Hydration is used only in extreme situations of dehydration. 3. The health care provider (HCP) will make the decision regarding hydration therapy. 4. Dehydration may prolong the dying process.

1. Dehydration is expected during the dying process. Dehydration is an expected event within the dying process. Hydration may be used in any situation of dehydration as long as it is within the client and family's wishes. Rehydrating the client may actually prolong the dying process. Decisions about treatment are made with the family.

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? 1. Document the client's choice and re-assess pain in 1 hour. 2. Emphasize the rationale for taking the medication now as ordered. 3. Try to persuade the client to take the medication as ordered by the doctor. 4. Ask the client's spouse wife to hold the client's hands while the nurse puts the pill under the tongue.

1. Document the client's choice and re-assess pain in 1 hour. A client has the right to choose whether to take medication. The nurse should assess the client's pain regularly and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication.

A client is two days postoperative of a hip replacement. The prescriber removed the gauze dressing and gave the patient and nurse instructions to keep the site open to air. In the afternoon, the nurse observed the client rubbing an oil on the surgical site. What is likely the client's rationale regarding the application of the complementary oil? 1. Tea tree oil has antibacterial properties. 2. Baby oil can assist with smooth skin. 3. Fish oil has antiviral properties. 4. Antiperspirant will aid with vasoconstriction.

1. Tea tree oil has antibacterial properties. Tea tree oil is an alternative therapy that has antifungal and antibacterial uses. Clients use it to treat burns, insect bites, irritated skin, and acne. The nurse should review the prescriber's instructions with the client and also call the prescriber to alert him or her to the use of the tea tree oil application on the surgical site. Fish oil is an oral therapy used for treatment of coronary disease. Baby oil can make the skin smooth but does not make the skin of a surgical incision smooth. Antiperspirants decrease the secretion of moisture and not vasoconstriction.

A 16-year-old boy who is academically gifted is about to graduate from high school early since he has completed all courses needed to earn a diploma. Within the last 3 months he has begun to experience panic attacks that have forced him to leave classes early and occasionally miss a day of school. He is concerned that these attacks may hinder his ability to pursue a college degree. What would be the best response by the school nurse who has been helping him deal with his panic attacks? 1. "It is natural to be worried about going into a new environment. I am sure with your abilities you will do well once you get settled." 2. "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment." 3. "It might be best for you to postpone going to college. You need to get these panic attacks controlled first." 4. "You are putting too much pressure on yourself. You just need to relax more, and things will be alright."

2. "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment." The client's concerns are real and serious enough to warrant assessment by a health care provider (HCP) rather than being dismissed as trivial. Though he is very intelligent, his intelligence cannot overcome his anxiety, and in fact, his anxiety is likely to interfere with his ability to perform in college if no assessment and treatment is received. Just postponing college is likely to increase the client's anxiety rather than lower it since it does not address the panic he is experiencing.

A client is admitted for treatment of a flare-up of irritable bowel disease, exacerbated by severe anxiety. The client resists any discussion of taking medications. The nurse reviews the nursing assessment and returns to the client to discuss what treatments work for the client outside of the hospital. The client reveals using a biofeedback device regularly for relief. The best response of the nurse is: 1. "Biofeedback does not work for severe anxiety." 2. "Tell me more about this. Do you have it with you?" 3. "Your device is just another expensive electronic toy." 4. "It does not work - you are back in the hospital."

2. "Tell me more about this. Do you have it with you?" The nurse should acknowledge that biofeedback is an evidence-based treatment for anxiety and commend the client for committing to this modality. It is considerate to ask the availability of this device and respectful to ask for more information as needed. It is demeaning to insist that biofeedback does not work, is not a serious treatment, or is not indicated for the client's symptom.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? 1. Abduction and flexion of the arms with flattened shoulders 2. Adduction and flexion of the extremities with gently rounded shoulders 3. Hyperabduction and extension of the arms with external rotation of the hips 4. Neck extension and back arching with flattened shoulders

2. Adduction and flexion of the extremities with gently rounded shoulders The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

The nurse is caring for a very anxious child whose pain has not been manageable. The parents stay in the child's room, crying and yelling at each other. Grandparents and other family members are also constantly in attendance. To effectively help the child with pain management, which action should be a priority for the nurse? 1. Administer medication to help the child sleep during the night. 2. Develop a visitation schedule with the family that allows the child to rest. 3. Request that hospital security remove all visitors from the child's room. 4. Tell the parents that their behavior is increasing the child's pain.

2. Develop a visitation schedule with the family that allows the child to rest. Establishing limits with the family can facilitate needed rest for the child and help decrease anxiety and pain. It may also decrease the anxiety of the family and provide them with clear directions. Although the behavior of the parents needs to be addressed, it must be done in a more tactful way.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? 1. Rub her nipples gently with lanolin cream. 2. Express a small amount of breast milk. 3. Apply an ice cube to the nipples. 4. Offer the neonate a small amount of formula.

2. Express a small amount of breast milk. Expressing a little milk before nursing, massaging the breasts gently, or taking a warm shower before feeding also may help to improve milk flow. Although various measures such as ice, heat, and massage may be tried to relieve breast engorgement, prevention of breast engorgement by frequent feedings is the method of choice. Applying ice to the nipples does not relieve breast engorgement. However, it may temporarily relieve the discomfort associated with breast engorgement. Using lanolin on the nipples does not relieve breast engorgement and is unnecessary. Use of lanolin may cause sensitivity and irritation. Having frequent breastfeeding sessions, rather than offering the neonate a small amount of formula, is the method of choice for preventing and relieving breast engorgement. In addition, offering the neonate small amounts of formula may result in nipple confusion.

Two days after a right total knee replacement, a client rates his right-knee pain as 9 on a 10-point pain scale. A physician orders hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain. When a nurse notifies the physician of the client's pain, the physician states that one hydrocodone/APAP tablet should be sufficient and refuses to order anything stronger for pain. Which measure should the nurse select to act as an advocate for the client? 1. Give the client 2 hydrocodone/APAP tablets every 4 hours. 2. Follow the chain of command to obtain adequate pain relief for the client. 3. Document that the physician was notified of the client's pain and continue to administer hydrocodone/APAP as ordered. 4. Give the client 1 hydrocodone/APAP tablet every 3 hours.

2. Follow the chain of command to obtain adequate pain relief for the client. Clients must receive adequate pain relief. Allowing a client to experience a pain score of 9 out of 10 is unacceptable nursing practice. Acting as a client advocate requires a nurse to be assertive, even if this means confronting a physician. If the physician doesn't give an order for adequate pain relief, the nurse should follow the chain of command to report the physician's inaction and obtain adequate pain relief for the client. A nurse may not adjust medication frequency or dosage without a physician's order.

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? 1. "Once you are tapered off the oxyocodone, you will find that non-addictive pain medicines will be enough to control your pain." 2. Your pain will be controlled by tapering doses of oxyocodone with other pain management strategies and medicines. 3. The oxyocodone will be stopped tomorrow, but you will have lorazepam to help you with the withdrawal symptoms. 4. "You are going to be switched from the oxyocodone to methadone for long-term pain management.

2. Your pain will be controlled by tapering doses of oxyocodone with other pain management strategies and medicines. Tapering doses of oxycodone, pain management strategies, and other pain control medicines are found to be the most helpful with opiate addictions resulting from chronic pain. Nonaddictive (over-the-counter) medicines alone are generally insufficient for chronic pain management. Methadone is an addictive opioid that involves substituting one addiction with another, so now clients are being detoxed off methadone as well. Lorazepam may help with anxiety during withdrawal from opiates, but it does not control the other symptoms of opiate withdrawal.

During the first few weeks after a cholecystectomy, the client should follow a diet that includes: 1. at least four servings daily of meat, cheese, and peanut butter to increase protein intake that aids incisional healing. 2. a limited intake of fat distributed throughout the day so there is not an excessive amount in the intestine at any one time. 3. a decreased intake of fruits, vegetables, whole grains, and nuts, to minimize pressure within the small intestine. 4. ingestion of pancreatic enzymes with meals to replace the normal enzyme secretion that has been surgically altered.

2. a limited intake of fat distributed throughout the day so there is not an excessive amount in the intestine at any one time. Bile flows almost continuously into the intestine for the first few weeks after gallbladder removal. Limiting the amount of fat in the intestine at any one time ensures that adequate bile will be available to facilitate digestion. Eating large amounts of meat, cheese, and peanut butter would be undesirable because these foods are often high in fat. There is no need to eliminate high-fiber foods, and doing so would tend to increase pressure within the large intestine, not decrease pressure in the small intestine. Removing the gallbladder does not decrease pancreatic secretions.

The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort? 1. absence of pain or swelling when the client dorsiflexes the left foot 2. red, warm, palpable linear cord along the vein that is painful on palpation 3. brown discoloration of the skin with edema in the lower left leg 4. dark, protruding veins of both legs that are uncomfortable when standing

2. red, warm, palpable linear cord along the vein that is painful on palpation Superficial thrombophlebitis is associated with pain, warmth, and erythema. The nurse can request a prescription for warm packs to relieve the pain. Venous insufficiency causes edema and a brown discoloration of the lower leg. Varicose veins are dark, protruding veins, and symptoms of discomfort increase with standing. Pain on dorsiflexion of the foot indicates deep vein thrombosis; the client does not indicate having this pain.

The nurse is conducting a health history of a child. The mother states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which of the following? 1. Ringworm 2. Sinusitis 3. Allergies 4. Fifth disease

3. Allergies In children, many symptoms of allergies are often vague and general. They revolve around frequent cold-like symptoms, allergic rhinitis, and pruritus. These symptoms are distracting to children and can affect their ability to concentrate in school. The "itching all the time" descriptor lends itself to allergies and histamine release rather than sinusitis, ringworm, and fifth disease.

One day after an appendectomy, a 9-year-old child rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. What should the nurse document on the child's chart? 1. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain. 2. The child doesn't understand the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling. 3. The child rates pain at 4 out of 5. Administered pain medication as ordered. 4. The child is in no apparent distress, and no pain medication is needed at this time.

3. The child rates pain at 4 out of 5. Administered pain medication as ordered. Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses passive coping behaviors (such as distraction and cooperative) may rate pain as more intense than children who use active coping behaviors (such as crying and kicking). Nurses frequently make judgments about pain based on behavior, which can result in children being inadequately medicated for pain.

A 10-year-old with scoliosis has to wear a brace. The nurse should develop a teaching plan with the client to include which instruction? 1. Use lotions to relieve skin irritations. 2. Wear the brace during waking hours. 3. Wear a form-fitting t-shirt under the brace. 4. Bathe the skin under the brace once per week.

3. Wear a form-fitting t-shirt under the brace. A form-fitting t-shirt can be worn under the brace to prevent skin irritation and collect perspiration. Braces are worn 23 hours each day. Lotions may cause irritation and should not be used. The skin under the brace should be bathed daily to help prevent irritation from the brace. The brace can be removed for bathing so all the skin can be bathed.

When developing a teaching plan for the mother of an infant about introducing solid foods into the diet, which measure should the nurse expect to include in the plan to help prevent obesity? 1. introducing the infant to the taste of vegetables by mixing them with formula or breast milk 2. using a large-bowled spoon for feeding solid foods during the first several months 3. decreasing the amount of formula or breast milk intake as solid food intake increases 4. mixing cereal and fruit in a bottle when offering solid food for the first few times

3. decreasing the amount of formula or breast milk intake as solid food intake increases Decreasing the amount of formula given as the infant begins to take solids helps prevent excess caloric intake. Because the infant is receiving calories from the solid foods, the formula no longer needs to provide the infant's total caloric requirements. Mixing vegetables with formula or breast milk does not allow the child to become accustomed to new textures or tastes. Solid foods should be given with a spoon, not in a bottle. Using a bottle with food allows the infant to ingest more food than is needed. Also, the infant needs to learn to eat from a spoon. A small-bowled spoon is recommended for infants because infants have a tendency to push food out with the tongue. The small-bowled spoon helps in placing the food at the back of the infant's tongue when feeding.

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: 1. take a hot bath. 2. increase the dose of muscle relaxants. 3. rest in an air-conditioned room. 4. avoid naps during the day.

3. rest in an air-conditioned room. Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.

After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first? 1. Self-catheterization 2. Artificial sphincter use 3. Fluid restriction 4. Kegel exercises

4. Kegel exercises Kegel exercises are noninvasive and are recommended as the initial intervention for incontinence. Fluid restriction is useful for the client with increased detrusor contraction related to acidic urine. Artificial sphincter use isn't a primary intervention for post-prostatectomy incontinence. Self-catheterization may be used as a temporary measure but isn't a primary intervention.

Which nursing measure would most likely relieve postoperative gas pains after abdominal hysterectomy? 1. applying a snugly fitting abdominal binder 2. offering the client a hot beverage 3. providing extra warmth 4. helping the client walk

4. helping the client walk The discomfort associated with gas pains is likely to be relieved when the client ambulates. The gas will be more easily expelled with exercise. The anesthesia, analgesics, and immobility have altered normal peristalsis. Peristalsis will be stimulated by exercise. Offering a hot beverage, providing extra warmth, and applying an abdominal binder are not recommended and could aggravate the discomfort of postoperative gas pains.

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The nurse should first: 1. secure the mitt with ties around the wrist tied to the bed frame. 2. place a folded pillow under the wrist. 3. place the mitt on top of the hand. 4. verify the prescription to use the restraint.

4. verify the prescription to use the restraint. Before using any restraints, the nurse must verify that a health care provider (HCP) has written a prescription for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmar surface of the hand.

During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which statement indicates the client's understanding of the nurse's instructions? 1. "I'll increase my intake of unrefined grains." 2. "I'll limit fluid intake to four 8-oz (240 mL) glasses." 3. "I'll take iron supplements regularly." 4. "I'll decrease my intake of green, leafy vegetables."

1. "I'll increase my intake of unrefined grains." To increase peristalsis and relieve constipation, the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined grains; and fruits) and fluids. The use of iron supplements can cause — rather than relieve — constipation.

The nurse is aware that a client's physiologic response to a health crisis is important to the health outcome. Which nursing intervention should be addressed first? 1. Helping the client effectively cope with the crisis 2. Teaching the family how to care for the client 3. Teaching the client basic information about the illness 4. Maintaining intravenous access, medications, and diet

1. Helping the client effectively cope with the crisis Although all of the answers are important in the care of the client, if the individual isn't able to cope with the emotional, spiritual, and psychological aspects of his crisis, the other components of care may be ineffective as well.

A home health nurse is providing care to a palliative care client with liver cancer. Which classifications of medications are anticipated on the medication administration record? Select all that apply. 1. Narcotics 2. Depressants 3. Antiemetic 4. Stool softeners 5. Chemotherapeutics

1. Narcotics 3. Antiemetic 4. Stool softeners The client with liver cancer who is also a palliative care client has decided to focus on quality of life and symptom management instead of curative treatment. Narcotics for pain relief, stool softeners to maintain a bowel regiment in light of narcotic use and antiemetics to control nausea and vomiting all assist the client to meet their goals. Chemotherapeutic agents are aggressive therapy to kill liver cancer cells. Antidepressants are used for symptoms of depression.

The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor. The client is writhing in pain and saying, "Help me, help me!" Her last vaginal exam 1 hour ago showed that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client? 1. Perform a vaginal examination to determine if the client is fully dilated. 2. Help the client through contractions until a narcotic can be given. 3. Ask the client for suggestions to make her more comfortable. 4. Palpate the bladder to see if it has become distended.

1. Perform a vaginal examination to determine if the client is fully dilated. Transition is the most difficult period of the labor process, and often when clients are tired, pain becomes more intensified. Clients during this stage verbalize anger and are outspoken and difficult to comfort. The most logical next step would be to determine if the client has completed transition and is ready to begin pushing. Performing a vaginal exam would provide this answer. The use of narcotic medications is discouraged at this stage as they can lead to respiratory depression in the neonate. Palpating the bladder is an important intervention but not the highest priority as it was done less than an hour ago. Since the nurse has correctly completed the most logical steps, asking for the client's input would certainly be in order but not the highest priority intervention.

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? 1. Suggesting that she walk for 1 hour twice per day 2. Teaching her to dorsiflex her foot during the cramp 3. Advising her to take over-the-counter calcium supplements twice per day 4. Instructing her to increase milk and cheese intake to 8 to 10 servings per day

2. Teaching her to dorsiflex her foot during the cramp Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours daily during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a well-balanced diet, calcium supplements and additional servings of high-calcium foods may be unnecessary.

Atropine sulfate is included in the preoperative prescriptions for a client undergoing a modified radical mastectomy. The expected outcome is to: 1. promote general muscular relaxation. 2. inhibit oral and respiratory secretions. 3. decrease nausea. 4. decrease pulse and respiratory rates.

2. inhibit oral and respiratory secretions. Atropine sulfate, a cholinergic blocking agent, is given preoperatively to reduce secretions in the mouth and respiratory tract, which assists in maintaining the integrity of the respiratory system during general anesthesia. Atropine is not used to promote muscle relaxation, decrease nausea and vomiting, or decrease pulse and respiratory rates. It causes the pulse to increase.

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? 1. "Take your temperature every 4 hours." 2. "Apply an antibacterial dressing to the incision daily." 3. "Increase your fluid intake to 2 to 3 L per day." 4. "Be aware that your urine will be cherry-red for 5 to 7 days."

3. "Increase your fluid intake to 2 to 3 L per day." The nurse should instruct the client to increase his fluid intake. Increasing fluid intake flushes the renal calculi fragments through — and prevents obstruction of — the urinary system. Measuring temperature every 4 hours isn't needed. Lithotripsy doesn't require an incision. Hematuria may occur for a few hours after lithotripsy but should then disappear.

After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should the nurse do first? 1. Notify the physician immediately. 2. Increase the I.V. flow rate. 3. Administer morphine sulfate, 2 mg I.V., as ordered. 4. Assess the irrigation catheter for patency and drainage.

4. Assess the irrigation catheter for patency and drainage. Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic, such as morphine sulfate, as ordered. Increasing the I.V. flow rate may worsen the pain. Notifying the physician isn't necessary unless the pain is severe or unrelieved by the ordered medication.

A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include: 1. administration of monthly intra-articular injections of corticosteroids. 2. vigorous physical therapy for the joints. 3. administration of opioids for pain control. 4. administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.

4. administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program. NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.