Chapter 35 Fundamentals PrepU PDF

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Nursing Process IV: Medical-Surgical Nursing NUR 411...

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A postoperative client who has been receiving for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? Naloxone treat narcotic overdose in emergency situation(Opiod antagonist that reverses respiratory-depressant effect of an opiod) A male college student age 20 years has been experiencing increasingly sharp pain in the RLQ of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing? Visceral Pain (occurs when organs stretch abnormally and become distended, ischemic, or inflamed) Cutaneous Pain superficial pain usually involving the skin or subcutaneous tissue Somatic Pain Commonly associated with tendons, ligaments, and bones. Referred Pain extended pain from its origin pain that is felt in a location other than where the pain originates Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients? Pain assessment may require multiple methods in order to ensure accurate pain data. A client has been admitted to a post surgical unit with a patient controlled analgesia inability to feel pain (PCA) system. Which statement is true of this medication delivery system? The dose that is delivered when the client activates the machine is preset. A nurse assesses a client who is being given an opioid analgesic and finds the client unresponsive to shaking or other stimuli. What drug might be ordered to reverse this state? Naloxone (used if stimulation is ineffective in arousing a client using opioids) A physician orders a placebo for a client. What is a placebo? An inactive substance given in place of a drug. A client with an amputated arm tells a nurse that sometimes he experiences throbbing headache pain or a burning sensation in the amputated arm. What kind of a pain is the client experiencing? Neuropathic Pain (Functional Pain, often experienced days, weeks, or even months after the source of pain has been treated and resolved) A nurse is caring for a client who was administered opioid pain reliver narcotics. The client reports constipation. What is another potential side effect of opioid narcotics? Sedation takhdir (Opioids can cause Sedation, Nausea, and Constipation) A nurse is caring for a client with acute back pain. When should the nurse assess the client's pain? Whenever the vital signs are measured and documented. A middle-age client tells the nurse that the client's neck pain reduced considerably after the client underwent a treatment in which thin needles were inserted into the skin. What kind of pain relief treatment did the client undergo? Acupuncture 3ilaj ibar Which guideline regarding pain should be included in the nurse's education pain for a group of parents with infants and toddlers? Pain can be a source of fear and threat to the toddler's security. After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what? "I could use the TENS unit if I feel pain somewhere else on my body" The nurse has completed a preoperative education session with a client who will receive morphine via a patient-controlled analgesia pump (PCA) after surgery. Which statements by the client indicates the need for further education? "I will remind my family member to push the PCA pump button for me if I doze of during the day." What is the most reliable method for assessing pain? Asking the client A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation; however, he can be aroused. What would be the sedation score for this client? Sedation score is a 3 Sedation Score 1 Patient is awake and alert Sedation Score 2 Patient is slightly drowsy but easily aroused.

Sedation Score 4 Patient is Somnolent, with minimal or no response to physical stimulation. While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable crying nothing is calming him. What scale should the nurse use when assessing pain in this infant? FLACC SCALE The nurse is caring for a client utilizing a PCA pump that is programed to allow a bolus dose every 10 minutes. The client is sleeping at the bedside. Which of the following instructions should the nurse give the client's visitors? "Only the client should push the pump button." The nurse is administering oxycodone to a client. To which category of analgesics does this belong? Opioid Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as: biofeedback. A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? The client is actively involved in pain management. A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as "Acute pain tends to increase during the day and is called a routine pain response" A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure? Cutaneous stimulation A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. drug regimen as an effective method of pain control would be the client: in the postoperative stage with occasional pain. The nurse prepares to promote the client's comfort using guided imagery. Which actions should the nurse take? Select all that apply. Ask the client to imagine oneself in a favorite place. Ask the client to concentrate on the details of a pleasant image. The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain? "How long have you experienced this pain?" The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? Examine the effectiveness of the current pain regimen A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action? Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. A nurse is assessing an adult client with back pain. The client is unable to speak English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain? 0 to 10 numeric rating scale The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data? How does the pain develop and progress? A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client? Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take? Reposition the client and gently massage the client's back. An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug? The client exhibits restless, uncharacteristic behavior after receiving the drug. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx d When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: a. document the client's lack of medication. b. assume the client does not need medication.

c. ask the client's family if he ever uses pain medicines. d. actively solicit information about the client's pain level. b A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? a. Decreased heart rate b. Guarding of the chest area c. Increased respiratory rate d. High blood pressure c A client who recently underwent amputation of a leg reports pain in the amputated part. What would be the nurse's best response? a. "Your pain cannot exist because the leg has been amputated." b. "Your pain is a phenomenon known as 'ghost pain.'" c. "Your pain is a real experience." d. "You are experiencing central pain syndrome." b A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action? a. Turn on the unit shortly before applying the electrodes to the client's skin. b. Start with the lowest intensity and gradually increase it to the appropriate level. c. Disinfect with chlorhexidine the areas where the electrodes will be applied d. Administer analgesia 30 minutes before beginning a TENS session. d Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain? a. This approach can only be used with oral analgesics. b. A PCA pump must be used and monitored in a health care facility. c. The PCA pump is not effective for chronic pain. d. The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. a A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? a. The dose that is delivered when the client activates the machine is preset. b. Thorough client education is necessary to prevent overdoses. c. Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. d. An antidote is automatically delivered if the client exceeds the recommended dose. c A nurse has attended a pain control workshop and learned about the psychological and physiological basis of placebos. What principle should guide the use of placebos in the treatment of pain? a. Placebos can effectively treat pain while avoiding unpleasant side effects of opioids. b. Placebos may be used in the treatment of pain in clients who have allergies or addictions. c. Placebos involve the use of deception and are considered unethical in most circumstances. d. Placebos should be used if the client provides written consent for their use. c The nurse is performing an assessment of a client that is experiencing pain after a surgical procedure. What symptoms does the nurse assess based on the pain response? a. Pulse rate is decreased. b. Blood pressure is normal. c. Pupils are dilated. d. Respirations are shallow. a A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? a. Naloxone b. Diphenhydramine c. Atropine d. Epinephrine c An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug? a. The client is unable to sleep without medication the following night. b. The client experiences respiratory depression after the drug takes effect. c. The client exhibits restless, uncharacteristic behavior after receiving the drug.

d. In the morning, the client is unable to identify his location or the day of the week. d Two hours after receiving a pain medication, the client reports still suffering from pain. Which question is most appropriate to ask the client? a. "Do you need your pain medication now?" b. "Have you ever had pain like this before?" c. "Tell me where your pain is located." d. "Tell me more about your pain." d A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client? a. "If you feel severe pain, either push the button yourself or ask one of your family members to push the button." b. "I'll have the unit's care aide come check on you every few minutes after I set up the system." c. "We'll be monitoring your use of the system closely, to ensure you don't develop an addiction to your pain medication." d. "The pump is programmed so that it's not possible for you to overdose on your pain medication." a Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? a. Respiratory b. Cardiovascular c. Peripheral Vascular d. Neuromuscular c Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take? a. Administer pain medications in smaller doses but more frequently. b. Decrease external stimuli in the room during painful episodes. c. Reposition the client and gently massage the client's back. d. Advise the client to try to sleep following administration of pain medication. d Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy? a. Physical therapy referral b. A walking aid c. Acupuncture d. A chronic opioid therapy plan d The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain? a. "When did your pain begin?" b. "Have you had this pain before?" c. "Could you please rate your pain on a 1-10 scale?" d. "How long have you experienced this pain?" b The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement? a. "This will allow me to control my own pain medication." b. "I should only take medication when my pain is intense." c. "I give myself the pain medication by pushing the button." d. "The pump is programmed to limit the chance of overmedicating." b A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first? a. Notify the physician. b. Stop the PCA pump. c. Administer naloxone. d. Increase the primary IV rate. a When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response? a. Behavioral b. Physiologic c. Affective d. Psychosomatic

d A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. drug regimen as an effective method of pain control would be the client: a. experiencing acute pain. b. in the early postoperative period. c. experiencing chronic pain. d. in the postoperative stage with occasional pain. b The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? a. B/P 178/92 and pulse 118 b. confused to time and place c. right shoulder immobilizer in place d. rates pain an 8 on a 0 to 10 scale a A nurse is caring for a client whose injured cells are releasing chemicals such as prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing? a. transduction b. transmission c. modulation d. perception b Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy? a. morphine b. gabapentin c. hydromorphone d. lorazepam b Endogenous opioids such as endorphins: a. excite neural pathways. b. contribute to analgesia. c. cause muscle spasms. d. release neurotensin. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what? "I could use the TENS unit if I feel pain somewhere else on my body." A nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique? The nurse gives the client a massage before bed.

A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? Select all that apply. Cutaneous Acute What type of nonpharmacologic pain relief measure uses electrical stimulation to inhibit transmission of painful impulses? TENS A nurse observes that a client who underwent knee surgery 2 weeks ago needs progressively larger doses of analgesics to get relief from pain. The nurse interprets this as: Tolerance A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique? A nurse applies intermittent heat and cold to a client's leg. The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? (Select all that apply.) Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain. When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: actively solicit information about the client's pain level. A nurse is performing pain assessments on clients in a physician's office. Which clients would the nurse document as having acute pain? Select all that apply.

A client who is having a myocardial infarction A client who presents with the signs and symptoms of appendicitis A client who fell and broke an ankle A client has been reluctant to ask for breakthrough doses of the opioid prescribed, despite showing signs of pain. The client states to the nurse, "I don't want to become addicted to the medication." How should the nurse respond to the client's statement? "There's only an extremely small chance that you will become addicted to this drug." A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure? Cutaneous stimulation How should the nurse position the head of the bed for a client receiving epidural opioids? Elevated 30 degrees The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.) Heat Massage Cold The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate? They bind to opioid receptor sites throughout the CNS. The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? ...