Term
A nurse is reviewing the assessment data from the admission assessment of a patient admitted from the emergency department. What specific element of a pain assessment is missing from the documentation?
Tab 1
Tab 2
Tab 3
General Survey
Subjective information
Abdominal assessment
Trembling
Doubled over
Right upper quadrant “belly pain.” Pain radiates to back.
More comfortable bent forward than in bed.
Similar pain in the past but only for 2 hr.
“This is the worst pain ever!”
Pain started after eating fish and chips at a fast food restaurant 4 hr ago.
Abdomen bloated and tender on examination
Skin warm and moist
Pattern
Quality
Intensity
Location |
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Definition
| The quality or characteristics of the pain is missing (e.g., cramping, stabbing, throbbing). The pattern includes the onset and duration (after eating fish and chips 4 hours ago). The intensity is “the worst pain ever!” The location is the right upper quadrant of the abdomen with radiation to the back. |
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Term
Which manifestation should the nurse attribute to adverse effects of morphine sulfate administered via PCA?
Diarrhea
Urinary frequency
Nausea and vomiting
Increased blood pressure |
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Definition
Nausea and vomiting
Rationale:
Morphine sulfate promotes nausea and vomiting by directly stimulating the chemoreceptor trigger zone in the medulla. Other common side effects include constipation, sedation, respiratory depression, decreased blood pressure, and pruritus |
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Term
The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient? (Select all that apply.)
Ataxia
Itching
Nausea
Urinary retention
Gastrointestinal bleeding |
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Definition
Itching
Nausea
Urinary retention
Rationale:
Common side effects of intraspinal opioids include nausea, itching, and urinary retention. Ataxia is a common side effect of intraspinal clonidine. |
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Term
A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate?
“PCA will never be effective unless a loading dose is given first.”
“The IV push dose will enhance the effects of the PCA for the next 8 hours.”
“The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA.”
“PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim.” |
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Definition
“The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA.”
Rationale:
An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off. |
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Term
A patient with osteoarthritis has been taking ibuprofen 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge?
Another NSAID may be indicated because of individual variations in response to drug therapy.
It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective.
If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy.
The patient may not be taking the drug correctly, so the nurse must assess the patient’s knowledge base and provide teaching. |
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Definition
Another NSAID may be indicated because of individual variations in response to drug therapy.
Rationale:
Patients vary in their response to medications, so when one NSAID does not provide relief, another should be tried. There is no evidence to ascertain any noncompliance to drug therapy. It does not take several months for the medication to reach therapeutic levels, and it should begin working after the first dose. |
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Term
The nurse is caring for a patient receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication?
Pain rating 3/10, awake and alert, respirations 24
Pain rating 2/10, awake and alert, respirations 18
Pain rating 2/10, drowsy but arousable, respirations 18
Pain rating 1/10, drowsy but arousable, respirations 16 |
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Definition
Pain rating 2/10, awake and alert, respirations 18
Rationale:
Effective pain management is achieved when there is adequate pain control (rating of 3 or less on a scale of 0 to 10) with normal respirations and an absence of sedation. These data exhibit the best effectiveness of the pain medication in all areas. |
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Term
The nurse is preparing to administer celecoxib to a patient. What medication taken by the patient should the nurse monitor because of an increased risk of adverse effects?
Aspirin
Scopolamine
Theophylline
Acetaminophen |
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Definition
Correct Answer:
Aspirin
Rationale:
Celecoxib is a nonsteroidal antiinflammatory drug (NSAID) of the cyclooxygenase-2 (COX-2) inhibitor type. Although celecoxib does not inhibit COX-1 and thus has a decreased risk of bleeding, bleeding is still of concern as an adverse effect. For this reason, the drug should not be taken with other drugs that increase risk of bleeding, such as aspirin. |
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Term
A patient is receiving morphine sulfate via patient-controlled analgesia (PCA). What nursing action is most effective to reduce the risk of adverse effects?
Tell the patient not to push the button too frequently.
Teach the caregiver not to push the button for the patient.
Ask the patient to do deep breathing exercises every hour.
Administer medications to prevent the occurrence of diarrhea. |
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Definition
Correct Answer:
Teach the caregiver not to push the button for the patient.
Rationale:
It is important to teach the caregiver not to push the button for the patient because it is only the patient who can determine the need for the medication. If the caregiver pushes the button, the patient could receive more of a dose than is needed, and this increases the risk of harm and adverse effects. The patient will be unable to successfully push the button too frequently because the medication will be locked out from administration with the pump programmed. The patient may have difficulty following the direction of deep breathing exercises every hour because they will be sedated from the morphine. Constipation, not diarrhea, is a side effect of morphine. |
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Term
The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8 breaths/min. Which medication would the nurse prepare to administer to treat these symptoms?
Atropine
Naloxone
Protamine sulfate
Neostigmine bromide |
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Definition
Naloxone
Rationale:
Naloxone is the antidote or reversal agent for opioid analgesics, such as morphine. Excessive sedation and respiratory depression are symptoms of overdose or severe adverse effects that must be reversed for patient safety. |
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Term
A patient has been prescribed a nonsteroidal antiinflammatory medication (NSAID). Which effect should the nurse teach the patient to immediately report?
Blurred vision
Nasal stuffiness
Urinary retention
Black or tarry stools |
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Definition
Black or tarry stools
Rationale:
Black, tarry stools could indicate gastrointestinal bleeding, which is a risk associated with NSAIDs. For this reason, the patient should be taught to report this sign and other signs of bleeding immediately. Blurred vision, nasal stuffiness, and urinary retention are not common side effects of NSAIDS. |
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Term
When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should act as soon as the patient’s respiratory rate drops down to or below which parameter?
10 breaths/min
12 breaths/min
14 breaths/min
16 breaths/min |
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Definition
12 breaths/min
Rationale:
To protect the patient from adverse effects of respiratory depression from this medication, the nurse should alert the health care provider as soon as the respiratory rate drops down to or below 12 breaths/min |
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Term
A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication?
Diarrhea
Agitation
Constipation
Urinary frequency |
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Definition
Constipation
Rationale:
Morphine sulfate is an opioid analgesic that can lead to constipation as a side effect, and tolerance to opioid-induced constipation does not develop. It is very important to use measures, such as increased fiber and fluids in the diet, and exercise when possible, to prevent this side effect. A gentle stimulant laxative plus a stool softener are also frequently needed to prevent constipation in a patient who is likely to develop this side effect. |
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Term
After administering acetaminophen with oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient’s room?
Ensure that the side rails are raised.
Leave the overbed light on at low setting.
Offer to turn on the television to provide distraction.
Ensure that documentation of intake and output is accurate |
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Definition
Ensure that the side rails are raised.
Rationale:
Percocet has acetaminophen and oxycodone as ingredients. Because the medication contains an opioid analgesic with sedative properties, the nurse must ensure patient safety before leaving the room, such as leaving the bedrails raised. This will help prevent the patient from falling from bed. Leaving the light or television on will not provide a positive environment for healing sleep. |
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Term
The patient with a documented history of opioid use just had surgery. The nurse is concerned about the high dose of opioid analgesic prescribed for this patient. What is the best action for the nurse to take?
Remember that pain can be observed in patients.
Relieve this patient’s pain to avoid adverse consequences.
Be sure the patient is really in pain before giving the analgesic.
This patient has the right to appropriate assessment and management of pain. |
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Definition
This patient has the right to appropriate assessment and management of pain.
Rationale:
Patients with substance use disorder (SUD) and pain have the right to be treated with dignity, respect, and the same quality of pain assessment and management as all other patients. For a patient with SUD, severe pain should be treated with a single opioid at much higher doses than those used with drug-naïve patients. Observation of pain is not always evident. The stress of unrelieved pain may contribute to increased drug use in the patient with SUD. |
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Term
Which nursing intervention is most appropriate when preparing to administer an opioid analgesic agent to a patient in pain?
Give the medication on an empty stomach.
Count the number of doses on hand before administration.
Give the medication with a glass of juice or cold beverage.
Assess the patient for allergies to aspirin before administration. |
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Definition
Count the number of doses on hand before administration.
Rationale:
Because opioid analgesics are controlled substances, the nurse needs to count the number of doses and check that it matches the number recorded before removing and administering the medication. The medication is better tolerated with a small meal or snack before taking it to decrease the effect of gastrointestinal upset. The medication can be taken with any type of beverage, and it does not have to be juice or a cold beverage. Opioid analgesics do not usually have any type of aspirin products, so it is unnecessary to inquire about allergy to aspirin. |
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Term
Which assessment is of highest priority for the nurse to complete before administering morphine?
Pain rating
Blood pressure
Respiratory rate
Level of consciousness |
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Definition
Respiratory rate
Rationale:
A decreased respiratory rate below 12 breaths/min is a sign of opioid toxicity. Using the ABC approach in prioritizing care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine. Although pain rating, blood pressure, and level of consciousness are important parts of the assessment of a patient receiving an opioid analgesic, the medication should not be administered if the respiratory rate is depressed. |
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Term
The nurse should teach a patient to avoid which medication while taking ibuprofen?
Aspirin
Furosemide
Nitroglycerin
Morphine sulfate |
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Definition
Aspirin
Rationale:
The patient should not take aspirin while taking ibuprofen because the combination could increase the risk of gastrointestinal bleeding. |
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Term
The patient is receiving fentanyl patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential life-threatening adverse effect of this medication?
Tachycardia
Hypertension
Pupillary dilation
Decreased respiratory rate |
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Definition
Decreased respiratory rate
Rationale:
Respiratory depression is a potentially life-threatening adverse effect of fentanyl (Duragesic), which is an opioid analgesic, via any route. |
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Term
The nurse should question an order written for acetaminophen with oxycodone for a patient exhibiting which clinical manifestation?
Severe jaundice
Oral candidiasis
Increased urine output
Elevated blood glucose |
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Definition
Severe jaundice
Rationale:
Acetaminophen and oxycodone are the ingredients in Percocet. Because acetaminophen is metabolized in the liver, the patient could develop acetaminophen toxicity in the presence of severe liver disease (evidenced by jaundice). The prudent nurse would question the order before administration. |
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Term
The patient’s neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient’s pain? (Select all that apply.)
Fentanyl
Antiseizure drugs
β-Adrenergic agonists
Tricyclic antidepressants
Nonsteroidal antiinflammatory drugs |
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Definition
Antiseizure drugs
Tricyclic antidepressants
Rationale:
Antiseizure drugs, tricyclic antidepressants, selective norepinephrine reuptake inhibitors, transdermal lidocaine, and α2-adrenergic agonists are used for multimodal treatment when opioid analgesics alone do not control neuropathic pain. |
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Term
The nurse is assessing an 11-year-old client receiving conscious sedation to set a fractured leg. Which assessment finding indicates that the client might need respiratory support?
a. Sleeping
b. Regular respiratory rate
c. Coughing
d. Absent gag reflex |
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Definition
Answer: d. Absent gag reflex
Feedback: The child who does not have a gag reflex is demonstrating signs of deep sedation. In deep sedation, protective reflexes are lost and respiratory support is needed. A child with a regular respiratory rate does not require respiratory support. Coughing is an indicator that the airway is intact. The child who is sleeping might just be under light sedation. This alone is not an indicator for respiratory support. |
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Term
The nurse is evaluating the effectiveness of client-controlled analgesia for a 10-year-old client. Which outcome is the best indicator that this delivery of pain medication is effective?
a. The child naps at frequent intervals.
b. The child presses the button on a regular basis.
c. The child reports a pain level of 0 on a 0-to-10 scale.
d. There is no evidence of respiratory depression. |
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Definition
c. The child reports a pain level of 0 on a 0-to-10 scale.
Feedback: The child's pain rating is the best indicator of whether the delivery method for pain medication is effective. The absence of respiratory depression does not indicate that the child has pain relief. Pressing the button on a regular basis indicates that the child knows how to use the device but does not indicate how much pain the child has. Although napping might indicate some pain relief, it also might serve as a coping measure. In addition, if pain is well controlled, the child might be able to sleep for longer intervals. |
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Term
The nurse caring for a 13-year-old has identified imagery as a way to help the client with pain management. Which instructions could the nurse use to help the client use imagery?
a. "Take some slow, deep breaths."
b. "Think about your favorite place to go in the summer."
c. "Relax while I rub your shoulders."
d. "Count to 10 very slowly." |
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Definition
b. "Think about your favorite place to go in the summer."
Feedback: Imagery involves a cognitive process in which the individual is encouraged to think about something positive, such as a favorite place. Taking slow, deep breaths is a breathing technique for pain control. Counting is a distraction technique. Touch is a type of cutaneous stimulation. |
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Term
An infant in the neonatal intensive care unit must undergo numerous painful procedures. Which complementary therapy to decrease pain during the procedures is most appropriate?
a. Massage
b. Sucrose pacifier
c. Imagery
d. Swaddling |
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Definition
b. Sucrose pacifier
Feedback: Sucrose provides short-term, natural pain relief and is most appropriate for use in infants and neonates to decrease pain during the procedure. Imagery is not appropriate for an infant. Massage and swaddling are appropriate comfort measures following |
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Term
Which pain-assessment tool is the most appropriate for a 14-year-old client?
a. FLACC behavioral pain assessment scale
b. FACES pain rating scale
c. Numeric scale
d. Poker chip tool |
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Definition
c. Numeric scale
Feedback: The FLACC scale is an observation scale used primarily with infants and preverbal children. Although the FACES scale and poker chip tool can be used for adolescents, a client this age should be very capable of using a numeric scale. The FACES scale and the poker chip tool are most appropriate with preschool- and young school-age children. |
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Term
The nurse is providing care for an 8-year-old client with a 2-year history of juvenile rheumatoid arthritis (JRA). The child takes nonsteroidal anti-inflammatory drugs (NSAIDs) on a regular basis to help control discomfort. What is the most appropriate nursing diagnosis for this client?
a. Knowledge Deficit: Pain Management related to lack of previous teaching
b. Coping Deficit related to discomfort associated with JRA
c. Acute Pain related to JRA
d. Chronic Pain related to JRA |
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Definition
d. Chronic Pain related to JRA
Feedback: Based on the information in the stem, the child experiences pain on a regular basis related to JRA, which is a chronic illness. There are no data given to suggest that the child has acute pain, coping deficit, or knowledge deficit. |
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Term
The nurse assesses a 10-year-old male client with multiple fractures shortly after the child arrives on the unit from the emergency department. The nurse attempts to assess the child's pain using a number scale and then a FACES scale. The child responds, "I do not know, I just hurt bad!" What is the most appropriate action by the nurse?
a. Explain the scale and tell the child that he needs to rate his pain.
b. Administer the prescribed dose of intravenous morphine.
c. Reassess the child in 30 minutes to see whether he will give a rating of his pain.
d. Give the prescribed dose of oral acetaminophen with codeine. |
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Definition
b. Administer the prescribed dose of intravenous morphine.
Feedback: The child is in severe pain and needs intravenous pain medication that will provide prompt relief. Although pain assessment is important, the nurse must rate the child's pain based on his actions and verbal statements instead of a FACES scale or numeric scale score. The child is not coping with the severe pain and therefore is unable to focus on scoring his pain. Explanations regarding pain rating scales are provided most effectively when the client is not in acute pain. Oral analgesics generally do not provide relief as effectively and promptly as intravenous medication does. |
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Term
The nurse asks a 6-year-old male client to rate his pain using the FACES pain-rating scale. The child is 12 hours postoperative for an appendectomy. The child chooses the first face, indicating that he does not have any pain, but the child's mother reports that just before the nurse entered the room, the child stated that his stomach was hurting badly. What is the most appropriate initial action by the nurse?
a. Ask the mother to report any more complaints of pain to the nurse.
b. Ask the child why he told his mother he had pain but rates his pain as a 0 on the pain scale.
c. Administer a dose of prescribed pain medication to the child.
d. Reassess the child in 1 hour. |
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Definition
c. Administer a dose of prescribed pain medication to the child.
Feedback: The male client might be trying to be brave in front of the nurse. He also might be concerned about the consequences of stating that he has pain (i.e., IM injection). Unrelieved pain delays healing. The nurse should expect this child to have pain, because he has recently had surgery. Prompt administration of pain medication is the most appropriate initial action by the nurse. She should reassess the child within 30 minutes of administering pain medication. Although asking the mother to report further complaints of pain is an appropriate action, it is not the most appropriate initial action. The nurse should not confront the child about his pain rating. |
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Term
A 3-year-old child is being discharged from the hospital following treatment for an acute illness. The child is scheduled to return to the clinic in 1 week to have blood drawn by venipuncture to reassess electrolyte values. The child's parents ask whether there is anything they can do prior to arriving at the clinic to decrease the child's discomfort from the procedure. What is the most appropriate response by the nurse?
a. Reassure the parents that the procedure is not painful.
b. Suggest therapeutic play prior to the procedure.
c. Obtain a prescription for EMLA or Ela-max from the primary healthcare provider and instruct the parents how and when to apply the medication.
d. Suggest that the parents reassure the child that the procedure will not hurt. |
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Definition
: c. Obtain a prescription for EMLA or Ela-max from the primary healthcare provider and instruct the parents how and when to apply the medication.
Feedback: EMLA and Ela-max are topical anesthetics that are appropriate to use to prevent or decrease pain associated with minor medical procedures. Parents can be taught how and when to apply the medication. Venipuncture is a painful procedure. Although therapeutic play can be a useful method to teach the child briefly about the procedure and to help relieve anxiety following the procedure, it will not actually decrease the discomfort that a child this age will experience from a needlestick. |
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Term
Which behavioral responses and verbal descriptions of pain are characteristic of a preschooler? (Select all that apply.)
a. Holds body very still when talking to the nurse.
b. Points to where the hurt is.
c. Cries and screams, unable to describe the type of pain.
d. Strikes out physically when painful procedures are performed.
e. States, "I'll try to be brave." |
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Definition
b. Points to where the hurt is; d. Strikes out physically when painful procedures are performed.
Feedback: The preschooler can point to where the pain is and can describe to some degree the type and intensity of the pain. A child this age will resist painful procedures by physically striking out. Holding the body very still to avoid pain and trying to be brave are characteristic of school-age children. Detailed description of pain is characteristic of adolescents. |
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Term
A 17-year-old male taking codeine after surgery has a history of myocarditis. For which side effect does the nurse carefully monitor?
a. Nausea and vomiting
b. Constipation
c. Sedation
d. Respiratory depression |
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Definition
d. Respiratory depression
Feedback: Carefully monitor for signs of respiratory depression (a major life-threatening complication), especially during drug-specific peak action time. Nausea and vomiting, constipation, and sedation are side effects from opioid administration, but are not the priority. |
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Term
A 5-year-old is showing signs of respiratory depression after receiving a dose of morphine postop surgical repair of a fracture to the right arm. For what signs and symptoms does the nurse observe?
a. Small pupils and shallow breathing
b. Tachypnea and sweating
c. Vomiting and anxiety
d. Delirium and hallucinations |
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Definition
a. Small pupils and shallow breathing
Feedback: Clinical signs that indicate the development of respiratory depression include sleepiness, small pupils, and shallow breathing. Tachypnea, sweating, vomiting, anxiety, delirium, and hallucinations are not signs indicative of developing respiratory depression. |
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Term
A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side?
1
Crackling
2
Wheezing
3
Decreased sounds
4
Adventitious sounds |
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Definition
| Because the affected lung will not expand, aeration of the lung is not complete, and breath sounds are diminished. Crackling sounds occur with pulmonary edema, not with a pneumothorax; with a pneumothorax there is no air in the alveoli to produce crackles. Wheezing sounds occur with asthma, not with a pneumothorax. "Adventitious sounds" is a broad term that includes all abnormal breath sounds; it is not specific to pneumothorax. |
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Term
The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance?
1
T-tube movement increases.
2
Pain at the incision site increases.
3
The nasogastric tube gets irritating.
4
The bandage on the abdomen is constricting. |
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Definition
| The incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations. |
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Term
Which is a sign of a ruptured ectopic pregnancy in an adolescent?
1
Labor pains
2
Abdominal pain and bleeding
3
Abdominal pain and hypotension
4
Abdominal pain and hypertension |
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Definition
| 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 cannot be diagnosed by normal labor pains. Ectopic pregnancy is ruled out if abdominal pain is associated with bleeding or hypertension. |
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Term
A client is diagnosed with a peptic ulcer. What should the nurse expect when assessing the client's pain?
1
Intensifies after vomiting stomach contents
2
Occurs in one to two hours after having a meal
3
Increases when an excess of fatty foods are ingested
4
Begins in the epigastrium and radiates to the abdomen |
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Definition
| Pain occurs after the stomach empties; eating stimulates gastric secretions, which act on the gastric mucosa of an empty stomach, causing gnawing pain. Vomiting temporarily alleviates pain because acid secretions are removed. There is no intolerance of fats and eating generally alleviates pain. Pain associated with the ingestion of fatty foods is associated with cholecystitis. Pain is localized in the epigastrium; however, it only radiates to the abdomen if the ulcer has perforated. |
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Term
A client with peripheral arterial insufficiency tells the nurse that walking sometimes results in severe pain in the calf muscles. Which information should the nurse share with the client?
1
This is called rest pain.
2
This is called intermittent claudication.
3
This is called phantom limb sensation.
4
This is called Raynaud phenomenon. |
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Definition
| Intermittent claudication is pain that results when the arterial system is unable to provide adequate blood flow to the tissues in the presence of increased demands for oxygen and nutrients during exercise; it is relieved by rest. Rest pain is not a response to exercise; it occurs in the extremities during rest, especially at night. Phantom limb sensation is the presence of unusual sensations or pain in the removed portion of an amputation. Raynaud phenomenon is intermittent episodes of constricted arteries and arterioles in response to extreme cold or emotional stress, causing pallor, paresthesias, and pain. |
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Term
The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client’s request for pain medication. What is the role of the nurse in this situation?
1
Educator
2
Manager
3
Advocate
4
Administrator |
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Definition
| 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 |
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Term
A 12-year-old child with sickle cell anemia is admitted during a vaso-occlusive crisis. What is the priority of care for this child?
1
Relieving pain
2
Exercising joints
3
Increasing urine output
4
Improving respirations |
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Definition
| A vaso-occlusive crisis is accompanied by severe pain because the clumped red blood cells block small vessels. Swollen limbs are painful and should not be exercised during a pain episode. Although increased urine output, associated with appropriate hydration, is an important objective, pain relief is the priority. Improved respiratory function occurs as pain is relieved. |
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Term
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client’s pain exhibits which characteristic?
1
Causes mild perspiration
2
Occurs after moderate exercise
3
Continues after rest and nitroglycerin
4
Precipitates discomfort in the arms and jaw |
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Definition
| When neither rest nor nitroglycerin relieves the pain, the client may be experiencing an acute myocardial infarction. Angina may cause mild diaphoresis; acute myocardial infarction causes profuse diaphoresis, which should be reported. Chest pain after exercise is expected; activity increases cardiac output, which can cause angina. Anginal pain can, and often does, radiate. |
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Term
Which caring intervention helps to provide comfort, dignity, respect, and peace to a client?
1
Listening
2
Spiritual caring
3
Providing presence
4
Relieving pain and suffering |
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Definition
| Relieving pain and suffering is not just about giving medications but providing comfort, dignity, respect, and peace to a client. Listening helps to obtain meaningful interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps to convey closeness and a sense of caring. |
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Term
A 37-year-old client with endometriosis visits the women’s health clinic because she has dysmenorrhea and dyspareunia. Which statement is the most accurate description of dysmenorrhea?
1
Pain with menses
2
Endometrial hyperplasia
3
Bleeding between menses
4
Heavy bleeding with menses |
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Definition
| Dysmenorrhea is defined as pain with menses. Endometrial hyperplasia results from anovulation and persistent estrogen stimulation. Bleeding between menses is metrorrhagia. Heavy bleeding with menses is menorrhagia. |
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Term
A client with pain and paresthesia of the left leg is scheduled for an electromyogram. What should the nurse discuss with the client before the test is performed?
1
Bed rest must be maintained after the procedure.
2
The involved area will be shaved before the procedure.
3
Needles will be inserted into the affected muscles during the test.
4
Monitoring of the heart rate and rhythm will be done throughout the test. |
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Definition
| Small needles will be inserted into the affected muscles during the test to assess electrical activity and to determine whether symptoms are primarily musculoskeletal or neurologic. Bed rest is not required after the procedure. Special preparation, like shaving, is not required for electromyography. Special care, like monitoring the heart, is not required during the procedure. |
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Term
An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level?
1
Asking the client's parent
2
Using Wong's "Pain Faces"
3
Observing the client's body language
4
Explaining the use of a 0 to 10 pain scale |
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Definition
| An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers. |
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Term
An 8-year-old child who is experiencing a sickle cell pain episode is admitted to the child health unit. What is the most appropriate nursing care during this acute period?
1
Limiting fluids until the crisis ends
2
Administering prescribed analgesics
3
Applying cold compresses to painful joints
4
Performing range-of-motion exercises of affected joints |
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Definition
| The priority is pain management; severe pain requires analgesics. Increased hydration is necessary to promote hemodilution, improve circulation, and prevent more sickling. Cold will constrict blood vessels, further depleting oxygenation to affected parts; warmth is preferable. There is too much swelling and pain in the joints during a crisis for the implementation of range-of-motion exercises. |
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Term
Which pain scale should a nurse use to measure the intensity of pain in toddlers?
1
FACES scale
2
Visual analogue scale
3
Numerical rating scale
4
Verbal descriptor scale |
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Definition
| The nurse should use a FACES scale to measure the intensity of pain in children. The scale consists of six cartoon faces ranging from a smiling face ("no hurt") to increasingly less happy faces and finally to a sad, tearful face ("hurts worst"). The visual analogue scale, numerical rating scale, and verbal descriptor scale can be used in young children and adults. |
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Term
A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen?
1
To prevent dyspnea
2
To prevent cyanosis
3
To increase oxygen concentration to heart cells
4
To increase oxygen tension in the circulating blood |
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Definition
| Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells. |
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Term
A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure?
1
Fear of dying
2
Skipped heartbeats
3
Pain at the insertion site
4
Anxiety in response to intensive monitoring |
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Definition
| Pain at the arterial puncture site is attributable to entry and cannulation of the artery and is a common complaint after a cardiac catheterization. Fear of dying might occur during the precatheterization period. Although skipped heartbeats may occur during the procedure because of trauma to the conduction system, usually it does not continue after the procedure. Although some clients may be anxious, many feel safe when receiving ongoing monitoring. |
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Term
A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?
1
Turning on the television for diversion
2
Calling the primary healthcare provider for another analgesic prescription
3
Placing the prescribed as-needed warm, wet compress on the elbow
4
Informing her gently that she must wait until the pump reactivates to get more medication |
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Definition
| Vasodilation should help reduce pain from cellular clumping; applying a warm, wet compress will address the pain until the pump can be activated. Television may be an adequate distractor for mild pain, not moderate or severe pain. Nursing measures should be attempted first to relieve the pain before the primary healthcare provider is called. Telling the adolescent to wait provides no comfort. |
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Term
A client is receiving patient-controlled analgesia (PCA) after surgery. What does the nurse identify as the primary benefit with this type of therapy?
1
Client is able to self-administer pain-relieving drugs as necessary
2
Amount of medication received is determined entirely by the client
3
Amount of drug used for analgesia matches sleep–wake cycles
4
Self-administration relieves the nurse of monitoring the client for pain relief |
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Definition
| The ability of the client to self-administer pain-relieving medications as necessary is the purpose of patient-controlled analgesia; usually smaller amounts of analgesics are used with self-administration. The amount and dosage of the medication are programmed to prevent accidents or abuse. Drug levels are kept in a maintenance range, and pain relief is achieved without extreme fluctuations. Requests for pain relief by any route would be anticipated to match sleep–wake cycles. The nurse is not absolved of responsibility when PCA is used; monitoring the client for effectiveness, refilling the apparatus with the prescribed narcotic, and charting the amount administered and the client's response are required. |
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Term
he student nurse is performing a rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse. Which parameters should the student nurse consider for proper assessment? Select all that apply.
1
Level of anxiety
2
Reaction to pain
3
Response to voice
4
Body temperature
5
Evidence of assault |
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Definition
| The disability examination provides a rapid baseline assessment of neurologic status. It helps to evaluate level of consciousness by the "AVPU" mnemonic, which also helps to assess the responsiveness to pain and voice. Level of anxiety is not assessed by a disability mnemonic. Body temperature and evidence of assault are assessed in a primary survey of exposure. |
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Term
Which herbal therapies would be beneficial to a client with menstrual cramping? Select all that apply.
1
Catnip
2
Fennel
3
Black haw
4
Bugleweed
5
Chamomile |
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Definition
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Term
A client who is diagnosed as having a herniated nucleus pulposus reports pain. What should the nurse most likely conclude is the cause of this client’s pain?
1
Inflammation of the lamina of the involved vertebra
2
Shifting of two adjacent vertebral bodies out of alignment
3
Compression of the spinal cord by the extruded nucleus pulposus
4
Increased pressure of cerebrospinal fluid within the vertebral column |
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Definition
| Pain results because herniation of the nucleus pulposus into the spinal column irritates the spinal cord or the roots of spinal nerves. Inflammation of the lamina of the involved vertebra is not involved; the lamina is that portion of the vertebra removed during surgery to gain access to the site. The vertebral bodies themselves are not shifting. Circulation of cerebrospinal fluid is not affected. |
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Term
A client is admitted to the hospital for the medical management of burns over 18% of the body’s surface. What should the nurse teach the client to help manage pain during dressing changes?
1
Deep breathing exercises
2
Progressive muscle relaxation
3
Active range-of-motion exercises
4
Important elements of wound care |
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Definition
| Deep breathing exercises are an effective intervention in controlling pain; this is a positive coping skill. Muscle relaxation techniques generally include muscle contraction and then relaxation, which may increase the pain. Active range-of-motion exercises may increase the pain. Understanding important aspects of wound care will not reduce pain; health teaching should be initiated before, not during, a procedure. |
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Term
After becoming incontinent of urine, an older client is admitted to a nursing home. The client’s rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client?
1
Control of pain
2
Immobilization of joints
3
Motivation and teaching
4
Bladder training and control |
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Definition
| After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client’s basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain. |
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Term
A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis?
1 Urinary retention
2 Gastric hyperacidity
3 Rebound tenderness
4 Increased lower bowel motility |
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Definition
| Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix. |
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Term
A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. The nurse concludes that the pain in the client's foot is a result of inadequate blood supply. Which information from the client will cause the nurse to intervene?
1
I have one glass of wine at supper.
2
I lower my limb when sitting.
3
I am a social smoker.
4
I drink a lot of water |
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Definition
| Nicotine (I am a social smoker) causes vasoconstriction and spasm of the peripheral arteries; therefore the nurse will intervene. Alcohol may stimulate dilation of blood vessels; one glass is not harmful. Lowering the limb enhances flow of blood into the foot by gravity to assist with the inadequate blood supply. Consuming water will decrease the viscosity of blood, possibly preventing the formation of thrombi. |
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Term
A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors?
1
Listen to the client's fears
2
Encourage the client to socialize
3
Grant the client's request about visitors
4
Darken the client's room by pulling the drapes |
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Definition
| Voicing fears often reduces the associated anxiety. Socialization, when feelings need exploration, is not therapeutic. Although the client's request about visitors should be granted, simply accepting the client's wishes is not by itself therapeutic. Darkening the client's room avoids the problem and is not therapeutic. |
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An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How should the nurse respond when the client complains of pain and requests medication?
1
By withholding the medication to help prevent addiction
2
By stating that the limb has been removed and that the pain is psychological
3
By acknowledging that the pain is real and administering medication to relieve it
4
By explaining that the phantom limb sensation will subside within a few more days |
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Definition
| 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. |
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Term
A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort?
1
Lactase
2
Sucrase
3
Maltase
4
Amylase |
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Definition
| 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. |
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