Deck 2 Module 3 Flashcards
The nurse is preparing to assess comfort for several clients. Which will the nurse assess, in addition to the client's physical experience of pain, during this process? Select all that apply. A) Religion B) Friendship C) Environment D) Psychospirituality E) Social interaction
C) Environment
D) Psychospirituality
E) Social interaction
Rationale:
Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, social, and environmental. Religion and friendship are encompassed in psychospiritual and social.
The nurse is teaching a class on the perception of pain. What will the nurse teach as being the second step in processing pain stimuli? A) Thalamus B) Reticular system C) Limbic system D) Cerebral cortex
D) Cerebral cortex
Rationale:
The thalamus is the main relay station for sensory information. Pain information is then transmitted to the cerebral cortex as well as the reticular and limbic systems for the processing and interpretation of pain. The cerebral cortex is the second step in processing pain stimuli. The transmission of pain moves through the limbic system after the thalamus. Transmission of pain impulses occurs in the reticular system after traveling though the thalamus as the main relay station.
The nurse, caring for a 1-year-old client recovering from a tonsillectomy, assesses the child for pain. If pain level is not addressed, what additional health problem could occur? A) Urinary retention B) Bowel obstruction C) Respiratory compromise D) Bradycardia
C) Respiratory compromise
Rationale:
The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory compromise and complications. Uncontrolled pain does not lead to cardiac complications such as bradycardia. Uncontrolled pain does not frequently lead to bowel complications such as obstruction. Uncontrolled pain does not usually lead to urinary complications such as retention.
A toddler-age client being prepared for a lumbar puncture begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate for the client at this time?
A) Knowledge Deficient of the procedure
B) Anxiety related to anticipated painful procedure
C) Fear related to the unfamiliar environment
D) Ineffective Coping related to an invasive procedure
B) Anxiety related to anticipated painful procedure
Rationale:
The Question Stem indicates that the child associates the treatment room with a painful procedure, and the reaction to entering the treatment room is based on anticipation of repeat discomfort. The child’s behavior is appropriate for coping in a child of this age. This child is not old enough to understand the need for a lumbar puncture. The child’s fear is related not to the unfamiliar environment but to the anticipated pain associated with the treatment room. The Question Stem indicates that the child has been through painful procedures in the treatment room, so Knowledge Deficient is not the most appropriate diagnosis.
A female client has returned to the unit following a hysterectomy. The nurse knows that which intervention will provide the most pain relief for the client?
A) Offer pain relief before the client complains of pain.
B) Assess the pain level every 4 hours around the clock.
C) Wait until the client can describe the pain specifically.
D) Allow the client to “sleep off” the anesthesia, and then offer pain medication.
A) Offer pain relief before the client complains of pain.
Rationale:
Anticipating a client’s pain will ensure a more manageable pain experience than waiting until the client complains of pain. Pain management needs to be implemented prior to the client’s describing specific postoperative pain, or “sleeping off” anesthesia. If the client is asleep, she should not be awakened simply to assess the pain every 4 hours unless there are other significant nonverbal signs during sleep that indicate that the client is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site.
The nurse is caring for a Catholic client who has suffered a massive cerebral hemorrhage and is not expected to survive. Which intervention is most appropriate?
A) Discuss the need to cremate the client, as burial is not accepted in this faith.
B) Make plans for the family to wash the body after death.
C) Contact a rabbi so that the client can participate in prayer.
D) Contact a priest to deliver the Sacrament of the Sick.
D) Contact a priest to deliver the Sacrament of the Sick.
Rationale:
In the Catholic faith, it is common to receive the Sacrament of the Sick from a priest in order to receive spiritual strength and prepare for death. Contacting a rabbi would be appropriate for a Jewish client, and making plans for the family to wash the body is appropriate for the Muslim faith. Cremation is not preferred over burial in the Catholic faith.
A young adult male client comes to the clinic with complaints of not being able to study effectively. The nurse plans the care based on a nursing diagnosis of Fatigue. Which client statement validates this nursing diagnosis?
A) “I sleep for 9 hours a night.”
B) “I have hay fever.”
C) “I drink one beer when I go out with friends.”
D) “I work out in the gym two days a week.”
B) “I have hay fever.”
Rationale:
Allergies and their reactions, such as hay fever, can cause a person to experience fatigue and to lose focus. Sleeping for 9 hours a night is sufficient. Working out in the gym will help counteract fatigue. Drinking a beer occasionally will not cause fatigue.
The nurse is teaching a female client with chronic fatigue due to clinical depression regarding ways to increase energy levels. Which client statement indicates that teaching has been effective?
A) “I need to increase exercise time each week.”
B) “I will spend time with friends.”
C) “I will take Wellbutrin as prescribed.”
D) “I will go shopping once a week.”
C) “I will take Wellbutrin as prescribed.”
Rationale:
Depression can cause chronic fatigue. Compliance with medications results in relief of depression and therefore increases energy levels. Shopping, spending time with friends, and increasing exercise levels will not help the client who is clinically depressed.
A client, who has multiple sclerosis, is complaining of fatigue. What should the nurse recommend?
A) Advise the client to begin a high-intensity exercise program.
B) Tell the client to begin a mild-to-moderate exercise program, with the approval of her physician.
C) Suggest that the client restrict her activity as much as possible.
D) Tell the client that she will have to adjust to fatigue and that, with MS, nothing will help.
B) Tell the client to begin a mild-to-moderate exercise program, with the approval of her physician.
Rationale:
Higher-intensity exercise does not appear to produce a greater reduction in fatigue. Clients who report persistent fatigue from some chronic conditions should be encouraged to begin a physician-approved mild-to-moderate exercise regimen. A sedentary lifestyle can contribute to fatigue and other health complications. The client does have options to address the problem of fatigue.
An Asian man brings his wife to the clinic and states, “I want you to fix my wife and tell her that there is nothing wrong with her.” The client has symptoms of pain, sleep disorders, and stiffness. Which would be most appropriate for the nurse to include in a plan of care for this family?
A) Medications used to treat fibromyalgia
B) An exercise program to increase energy
C) Information and literature on fibromyalgia
D) Suggested dietary changes to help with the pain
C) Information and literature on fibromyalgia
Rationale:
In many cultures, accepting a disease like fibromyalgia may be difficult due to the vagueness of the disease. Information and written literature may help the family understand that the disease is real. The physician orders medication and diets. There is no proof that exercise, or lack thereof, causes fibromyalgia.
A client having difficulty sleeping asks the nurse what the complications of sleep deprivation might be. Which topic will the nurse include when responding to the client? A) Fatigue occurring at night B) Auditory hallucinations C) Improved wound healing D) Development of Alzheimer's disease
B) Auditory hallucinations
Rationale:
The client who is deprived of sleep may experience visual or auditory hallucinations. Sleep deprivation is not known to be a causative factor for Alzheimer’s disease but is known to exacerbate behavioral problems in persons with Alzheimer’s disease. Fatigue may occur but this is during the daytime. Delayed healing is associated with sleep deprivation.
The nurse is caring for a client recently diagnosed with schizophrenia. For which sleep issues is this client at risk because of this diagnosis? Select all that apply. A) Circadian cycle disruption B) Great difficulty getting to sleep C) REM rebound D) High nighttime levels of melatonin E) Reduced REM sleep
A) Circadian cycle disruption
B) Great difficulty getting to sleep
E) Reduced REM sleep
Rationale:
The client with schizophrenia may have circadian cycle disruption, reduced REM sleep, and difficulty getting to sleep. This client may also have low nighttime levels of melatonin. This client will not experience REM rebound.
A client with clinical depression asks the nurse for suggestions on how to improve the quality of sleep. After reviewing the client’s history, which suggestion by the nurse is the most appropriate?
Select all that apply.
A) Avoid the use of alcohol late in the evening.
B) Consume a cup of tea before bed to relax.
C) Adjust the temperature in the room to a comfortable level.
D) Change the time of aerobic exercise to 1 hour prior to sleep.
E) Avoid smoking before bedtime.
A) Avoid the use of alcohol late in the evening.
C) Adjust the temperature in the room to a comfortable level.
E) Avoid smoking before bedtime.
Rationale:
A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep and should be consumed well before bedtime. Nicotine is a stimulant and may prevent the client from falling asleep. Exercise within a few hours of bedtime acts as a stimulant and can cause the client to be unable to sleep. Tea contains caffeine, which is a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake during the night to urinate.
