Deck 3 - Module 3 Flashcards
The nurse is preparing to assess comfort for several clients. If the nurse, in addition to assessing the client's physical experience of pain, assesses whether the client has a present and reliable personal support network, then the nurse is assessing which context of holistic human experience during this process? A) Transcendence B) Environmental C) Psychospiritual D) Sociocultural
D) Sociocultural
Rationale:
Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, sociocultural, and environmental. Sociocultural comfort is related to family and social relationships, which a personal support network would exemplify. Transcendence is not a context of holistic human experience.
The nurse provides an in-service to peers regarding situations that can affect the comfort level of the clients on the unit. Which client statement indicates that the client’s sense of well-being is negatively impacted?
A) “I feel like I have no energy today.”
B) “I don’t feel any physical pain today.”
C) “I was able to sleep uninterrupted last night.”
D) “I am so glad that playing cards takes my mind off my worries.”
A) “I feel like I have no energy today.”
Rationale:
Fatigue is a lack of energy and motivation. A fatigued client is unable to focus on healing and lacks the ability to cope in stressful situations. Restful sleep, physical well-being without pain, and appropriate diversion all promote a sense of comfort for the client.
A client is experiencing sudden-onset severe pain in the left lower quadrant of the abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing nausea, vomiting, and restlessness. Based on this data, the nurse concludes that the client is experiencing which phenomenon? A) Acute pain B) Chronic pain C) End-of-life pain D) Fibromyalgia pain
A) Acute pain
Rationale:
Duration establishes the difference between acute and chronic pain. Acute pain is defined as pain that lasts only through the expected recovery period, which is usually 30 days to 6 months. Acute pain typically has a sudden onset related to injury, surgery, or illness. Chronic pain outlasts the illness and extends beyond the recovery period. End-of-life and fibromyalgia would most likely involve chronic pain.
The nurse is preparing to assess a 1-year-old client for signs of discomfort. When conducting the assessment, which action by the nurse is the most appropriate?
A) Asking the client to rate the pain on a scale of 0-10 during the assessment process
B) Asking the parent to hold the client in the lap during the assessment process
C) Reading a book to the client during the assessment process
D) Recommending that the parent leave the room during the assessment process
B) Asking the parent to hold the client in the lap during the assessment process
Rationale:
Children may be fearful of physical assessment. To promote comfort, allow the child to sit on the parent’s or guardian’s lap during the assessment process, rather than asking the parent to leave the room. A numeric pain scale is not appropriate until the client is older; a faces pain scale would be better. Reading a book during the assessment process is not age appropriate.
The nurse is caring for a pediatric client with a surgical wound. The wound is red with purulent drainage and is causing discomfort for the client. Which diagnostic test will determine if the discomfort of the wound is caused by an infection? A) White blood cell count B) Hematocrit measurement C) Urine analysis D) X-rays of the site
A) White blood cell count
Rationale:
There are a few tests that can help the medical team determine the source of the client’s discomfort. In this case, a white blood cell count will determine if the discomfort is being caused by an infection. An x-ray is useful for determining the existence of physical injuries, not the presence of infection. Urine analysis may indicate illness or malnutrition, whereas hematocrit measurement may identify iron deficiency anemia.
An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. Which action by the nurse is the most appropriate?
A) Allow the toddler to sit on the parent’s lap and begin the assessment.
B) Allow the toddler to stand on the floor until the crying stops.
C) Ask another nurse in the office to hold the toddler because the parent is not able to control the toddler’s behavior.
D) Instruct the parent to hold the toddler down tightly to complete the examination.
A) Allow the toddler to sit on the parent’s lap and begin the assessment.
Rationale:
Toddlers are most comfortable when sitting with the parents. Vaccinations can be administered in this way if the parent is taught proper therapeutic holding techniques to keep everyone safe for the procedure. Allowing the toddler to stand on the floor or holding the toddler down tightly are inappropriate. A nurse can assist if the parent is unable to hold the child during the vaccinations to prevent injury from movement.
The nurse is caring for a client who is experiencing acute chest pain that is rated as a 9 on a 0 to 10 pain scale. Based on this data, which medication does the nurse expect to administer? A) Acetaminophen B) Morphine C) Ibuprofen D) Naproxen
B) Morphine
Rationale:
Acute pain is often treated with an opioid such as morphine. Morphine is often used to treat chest pain that is associated with a myocardial infarction. Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain.
B) Acute pain is often treated with an opioid such as morphine. Morphine is often used to treat chest pain that is associated with a myocardial infarction. Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain.
The nurse is designing a teaching plan for community members on ways to prevent chronic pain. Which information should the nurse include in this teaching plan? Select all that apply.
A) Eating a healthy diet
B) Obtaining adequate sleep
C) Avoiding illicit drug use
D) Limiting smoking to only before bedtime
E) Avoiding repetitive movements
A) Eating a healthy diet
B) Obtaining adequate sleep
C) Avoiding illicit drug use
E) Avoiding repetitive movements
Rationale:
Lifestyle habits that predispose individuals to chronic health alterations increase an individual’s risk for experiencing discomfort. Eating a healthy diet and obtaining adequate sleep can prevent the development of chronic diseases that lead to symptoms of discomfort. Using illicit drugs and smoking can cause emotional and physical withdrawal symptoms when the drug is no longer used. It is wise to not engage in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements can increase the risk for injury and fatigue, leading to discomfort.
Which client is most likely to reject attempts at comfort?
A) An infant crying
B) A school-age child with abdominal pain who is anxious about a procedure
C) An adolescent with a sleep disorder who doesn’t want his parents to be near him
D) An older adult with end-stage renal disease
D) An older adult with end-stage renal disease
Rationale:
Adolescents may respond to treatment and comfort better if you interact with them as adults rather than as children. Some adolescents may reject any offer of comfort, and an adolescent with a sleep disorder who has displayed antagonism toward his parents’ presence is probably irritable from his condition and may immediately reject attempts at comfort, at least at first. An infant crying is verbalizing the need for comfort. A school-age child anxious about a medical procedure craves reassurance. An older adult with a terminal illness likely will welcome comfort measures even if she has accepted that she is going to die.
Which of the following is a pharmacologic therapy for acute pain? A) Antidepressants B) Muscle relaxants C) Opioid analgesics D) Stimulants
C) Opioid analgesics
Rationale:
Pharmacologic pain management for acute pain involves opioid analgesics, nonopioid analgesics, or nonsteroidal anti-inflammatory drugs (NSAIDs). It does not involve antidepressants, stimulants, or muscle relaxants.
Which of the following statements best describes the therapeutic approach to acute and chronic pain, fatigue, fibromyalgia, and sleep disorders?
A) Therapy is primarily psychosocial in nature.
B) Therapy involves both pharmacologic and nonpharmacologic approaches.
C) Therapy is essentially physiologically focused.
D) Therapy mostly involves the client avoiding risk behaviors.
B) Therapy involves both pharmacologic and nonpharmacologic approaches.
Rationale:
For all of these conditions, therapy involves both pharmacologic and nonpharmacologic approaches. Therapy for these conditions is both physiological and psychosocial, addressing all components of client’s conditions. Therapy involves treatment of existing conditions, not just risk prevention measures on the client’s part.
Which of the following best characterizes the sociocultural context of holistic human experience?
A) Balance of physical processes
B) Connection to a higher power
C) Connection to others
D) Equilibrium with external circumstances
C) Connection to others
Rationale:
The sociocultural context of holistic human experience involves connection with others in society. Connection to a higher power is involved in the psychospiritual context. Homeostatic balance is involved in the physical context. Equilibrium with external circumstances is involved in the environmental context.
What is an example of chronic pain?
A) Pain that precedes injury
B) Pain that follows injury and ends when healing is complete
C) Pain that is felt during injury and immediately after
D) Pain that outlasts the healing process
D) Pain that outlasts the healing process
Rationale:
Chronic pain is pain that lasts beyond the expected time of healing, usually for at least 6 months; it does not always have a known cause. Pain can range from mild to severe, and autonomic responses decrease over time as the body adapts to the persistent pain impulses. Chronic pain does not precede injury, nor does it subside immediately after injury, and it may not be related to an injury. It does not end when healing is complete.
What is the relationship between a full opioid agonist and the ceiling effect?
A) A full opioid agonist produces few withdrawal symptoms when the drug’s effects plateau and the client begins easing off the drug.
B) A client may use a full opioid agonist as much or as little as necessary to control chronic pain with no ill effects.
C) Side effects may limit a full opioid agonist’s use but not a plateau in the beneficial effects it produces.
D) At some point, a full opioid agonist’s side effects cease to increase in potency, but the pain-relieving effect continues to increase.
C) Side effects may limit a full opioid agonist’s use but not a plateau in the beneficial effects it produces.
Rationale:
Full opioid agonists do not have a ceiling effect. Therefore, full opioid agonists can be given in increasing doses until pain is relieved or side effects become intolerable.
A client who has been undergoing treatment for chronic back pain has been considering various over-the-counter nonopioids to manage the pain. The nurse has assessed the client’s needs and discussed the use of available methods with the client. Which client statement indicates the need for further instruction?
A) “Nonopioid pain medications can have serious side effects I need to consider and watch for carefully.”
B) “I should not take a higher than recommended dose because the beneficial effect isn’t likely to be higher with a higher dose.”
C) “I may use these medications for as long as I think they are necessary.”
D) “I may use both opioid and nonopioid medications together, especially to relieve severe pain.”
C) “I may use these medications for as long as I think they are necessary.”
Rationale:
Over-the-counter (OTC) nonopioids are associated with severe side effects, especially when taken long term. NSAIDs can produce gastrointestinal (GI) toxicity and prolong bleeding times, and acetaminophen can produce liver and kidney toxicity. Nonopioids have a ceiling effect, so taking a higher dose will not produce a greater analgesic effect. While nonopioids are rarely effective alone for severe pain, they may produce a synergistic effect to relieve pain when combined with an opioid.
A toddler 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 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 from having undergone painful procedures there.
The nurse is creating a pain management plan using the three-step approach for a client with intractable pain. Which interventions should the nurse include in this plan? Select all that apply.
A) Administer a nonopioid analgesic first.
B) Administer an opioid analgesic first.
C) Administer a nonopioid with an opioid second.
D) Administer an opioid analgesic last.
E) Administer analgesics upon client request.
A) Administer a nonopioid analgesic first.
C) Administer a nonopioid with an opioid second.
D) Administer an opioid analgesic last.
Rationale:
The first step in the three-step approach to pain management involves administering a nonopioid drug first. If pain is not adequately controlled with this mild intervention, clients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drug. If the client is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. Pain-relieving drugs should be given “by the clock” (every 3-6 hours) rather than on demand to maintain freedom from pain.
Which of the following statements best characterizes risk for injury as it relates to pain?
A) Risk for injury is an external risk factor for pain.
B) It is difficult to predict what might pose a risk for injury.
C) Risk for injury can be decreased by living a healthy lifestyle.
D) Precautions against risk for injury are rarely successful in preventing injury.
A) Risk for injury is an external risk factor for pain.
Rationale:
External risk factors for pain, such as the risk for injury, can be decreased by safety precautions such as wearing a seat belt or helmet. Similarly, internal risk factors for pain, such as the risk for developing a chronic disease, can be decreased by living a healthy lifestyle. It is not difficult to anticipate what might pose a risk for injury.
The nurse is reviewing the admission orders for an older adult client who is being admitted for a hysterectomy. The client, who has been diagnosed as having uterine cancer, has chronic pain caused by arthritis. The healthcare provider has prescribed long-acting oral narcotic medication to be administered every 4 hours. What should the nurse do when providing the medication to the client?
A) Administer the medication if the client requests it.
B) Administer the medication every 4 hours around the clock.
C) Consult the provider to order intravenous pain medication.
D) Administer the medication sparingly to avoid narcotic addiction.
B) Administer the medication every 4 hours around the clock.
Rationale:
Administer analgesics as prescribed. Analgesics should be administered around the clock or by self-administration with a patient-controlled analgesic (PCA) pump to keep the pain from becoming severe. In this case, the nurse should follow the prescribed administration plan of every 4 hours around the clock. The client shouldn’t need to request the medication, the medication should be administered around the clock as prescribed rather than sparingly, and the nurse should administer the medication orally as prescribed rather than consult the provider for intravenous medication.
A preschool-age client's IV has infiltrated and must be restarted immediately for medication administration. There is no time for placing local anesthetic cream on the skin to decrease the pain associated with the procedure. Which complementary therapy would be most helpful when placing the IV for this pediatric client? A) Moderate sedation B) Restraint using a "mummy wrap" C) Anesthesia D) Distraction using bubbles
D) Distraction using bubbles
Rationale:
Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure. Playing games such as blowing bubbles would provide distraction for this pediatric client and be a valid nursing intervention. All the other choices are not considered complementary therapies and are inappropriate for the situation.
Which of the following triggers pain? A) The central nervous system B) The peripheral nervous system C) The musculoskeletal system D) The cardiovascular system
B) The peripheral nervous system
Rationale:
Pain is triggered by the peripheral nervous system, which lies outside the brain and spinal cord of the central nervous system and does not involve the musculoskeletal or cardiovascular systems.
Which of the following statements best describes the body’s adaptation to pain?
A) The worse pain becomes, the more obvious it is.
B) Once the body adapts to pain, its detrimental effects cease.
C) The observation of pain’s effects may become more difficult.
D) The body’s sympathetic response increases.
C) The observation of pain’s effects may become more difficult.
Rationale:
As the body adapts to pain, visible and physiological symptoms of pain may be harder to detect. The sympathetic response returns to baseline levels unless the client experiences breakthrough pain, and some visible signs of pain, such as crying, cease. Pain fibers may become sensitized so that the intensity and perception of pain increase over time.
Which of the following statements describes all pain?
A) Pain is the result of tissue damage.
B) Pain’s effects are primarily physiological, not mental or emotional.
C) Pain can be localized to a particular area of the body.
D) Pain’s effects can be verbalized.
D) Pain’s effects can be verbalized.
Rationale:
Pain can be described by the client, and so all pain can be verbalized. It may be the result of tissue damage or a warning of the potential for damage. Pain is both a physical and an emotional experience. Pain may not be localized in its effects.
The nurse is taking care of a client with terminal lung cancer who is showing signs of imminent death. What change should the nurse most expect the client to exhibit first? A) Decreased blood pressure B) Blurry vision C) Confusion D) Irregular pulse rate
A) Decreased blood pressure
Rationale:
Low blood pressure, or hypotension, occurs as a client’s body begins to near death. This is often accompanied by cool skin and an irregular pulse rate. Hypotension can lead to blurry vision, as well as confusion and dizziness; however, etiologies other than low blood pressure may also be the source of these symptoms. The nurse should most expect hypotension, potentially presenting with the other signs and symptoms.
A competent older adult client has a living will that expresses the client’s desire to avoid resuscitation and heroic life support measures. The family members are not supportive of this directive and plan to contest the living will. Which nursing action is the most appropriate?
A) Place the document on the chart.
B) Contact the Social Services department.
C) Explain to the client that the conflict could invalidate the document.
D) Notify the hospital attorney.
A) Place the document on the chart.
Rationale:
The client is competent. The wishes of the client must take priority. The document should first be placed on the chart and the provider notified. If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted. There is no need to notify the hospital attorney at this time. A lack of support by the family, or a plan to contest, does not invalidate the document legally.
The nurse is caring for a client who has suffered a massive cerebral hemorrhage and is not expected to survive. The client’s mother indicates the client is Catholic. Which intervention is most appropriate?
A) If the nurse is not Catholic, then finding a Catholic nurse to continue care for the client is necessary.
B) The nurse should contact a priest and ask him what must be done for the client.
C) The nurse should assume the client’s desires based on the nurse’s existing understanding of the Catholic faith.
D) The nurse should ask the client or the client’s family what they want in terms of religious rituals.
D) The nurse should ask the client or the client’s family what they want in terms of religious rituals.
Rationale:
Cultural and religious beliefs and traditions are often of paramount importance for end-of-life clients and their families. Nurses should work to facilitate requests to every extent possible. Contacting a priest may be necessary for the client to receive the Anointing of the Sick, but the nurse should follow the client’s or family’s request in this matter. The nurse doesn’t need to find a Catholic nurse to continue care and should not simply assume what the client wants in this regard.
The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis for this family? A) Grieving B) Hopelessness C) Compromised Family Coping D) Caregiver Role Strain
A) Grieving
Rationale:
Grieving prior to the actual loss is termed anticipatory grieving. There are no assessment findings that indicate compromised family coping or hopelessness. This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain.
An older adult client with terminal lung cancer is not breathing well and has cold and mottled skin. The client has a living will and requests comfort measures only. What should the nurse do to help this client?
A) Ask the family what they want to be done for the client.
B) Withhold all care until the client dies.
C) Contact the provider for orders to control the client’s breathing.
D) Provide the client with pain medication as ordered.
D) Provide the client with pain medication as ordered.
Rationale:
“Comfort measures only” indicates that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide client comfort is intensified and maintained through the end stages of the client’s life. Clients with a CMO order should receive effective pain and symptom management, spiritual care, food and fluids as the client is able, and hygiene care. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the provider to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the client’s written wishes when a living will is present and in force.
The nurse is caring for a dying child. Which nursing action supports the primary goal for a dying child?
A) Keep the child entertained so she does not think about dying.
B) Ensure that a good relationship is maintained with the family.
C) Administer pain medication as ordered.
D) Maintain a busy schedule for child and family members.
C) Administer pain medication as ordered.
Rationale:
Children with life-limiting conditions should receive palliative care in much the same way it is provided to adults. The major goal for the dying child is to promote comfort and keep the child pain-free by providing analgesia to promote optimal pain relief. Maintaining a good relationship is important but not a major goal for the child’s care. Keeping the child entertained is good, but the client needs to voice her feelings about death and dying. A dying child does not have the energy to maintain a busy schedule.
The parents of a child with terminal cancer ask the nurse that the child not be told that he will not recover. The nurse anticipates that the child might ask the nurse if he is dying. What would be most appropriate for the nurse to do?
A) Suggest a meeting with the healthcare team and the parents.
B) If the child asks about death, offer to bring in the child life therapist to help explain the situation.
C) Tell the child he is dying if the child asks and offer to stay with him.
D) Prepare to ignore the child’s question if the child asks it and change the subject.
A) Suggest a meeting with the healthcare team and the parents.
Rationale:
Offering to set up a meeting with the healthcare team to discuss the parents’ fears and concerns about telling their child the truth is the best action by the nurse. Telling the child he is dying would be going against the parents’ wishes. Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate, and the nurse should not simply pass the issue off to a therapist.
