Exam #3: Check your knowing Flashcards

1
Q

It is most important for the nurse to understand the various ways in which pain is classified so that he or she can…

A.) Document the client’s pain using accurate terms
B.) Be clear in communication with the physician
C.) Develop an effective pain management plan
D.) Educate the client thoroughly

A

C.) Develop an effective pain management plan

Different modalities are used in treatment/ management of pain and are often on how the pain is classified (e.g., acute versus chronic)

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2
Q

Which Pain assessment scale is most appropriate for a verbal, alert adult with no cognitive impairment

A.) Visual Analog scale (VAS)
B.) 1-10 Numeric Pain Intensity Scale
C.) FACES
D.) FLACC

A

B.) 1-10 Numeric Pain intensity scale

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3
Q

Which pain assessment scale is most appropriate for a 13 month-old patient

A.) Visual Analog scale (VAS)
B.) 1-10 Numeric Pain Intensity Scale
C.) FACES
D.) FLACC

A

D.) FLACC

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4
Q

The Nurse is assessing the confused client. In trying to determine the client’s level of pain, the nurse should

A.) Be aware that confused clients do not feel as much pain due to their confusion
B.) Observe the client carefully for changes in behaviors or vital signs
C.) Ask the client’s family how much pain the client normally has
D.) Use only pain scales that feature numbers or “faces” the client can point to

A

B.) Observe the client carefully for changes in behavior or vital signs

-The nurse should observe the confused client for nonverbal cues to pain

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5
Q

Mr. Zenobia’s chronic cancer pain has recently increased and asks the home health nurse what can be done. In relation to his long-acting opioid, which is an appropriate response by the nurse?

A.)”If you take more opioid, it will not change your pain relief.”
B.) “I’ll call the primary care provider and ask for an increased dose.”
C.) “The amount you are taking now is all I can give you.”
D.) “I’m worried if we increase your dose that you will stop breathing.”

A

B. “I’ll call the primary care provider and ask for an increased dose.”

-There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a tolerance to the effects, which often necessitates an increase in the dose.

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6
Q

The Nurse is completing an admission assessment. Which interview question best reflects a belief related to holistic healthcare?

A.) “Can you tell me the names of the medications you are taking?”

B.) “Can you tell me how you normally handle stress?”

C.) “Can you tell me how long you have had your symptoms?”

D.) “Can you tell me your age and where you live?”

A

B. “Can you tell me how you normally handle stress?”

-By asking the patient how she handles stress, the nurse is eliciting information about the patient’s personality traits, health practices, and possibly spirituality, as well as the potential use of alternative modalities.

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7
Q

In order to provide safe, effective care, when assessing a client’s use of alternative therapies, the nurse should ask:

A.) “what herbal supplements have you taken?”
B.) “Have you ever used relaxation therapy?”
C.) “What types of activities or remedies do you use when you do not feel well?”
D.) “Do you use holistic treatments?’

A

a.) “What herbal supplements have you taken?”

-Phrasing the question in a nonjudgemental way allows the patient to provide an answer that they are comfortable with. It also encourages honesty and acceptance of the patient’s chosen activities.

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8
Q

Which healing modalities would be least appropriate for the patient receiving chemotherapy to use?

A.) Acupuncture
B.) Meditation
C.) Biofeedback
D.) Yoga

A

A.) Acupuncture

-Patients receiving chemotherapy are at risk of developing thrombocytopenia. Even the small needs used in acupuncture may cause undue bleeding if the thrombocytopenia is significant

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9
Q

You are assessing an older adult experiencing intense, acute pain related to a hip fracture. Her health record includes documented abuse of prescription narcotics. One hour after receiving the opioid dose she is moaning loudly in pain while rattling the bed rails. She repeatedly calls you for more pain reliever, even though you have already administrated analgesics as prescribed. What might you assume about what is going on in this situation?

A

-The healthcare provider and prescriber might be uncomfortable asking questions about alcohol and ilicit drug use and failed to obtain a thorough assessment of past history for narcotic use. However, gathering a reliable substance use history is important to provide a foundation for good pain management
-Previously the patient developed a tolerance to the opioid analgesic, based on prior exposure to the medication before this hospitalization (hip fracture)
-Healthcare providers and prescribers might be underdosing the patient in fear of contributing further to narcotic addition
-Healthcare providers might not have provided sufficient nonpharmacological therapies as an adjunct to opioid pain relievers
-There might e additional factors contributing to and aggravating the patient’s intensity of pain (e.g., fear and anxiety related to hospitalization, surgery, medical expenses, etc., past experience with pain; sociocultural expression of pain; insufficient family/social support system)

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10
Q

An obese, 65-year-old patient suffers with chronic back pain dur to a herniated disk that developed after a motor vehicle accident. How might you help him to achieve better pain control?

A

Following are some types of treatment for chronic back pain:
-Hot or cold therapy to soothe sore, stiff backs. Heat reduces muscle spasms and pain. Cold helps reduce swelling and numbs deep pain. Using hot or cold packs may relieve pain, but this treatment does not fix the cause of chronic back pain
-Exercise: helps to ease chronic pain but should not be used for acute back pain. Your doctor of physical therapist can tell you the best types of exercise to do
-Medications:
-Over-the counter drugs (acetaminophen, aspirin) or prescription pain medications
-Topical analgesics are creams, ointments, and salves that can be rubbed onto the skin over the site of pain.
-NSAIDs are drugs that reduce both pain and swelling. NSAIDs include over-the-counter drugs (e.g., ibuprofen, naproxen) or prescription-strength NSAIDs.
-Muscle relaxants
-Antidepressants
-Injections (e.g., corticosteroid) to lessen chronic pain.
-Complementary and alternative medical (CAM) therapy
-Manipulation: Chiropractic or soft tissue massage or active release therapy for the spine or supporting muscles and tissues.
-Transcutaneous electrical nerve stimulation (TENS) sends mild electrical pulses to nerves to interrupt the transmission of pain impulses. However, TENS treatments are not always effective for reducing pain.
-Acupuncture or acupressure may be effective when used as a part of a comprehensive treatment plan for low back pain.
-Surgery: Spinal fusion, laminectomy, foraminotomy, discectomy, disk replacement, interlaminar implant.
-Patient teaching: Instruct patients how to lift, push, and pull with less stress on the back. You can also help your patient to modify the way he moves his back, exercises, relaxes, and sleeps in order to lessen back pain. Eating a healthy diet and not smoking also helps.

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11
Q

A 45-year-old female patient with chronic pain secondary to fibromyalgia tells you that she is not having any relief from the pain medication she received 1 hour ago. the charge nurse has suggested additional pain medication. Based on theoretical knowledge and your own personal experiences what other interventions can you suggest, and why do you think they might work?

A

Massage Therapy

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12
Q

Maria is pregnant for the fourth time. She had one abortion at 8 weeks’ gestation. She has a daughter who was born at 40 weeks’ gestation and a son born at 34 weeks. What is her 5-digit and 2-digit system?

A

Five:
Gravida: 4
Term: 1
Preterm: 1
Abortion/miscarriage: 1
Living: 2

Two:
Gravida: 4
Para: 2

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13
Q

A woman’s cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur during development Which response by the nurse is most accurate?

1.) “It depends on what caused the defect.”
2.) “We don’t really know when such defects occur.”
3.) They usually occur in the first 2 weeks of development.”
4.) “They occur between the third and fifth weeks of development.”

A

4.) “They occur between the third and fifth weeks of development.”

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14
Q

The hormonal reports of a pregnant female reveal increased estrogen levels in the body. Which related signs would the nurse find in the patient? Select all that apply.

1.) Mucoid discharge from the cervix
2.) Heaviness in the patient’s breast
3.) Well-defined pink blotches on the palm
4.) Milk discharge from the patient’s nipples
5.) Decreased chest expansion of the patient

A

1,2,5

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15
Q

A pregnant patient complains of constipation. While checking the patient’s history, the nurse learns that the patient is taking oral iron supplements. What instruction does the nurse give the patient to relieve constipation?

1.) To raise the woman’s legs
2.) To turn the woman on her side
3.) To have the woman breathe into a paper bag
4.) To assess the woman’s blood pressure and pulse

A
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16
Q

Denise is 5 cm dilated, at 9 station with contractions that are moderate, occurring every 3-4 minutes, lasting 40-55 seconds

1.) What phase of labor is she in?
2.) What behavior might she demonstrate
3.) What physical care, teaching and emotional support measure would you implement for her?

A

1.) latent phase
2.) Excited starting to turn inward, might not be talking, serious about managing contraction
3.) provide support, helping position her to what is comfortable

17
Q

Danielle is 2 cm dilated, at -1 station with contractions that are mild, occurring every 5-6 minutes, lasting 30-35 seconds.

1.) what phase of labor is she in?
2.) What behavior might she demonstrate?
3.) What physical care, teaching and emotional support measures would you implement for her?

A

1.) latent phase
2.) Talk through her contractions, nervous/excited, outward talk about birth plan
3.) Pain management, what does she want

18
Q

Teresa is 9 cm dilated, at 2+ station with contractions that are strong, occurring every e minutes, lasting 70-90 seconds.

What phase of labor is she in?
2.) What behavior would she demonstrate?
3.) What physical care, teaching and emotional support measures would you implement for her?

A

1.) Active phase
2.) Close eyes, focus in, have a hard time coping, not interacting well, panicky feeling
3.) Hypnobirthing, support patient

19
Q

A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor. Which of the following occurs in the second stage of labor?

1.) The patient has bloody show
2.) The contractions are regular
3.) The membranes have ruptured
4.) The cervix is dilated completely

A

4.) The cervix is dilated completely

20
Q

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. What is the location of the fetal presenting part?

1.) 1 cm about the ischial spine
2.) 1 fingerbreadth below the symphysis pubis
3.) 1 inch below the coccyx
4.) 1 inch below the iliac crest

A

1.) 1 cm above the ischial spine

21
Q

A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. What is happening with the patient?

1.) Hematoma
2.) Placenta previa
3.) Uterine atony
4.) Placental separation

A

4.) Placental Separation

22
Q

The nurse cares for a patient in labor. Which of the following fetal positions is most favorable for birth?

1.) Vertex presentation
2.) Transverse lie
3.) Frank breech presentation
4.) Posterior position of the fetal head

A

1.) Vertex presentation

23
Q

The nurse is caring for a patient receiving an epidural during labor. What is the most common and potentially harmful maternal complication of epidural anesthesia?

1.) Severe postpartum headache
2.) Limited perception of bladder fullness
3.) Increase in respiratory rate
4.) Hypotension

A

4.) Hypotension

24
Q

You are performing a one minutes APGAR test on a newborn, The baby has a strong cry and is pink with cyanotic hands and feet. You assess a pulse of 122 beats per minute and the baby has some flexion of both arms and legs. While drying the newborn is responsive and cries while you dry it. What is the APGAR score?

A

A:1 pink with cyanotic hands and feet
P: 2 pulse is 122 (>100)
G: 2 responsive and cries while you dry it
A: 1 some flexion of both arms and legs
R: 2 strong cry

APGAR Score: 8

25
Q

The nurse is preparing to teach a class to a group of middle-aged women regarding the most common vasomotor symptoms experienced during menopause and possible modalities of treatment available. Common vasomotor symptoms would include which of the following?

A.) Chronic fatigue and confusion
B.) Forgetfulness and irritability
C.) Night sweats and hot flashes
D.) Decrease in sexual response and appetite

A

C.) Night sweats and hot flashes

26
Q

A client asks why the nurse touches the area near the armpit when conducting a breast examination. What should the nurse respond to this client?

A.) “The mammary ducts are in this region.”
B.) “I’m checking the integrity of your fibrous tissue.”
C.) “This is where most of the fatty breast tissue is located.”
D.) “The upper outer quadrant of the breast extends into the axillae.”

A

D.) “The upper outer quadrant of the breast extends into the axillae.”

27
Q

Which of the following contraceptive methods offers protection against sexually transmitted infections (STIs)?

1.) Oral contraceptives
2.) Withdrawals
3.) Latex condom
4.) Intrauterine system

A

3.) Latex condoms

28
Q

The nurse’s discharge teaching plan for the woman with PID should reinforce which of the following potentially life-threatening complications?

1.) Involuntary infertility
2.) Chronic pelvic pain
3.) Depression
4.) Ectopic pregnancy

A

4.) Ectopic pregnancy

29
Q

A 15 year old female comes into the clinic with odorous vaginal discharge. The patient is accompanied by a parent.
-What would you include in your nursing assessment?
-What teaching and education would you provide?

A

What would you include in your nursing assessment?
Ask the parent to leave the room to ask personal questions
Ask if sexually active (are you using safe sex practices,? What type of safe sex practices? how many partners do you have?)
Are you safe at home?
Do you regularly test for STI? Does your partner(s) get regularly tested?
Are you experiencing any other symptoms
What color and consistency is the vaginal discharge?
What teaching and education would you provide?
If sexually active, educate on the proper way to use a condom
Good Hygiene practices
Importance of preventing/getting STI testing regularly
Practicing safe sex methods
Asking the patient if they have gotten the 3 shot series for HPV vaccine
Believe what the patient says

30
Q

A 52 year old female patient comes in complaining of hot flashes and night sweats. What other information would you want to ask?

A

When was your last menstrual period?
Is your period regular/irregular?
When did your symptoms start?
Ask if they are managing their symptoms well