Exam II Flashcards
A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (SATA) A. Muscular pain B. Active bleeding C. Backache D. Menstrual discomfort E. Swollen extremity
A, C, & D
A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (SATA) A. Face B. Legs C. Alert D. Circulation E. Consolability
A, B, & E
A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicate an understanding of the information? (SATA)
A. “A clients religious beliefs might affect the way they respond to pain.”
B. “Herbal therapies are not permitted for a client receiving prescription pain medication.”
C. “The client’s past pain experiences are not related to their current pain and pain management.”
D. “If a client can rate their pain using a numeric pain scale, there is no need to note nonverbal findings.”
E. “Pain control might be harder to achieve if the nurse and client speak different primary languages.”
A, C, & E
A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make?
A. “Justice allows the client the freedom of choice.”
B. “Justice allows the client the opportunity to be treated fairly.”
C. “Justice is causing no harm to the client.”
D. “Justice is doing good for the client.”
B
A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4-6 hrs as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. What action should the nurse take?
Offer to assist the client with non pharmacological relief strategies.
A nurse is evaluating a group of clients who are experiencing pain. Which client should the nurse identify as experiencing neuropathic pain?
A. Client who has osteoarthritis and reports difficulty ambulating for the past 6 months.
B. Client who had surgery to repair a fractured tibia and reports incisional pain.
C. A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury.
D. A hospice client who has prostate cancer and reports pelvic pain.
C. A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury.
A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. What action should the nurse take?
Evaluate the client for pain by observing their behavior.
A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which medication should the nurse ensure is available in case the client develops respiratory depression? A. Naloxone B. Lidocaine C. Prednisone D. Amitripyline
A. Naloxone
A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the clients pain and administer prescribed pain medications. What can the nurse be charged with? A. Malpractice B. Negligence C. Nonmaleficence D. Beneficence
B. Negligence
A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)? (SATA) A. Bowel sounds B. Deep tendon reflexes C. Respiratory rate D. Capnography E. Oxygen saturation
C, D, & E
A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of-life pain management? (SATA)
A. Fear of addiction
B. Belief that pain is an expected part of their illness
C. Inability to sleep
D. Lack of support
E. Inadequate pain assessment
A, B, & E
A nurse is caring for a client who has kidney stones. What manifestations is an objective indicator of pain?
The client is a diaphoretic
A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the clients knee for how long?
20 min on and 20 minutes off
A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which statements should the nurse include? (SATA)
A. “You can be taught how to use TENS therapy at home.”
B. “We will insert very small sterile needles into your skin to block your pain.”
C. “This therapy may result in you having some temporary bruising at the site of application.”
D. “The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas.”
E. “We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy.”
A, D, & E
A nurse is evaluating a clients pain lever using the PQRST mnemonic. What question should the nurse ask to evaluate the letter “R”?
“Can you point to where you are having your pain.”
A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. What statement should the nurse include?
“You should write down the pain interventions you use and your pain rating before and after.”
A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. What statement should the nurse include?
“You should write down the pain interventions you use and your pain rating before and after.”
A nurse is discussing cutaneous stimulation with a client who has back pain. Which methods should the nurse include? (SATA)
A. Transcutaneous electronic stimulating unit (TENS unit)
B. Distraction techniques
C. Massage
D. Acupuncture
E. Cold therapy
A, C, D, & E
A nurse is caring for a group of clients on the pediatric unit. Which clients should the nurse use the CLACC pain scale to determine their pain level? (SATA)
A. 12 YO client who has had an appendectomy
B. 3 YO toddler who has a fractured femur
C. 6 day old infant who had a surgical repair of a heart defect
D. 14 YO client who has severe cognitive and developmental delays
E. 5 YO preschooler who is experiencing pain during a sickle cell crisis
B, D, & E
A nurse is assessing a client who is nonverbal for the presence of pain. Which findings indicate an increased level of discomfort? (SATA) A. Grimacing B. Restlessness C. Elevated temperature D. Increased diaphoresis E. Bradycardia
A, B, & D
A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. What is the categorization of this clients pain?
Chronic pain
A nurse is providing end-of-life care for a client who is unresponsive and near death. The clients family asks the nurse about managing the clients pain. What statement should the nurse make to the clients family?
“Your family member has the right to receive effective pain management.”
A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hrs PRN. What statement by the client indicates an understanding of the instructions?
“I will keep the morphine bottle in a locked cabinet in my kitchen.”
A charge nurse is reviewing factors that can affect a clients perception of pain with a newly licensed nurse. Which should the charge nurse include? (SATA) A. Stress B. Dietary practices C. Culture D. Social support E. Disease severity
A, C, D, & E
A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for pain rate 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. What action should the nurse plan to take?
Administer 1 mg
A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which actions should the nurse plan to take to evaluate the clients pain control? (SATA)
A. Consider each clients cultural preferences.
B. Determine the effectiveness of non pharmacological strategies.
C. Record the clients subjective reports rather than the nurses objective observations
D. Recognize the older adult clients over-report their pain level.
E. Use a pain scale specific to each clients cognitive abilities.
A, B, & E
A nurse is reviewing information for several clients on the unit. The nurse should recognize that which client is at greatest risk for respiratory depression?
A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN
A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. What example should the nurse include as autonomy?
A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.
A nurse is preparing to administer acetaminophen 1,000 mg PO every 12 hr for a client who has arthritic pain. The nurse should monitor the client for which of the following adverse effects? A. Hepatotoxicity B. Salicylism C. Respiratory depression D. Gastrointestinal bleeding
A. Hepatotoxicity
A nurse is assessing a client’s pain. Which of the following questions should the nurse ask the client to assess the quality of the pain?
A. “When did the pain begin?”
B. “How would you rate your pain on a scale from 0 to 10?”
C. “What does your pain feel like?”
D. “Can you show me where you have pain?”
C. “What does your pain feel like?”
