Skills questions 15-16 Flashcards
What is the best approach to take in exploring cultural considerations for patients in pain?
A) Cultural influences on pain can be determined by a person’s ethnicity (e.g., Italians are very expressive).
B) Cultural influences on pain are rarely considered in the United States today because of the diversity of the population.
C) Patients should be individually assessed by the nurse to determine their cultural influences on pain.
D) It is the social worker’s role to assess cultural influences on pain and then report this information to the nurse.
C
It is the nurse’s role to assess influences on pain for each patient on an individual basis. Knowledge of cultural influences on the patient is helpful, but each patient has his own beliefs about pain, shaped by many factors. Ethnicity is just one aspect of cultural influence; use of this alone creates a narrow view. Knowledge of cultural influences is more important than ever today because of the vast differences in our population. Both nurse and social worker perform cultural assessment as part of their roles. The nurse looks at culture in relation to beliefs about pain and its treatment, diet, environment, and many other factors. The social worker’s notes often contain valuable information that the nurse can incorporate into her cultural assessment. (REF: p. 347-348)
After completing a massage, the nurse tells the patient to inhale deeply, exhale, and then move slowly for a few minutes. What is the rationale for ending the massage with this teaching? A) To prevent muscle cramping B) To prevent intravascular clotting C) To prevent the Valsalva maneuver D) To prevent postural hypotension
D
A massage can cause deep relaxation; thus sitting up too quickly can cause temporary postural hypotension. Deep breathing relaxes the patient but does not affect muscle cramping or clotting. Holding one’s breath and straining are Valsalva maneuvers. (REF: p. 370)
Which symptoms would lead you to suspect bupivacaine (Marcaine) toxicity in a patient connected to a local anesthetic infusion pump?
A) Hypotension, dizziness, and severe itching
B) Reduced sensation in lower extremities, urinary retention, and distended bladder
C) Reduced respiratory rate and depth with an increase in sedation level
D) Orthostatic hypotension and tingling in the extremities
A
Bupivacaine (Marcaine) toxicity presents with hypotension, dizziness, tremor, severe itching, swelling of the skin or throat, irregular heartbeat, palpitations, confusion, ringing in the ears, muscle twitching, numbness around the mouth, metallic taste, and seizures. (REF: p. 364)
A patient with an epidural catheter in place postoperatively has a respiratory rate of 8, respirations are shallow, and the patient is difficult to arouse. Which of the following steps should the nurse take? (Select all that apply.)
A) Try to arouse the patient and encourage deep breaths.
B) Check the infusion tubing to be sure that it is connected to the epidural catheter.
C) Discuss with the health care provider the need for a possible basal dose analgesic.
D) Prepare to administer naloxone (Narcan) per order.
E) Stop or reduce the rate of epidural infusion, and notify the health care provider.
A,D,E
No indication suggests that the catheter is disconnected. Seeking a basal dose analgesic is not appropriate because the patient has signs of respiratory depression and oversedation. (REF: p. 352, 357)
A dying patient wants to have an open casket at his funeral. After the patient’s death, which action by the nurse is most critical in maintaining his appearance?
A) Tape his eyelids down so the eyeballs maintain their moisture and shape.
B) Place him supine with the head of the bed elevated 30 degrees.
C) Tie his hand together to prevent them from moving when the body is transported.
D) Remove all indwelling devices and bandages before bathing the patient.
B
Elevating the head prevents pooling of blood in the facial area and preserves a natural facial color. Tying the hands could leave abrasions or cuts in the skin. (REF: 385-386)
A nurse is providing postmortem care. Which action should be the priority?
A) Locating the patient’s clothing
B) Providing culturally and religiously sensitive care in body preparation
C) Properly identifying the body
D) Providing all postmortem care to protect the family of the deceased from having to see the body
E) B and C
F) C and D
E
The highest priority in postmortem care is to complete all activities with dignity and respect for cultural and religious beliefs. Proper identification of the body is essential to avoid situations of serious miscommunication. (REF: 386-387)
A patient who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as possible. Which of the following nursing responses reflects a helpful understanding of the importance of patient self-care at the end of life?
A) “Learning to accept that you can’t do some activities anymore will bring you peace.”
B) “Spend more of your time resting or reading to conserve your energy.”
C) “People in your life want to help you with things, so allow them to do what they want to do for you.”
D) “What activities are most important for you, and how can you continue to perform them?”
D
Patient-centered care includes helping patients identify ways in which they can continue their self-care and maintain normalcy in life. They should be encouraged to continue important activities. The other three responses show the nurse giving advice instead of eliciting patient preference. (REF: 376)
You have identified three nursing diagnoses for a patient who is showing decreased interest in food, insomnia, and hopelessness upon hearing that no treatment options are available for her disease. What general approach will you take in prioritizing the nursing diagnoses?
A) Use family members and physician orders as primary resources for prioritizing your actions.
B) Address the nursing diagnosis that is most related to the medical diagnosis.
C) Determine what the patient believes is the most distressing symptom, and first address that diagnosis.
D) Address the problem that you believe is the underlying cause of the other diagnoses.
E) C and D
F) A and B
E
Prioritize care by addressing the patient’s most distressing problem and by identifying symptoms that might be causing some of the other issues, so that the patient may attain greater overall symptom relief. (REF: 376)
People are able to express their values and preferences for care through a(n) _________________________ when they can no longer speak for themselves.
Advance directive
