Week 1 TB Ch 3, 8 49, 51

Question 1

1. A student asks the nurse what is the best way to assess a client’s pain. Which response by the nurse is best?

a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Client’s self-report

Answer 1

ANS: D

Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

Question 2

2. A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best?

a. “Being able to sleep doesn’t mean pain doesn’t exist.”
b. “Have you ever experienced any type of pain?”
c. “The client should be assessed for drug addiction.”
d. “You’re right; I would put the medication back.”

Answer 2

ANS: A

A client’s description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the client’s descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client’s report of pain serves no useful purpose.

Question 3

3. The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the client’s long-term outcome?

a. “At least you know that the pain after surgery will diminish quickly.”
b. “Discuss acceptable pain control after your operation with the surgeon.”
c. “Opioids often cause nausea but you won’t have to take them for long.”
d. “The nursing staff will give you pain medication when you ask them for it.”

Answer 3

ANS: B

The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.

Question 4

4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment?

a. Numeric rating scale
b. Verbal Descriptor Scale
c. FACES Pain Scale-Revised
d. Wong-Baker FACES Pain Scale

Answer 4

ANS: C

All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.

Question 5

5. The nurse is assessing a client’s pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment?

a. “Are you worried about addiction to pain pills?”
b. “Do you attach any spiritual meaning to pain?”
c. “How high would you say your pain tolerance is?”
d. “What pain rating would be acceptable to you?”

Answer 5

ANS: D

A comprehensive pain assessment includes the items listed in the question plus the client’s opinion on a functional goal, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.

Question 6

6. A nurse is assessing pain in an older adult. What action by the nurse is best?

a. Ask only “yes-or-no” questions so the client doesn’t get too tired.
b. Give the client a picture of the pain scale and come back later.
c. Question the client about new pain only, not normal pain from aging.
d. Sit down, ask one question at a time, and allow the client to answer.

Answer 6

ANS: D

Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the client may not know how to use it. There is no normal pain from aging.

Question 7

7. The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is “on the light constantly” asking for more pain medication. When assessing this client’s pain, what statement or question by the nurse is most appropriate?

a. “Help me understand how pain is affecting you right now.”
b. “I wish I could do more; is there anything I can get for you?”
c. “You cannot have more pain medication for 3 hours.”
d. “Why do you think the medication is not helping your pain?”

Answer 7

ANS: A

This is an example of therapeutic communication. A client who is preoccupied with physical symptoms and is “demanding” may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the client’s situation. “Why” questions are probing and often make clients defensive, plus the client may not have an answer for this question.

Question 8

8. A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?

a. Client being discharged later on a complicated analgesia regimen
b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
c. Postoperative client who received oral opioid analgesia 45 minutes ago
d. Client who has returned from physical therapy and is resting in the recliner

Answer 8

ANS: B

Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral medication to become effective and should be seen shortly to assess for effectiveness. The client going home requires teaching, which should be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

Question 9

9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?

a. Assess physiologic indicators and vital signs.
b. Do not give pain medication as no pain is indicated.
c. Document the findings and continue to monitor.
d. Try a small dose of analgesic medication for pain.

Answer 9

ANS: A

Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse does need to treat the client for pain.

Question 10

10. A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best?

a. “A multimodal approach is the preferred method of control.”
b. “Doctors are much more liberal with pain medications now.”
c. “Pain is so complex it takes different approaches to control it.”
d. “Clients are consumers and they demand lots of pain medicine.”

Answer 10

ANS: C

Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the student if the terminology is not understood. Doctors may be more liberal with pain medications, but that is not the best reason for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is discounting their pain experiences.

Question 11

11. A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the client’s care plan?

a. As-needed pain medication after therapy
b. Client-controlled analgesia with a basal rate
c. Pain medications prior to therapy only
d. Round-the-clock analgesia with PRN analgesics

Answer 11

ANS: D

Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continuous, not just administered prior to therapy.

Question 12

12. A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?

a. Client who appears to be sleeping soundly
b. Client with no bolus request in 6 hours
c. Client who is pressing the button every 10 minutes
d. Client with a respiratory rate of 8 breaths/min

Answer 12

ANS: D

Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that client’s pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

Question 13

13. A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?

a. Assesses the client’s pain level per agency policy
b. Monitors the client’s respiratory rate and sedation
c. Presses the button when the client cannot reach it
d. Reinforces client teaching about using the PCA pump

Answer 13

ANS: C

The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should intervene at this point. The other actions are appropriate.

Question 14

14. A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the client’s health history would lead the nurse to consult with the provider over the choice of medication?

a. 25–pack-year smoking history
b. Drinking 3 to 5 beers a day
c. Previous peptic ulcer
d. Taking warfarin (Coumadin)

Answer 14

ANS: B

The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

Question 15

15. A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider?

a. Bilateral lung crackles
b. Hypoactive bowel sounds
c. Self-reported pain of 3/10
d. Urine output of 20 mL/2 hr

Answer 15

ANS: D

Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the-clock regimen to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client if he or she still wants it.

Question 16

16. A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?

a. Assess and record the client’s pain every 4 hours.
b. Ensure the client is eating a high-fiber diet.
c. Monitor the client’s bowel function every shift.
d. Remove the old patch when applying the new one.

Answer 16

ANS: D

The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety.

Question 17

17. A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose?

a. Hydrocodone and acetaminophen (Lorcet)
b. Hydromorphone (Dilaudid)
c. Meperidine (Demerol)
d. Tramadol (Ultram)

Answer 17

ANS: B

Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not choose Lorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadol should not be used due to the potential for interactions with the client’s sertraline. Meperidine is rarely used and is often restricted.

Question 18

18. A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client’s oxygen saturation is 87%. What action should the nurse perform first?

a. Apply oxygen at 4 L/min.
b. Attempt to arouse the client.
c. Give naloxone (Narcan).
d. Notify the Rapid Response Team.

Answer 18

ANS: B

The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the client’s respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score.

Question 19

19. An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client?

a. Desipramine (Norpramin)
b. Duloxetine (Cymbalta)
c. Morphine sulfate
d. Nortriptyline (Pamelor)

Answer 19

ANS: B

Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, older adults do not tolerate tricyclic antidepressants very well, which eliminates desipramine and nortriptyline. Duloxetine would be the best choice for this older client.

Question 20

20. An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control methodologies as an adjunct to medication. Which strategy would be most successful with this client population?

a. Listening to music on a headset
b. Participating in biofeedback
c. Playing video games
d. Using guided imagery

Answer 20

ANS: A

Listening to music on a headset would be the most successful cognitive-behavioral pain control method for several reasons. First, in the ED, the nurse does not have time to teach clients complex modalities such as guided imagery or biofeedback. Second, clients who are anxious and in pain may not have good concentration, limiting the usefulness of video games. Playing music on a headset only requires the client to wear the headset and can be beneficial without strong concentration. A wide selection of music will make this appealing to more people.

Question 21

21. An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important?

a. Discuss the need for home health care.
b. Give the client follow-up information.
c. Provide written discharge instructions.
d. Request a home safety assessment.

Answer 21

ANS: D

All these activities are appropriate when discharging a client whose needs will continue after discharge. A home safety assessment would be most important to ensure the safety of this older client.

Question 22

22. A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should the nurse see first?

a. Client who is crying and agitated
b. Client with a heart rate of 104 beats/min
c. Client with a Pasero Scale score of 4
d. Client with a verbal pain report of 9

Answer 22

ANS: C

The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.

Question 23

23. A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?

a. Assess and record vital signs every 2 hours.
b. Have another nurse double-check the pump settings.
c. Instruct the client to report any unrelieved pain.
d. Monitor for numbness and tingling in the legs.

Answer 23

ANS: B

PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double-checked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling in the legs is an important function but will manifest after something has occurred to the client; monitoring does not prevent the event from occurring.

Question 24

24. A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?

a. Ask the client about pain goals and if they are being met.
b. Ask the client why he or she is being uncooperative with therapy.
c. Increase the dose of analgesia given prior to therapy sessions.
d. Tell the client that physical therapy is required to regain function.

Answer 24

ANS: A

A comprehensive pain management plan includes the client’s goals for pain control. Adequate pain control is necessary to allow full participation in therapy. The first thing the nurse should do is to ask about the client’s pain goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can assess for other factors influencing the client’s behavior. Asking the client why he or she is being uncooperative is not the best response for two reasons. First, “why” questions tend to put people on the defensive. Second, labeling the behavior is inappropriate. Simply increasing the pain medication may not be advantageous. Simply telling the client that physical therapy is required does not address the issue.

Question 25

25. A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client?

a. “Call the doctor if the Lorcet does not relieve your pain.”
b. “Check any over-the-counter medications for acetaminophen.”
c. “Eat more fiber and drink more water to prevent constipation.”
d. “Keep your follow-up appointment with the surgeon as scheduled.”

Answer 25

ANS: B

All instructions are appropriate for this client. However, advising the client to check over-the-counter medications for acetaminophen is an important safety measure. Acetaminophen is often found in common over-the-counter medications and should be limited to 3000 mg/day.

Question 26

1. A faculty member explains to students the process by which pain is perceived by the client. Which processes does the faculty member include in the discussion? (Select all that apply.)

a. Induction
b. Modulation
c. Sensory perception
d. Transduction
e. Transmission

Answer 26

ANS: B, C, D, E

The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.

Question 27

2. A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which information is accurate? (Select all that apply.)

a. Addiction is a chronic physiologic disease process.
b. Physical dependence and addiction are the same thing.
c. Pseudoaddiction can result in withdrawal symptoms.
d. Tolerance is a normal response to regular opioid use.
e. Tolerance is said to occur when opioid effects decrease.

Answer 27

ANS: A, D, E

Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.

Question 28

3. A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Ask the client to point out any areas of numbness or tingling.
b. Determine how many people are needed to ambulate the client.
c. Perform a bladder scan if the client is unable to void after 4 hours.
d. Remind the client to use the incentive spirometer every hour.
e. Take and record the client’s vital signs per agency protocol.

Answer 28

ANS: C, D, E

The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and should ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.

Question 29

4. A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. What actions by the nurse are most appropriate? (Select all that apply.)

a. Ask for a physical therapy consult.
b. Educate the client on cold therapy.
c. Offer to provide a heating pad.
d. Repeat the ice application.
e. Teach the client relaxation techniques.

Answer 29

ANS: B, D, E

Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse should focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. A physical therapy consult will not help relieve acute pain. Heat would not be a good choice for this type of injury.

Question 30

5. A student nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.)

a. Decreased immune response
b. Development of chronic pain
c. Increased gastrointestinal (GI) motility
d. Possible immobility
e. Slower healing

Answer 30

ANS: A, B, D, E

There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand.

Question 31

6. A nursing student is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.)

a. Neuropathic pain sometimes accompanies amputation.
b. Nociceptive pain originates from abnormal pain processing.
c. Deep somatic pain is pain arising from bone and connective tissues.
d. Somatic pain originates from skin and subcutaneous tissues.
e. Visceral pain is often diffuse and poorly localized.

Answer 31

ANS: A, C, D, E

Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

Question 32

7. A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.)

a. Avoid using other medications that cause sedation.
b. Delay giving medication if the client is sleeping.
c. Give the lowest dose that produces good control.
d. Identify clients at high risk for unwanted sedation.
e. Use an oximeter to monitor clients receiving analgesia.

Answer 32

ANS: A, C, D, E

Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse should identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client’s oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.

Question 33

8. A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. What actions by the nurse are most appropriate? (Select all that apply.)

a. Consult with the prescriber and voice objections.
b. Delegate administration of the placebo to another nurse.
c. Give the placebo and reassess the client’s pain.
d. Notify the nurse manager of the physician’s request.
e. Tell the client what the prescriber ordered.

Answer 33

ANS: A, D

Nurses should never give placebos to treat a client’s pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse should voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse should not delegate giving the placebo to someone else, nor should the nurse give it. The nurse should not tell the client unless absolutely necessary (the client asks) as this will undermine the prescriber-client relationship.

Question 34

1. A client is to receive 4 mg morphine sulfate IV push. The pharmacy delivers 5 mg in a 2-mL vial. How much should the nurse administer for one dose? (Record your answer using a decimal rounded to the nearest tenth.) ____ mL

Answer 34

ANS:
1.6 mL

5x = 8 mL
x = 1.6 mL

Question 35

2. A nurse is preparing to give an infusion of acetaminophen (Ofirmev). The pharmacy delivers a bag containing 50 mL of normal saline and the Ofirmev. At what rate does the nurse set the IV pump to deliver this dose? (Record your answer using a whole number.) ____ mL/hr

Answer 35

ANS:
200 mL/hr
Intravenous acetaminophen (Ofirmev) is approved for treatment of pain and fever in adults and children ages 2 years and older and is given by a 15-minute infusion. To deliver 50 mL in 15 minutes, set the IV pump for 200 mL/hr. To run 50 mL in 60 minutes, the pump would be set for 50 mL/hr. To run this volume in one quarter of the time, divide by 4: 200 ÷ 4 = 50.

Question 36

CHAPTER 8

Answer 36

Concepts of Emergency and Trauma in Nursing

Question 37

1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client’s care?

a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse

Answer 37

ANS: C

All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

Question 38

2. The emergency department team is performing cardiopulmonary resuscitation on a client when the client’s spouse arrives at the emergency department. Which action should the nurse take first?

a. Request that the client’s spouse sit in the waiting room.
b. Ask the spouse if he wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the client.
d. Refer the client’s spouse to the hospital’s crisis team.

Answer 38

ANS: B

If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

Question 39

3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?

a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg

Answer 39

ANS: C

The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

Question 40

4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first?

a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.

Answer 40

ANS: C

A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department.

Question 41

5. A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?

a. A 22-year-old with a painful and swollen right wrist
b. A 45-year-old reporting chest pain and diaphoresis
c. A 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F

Answer 41

ANS: B

A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

Question 42

6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

a. Level I – Located within remote areas and provides advanced life support within resource capabilities
b. Level II – Located within community hospitals and provides care to most injured clients
c. Level III – Located in rural communities and provides only basic care to clients
d. Level IV – Located in large teaching hospitals and provides a full continuum of trauma care for all clients

Answer 42

ANS: B

Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made.

Question 43

7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first?

a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.

Answer 43

ANS: A

The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

Question 44

8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?

a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.

Answer 44

ANS: B

Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

Question 45

9. A nurse is triaging clients in the emergency department. Which client should be considered “urgent”?

a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F
d. A 50-year-old male with new-onset confusion and slurred speech

Answer 45

ANS: C

A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

Question 46

10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?

a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.

Answer 46

ANS: D

When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

Question 47

11. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide?

a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.

Answer 47

ANS: C

Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

Question 48

12. An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the client’s trust?

a. Speak in a quiet and monotone voice.
b. Avoid eye contact with the client.
c. Listen to the client’s concerns and needs.
d. Ask security to store the client’s belongings.

Answer 48

ANS: C

To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the client’s belongings and personal space.

Question 49

13. A nurse is triaging clients in the emergency department. Which client should the nurse classify as “nonurgent?”

a. A 44-year-old with chest pain and diaphoresis
b. A 50-year-old with chest trauma and absent breath sounds
c. A 62-year-old with a simple fracture of the left arm
d. A 79-year-old with a temperature of 104° F

Answer 49

ANS: C

A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

Question 50

1. A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.)

a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.

Answer 50

ANS: B, C, D

To ensure client and staff safety, nurses should use two identifiers per The Joint Commission’s National Patient Safety Goals; follow the hospital’s security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.

Question 51

2. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.)

a. Mechanism of injury
b. Diagnostic test results
c. Immunizations
d. List of home medications
e. Isolation precautions

Answer 51

ANS: A, B, E

Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client’s situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.

Question 52

3. An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.)

a. Foley catheterization
b. Needle decompression
c. Initiating IV fluids
d. Splinting open fractures
e. Endotracheal intubation
f. Removing wet clothing
g. Laceration repair

Answer 52

ANS: B, C, E, F

The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

Question 53

4. The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.)

a. Psychiatric crisis nurse – Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis
b. Forensic nurse examiner – Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources
c. Triage nurse – Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs
d. Emergency medical technician – Obtains client histories, collects evidence, and offers counseling and follow-up care for victims of rape, child abuse, and domestic violence
e. Paramedic – Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

Answer 53

ANS: A, E

The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client’s behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

Question 54

5. A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.)

a. Provide medical supplies to the family.
b. Consult a home health agency.
c. Encourage participation in community activities.
d. Screen for depression and suicide.
e. Complete a functional assessment.

Answer 54

ANS: D, E

Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

Question 55

Chapter 49

Answer 55

Assessment of the Musculoskeletal System

Question 56

1. A client is having a myelography. What action by the nurse is most important?

a. Assess serum aspartate aminotransferase (AST) levels.
b. Ensure that informed consent is on the chart.
c. Position the client flat after the procedure.
d. Reinforce the dressing if it becomes saturated

Answer 56

ANS: B

This diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.

Question 57

2. A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test?

a. Administer sedation as prescribed.
b. Assess for seafood or iodine allergy.
c. Ensure that the client has no metal on the body.
d. Provide preprocedure pain medication.

Answer 57

ANS: B

Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.

Question 58

3. A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best?

a. Assess the neurovascular status of the right leg.
b. Document the findings in the client’s chart.
c. Elevate the left leg on at least two pillows.
d. Notify the provider of the findings immediately.

Answer 58

ANS: A

The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.

Question 59

4. A hospitalized client’s strength of the upper extremities is rated at 3. What does the nurse understand about this client’s ability to perform activities of daily living (ADLs)?

a. The client is able to perform ADLs but not lift some items.
b. No difficulties are expected with ADLs.
c. The client is unable to perform ADLs alone.
d. The client would need near-total assistance with ADLs.

Answer 59

ANS: A

This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.

Question 60

5. A client is distressed at body changes related to kyphosis. What response by the nurse is best?

a. Ask the client to explain more about these feelings.
b. Explain that these changes are irreversible.
c. Offer to help select clothes to hide the deformity.
d. Tell the client safety is more important than looks.

Answer 60

ANS: A

Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client’s feelings as possible. Explaining that the changes are irreversible discounts the client’s feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.

Question 61

6. The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system?

a. Cancellous tissue
b. Collagen matrix
c. Red marrow
d. Yellow marrow

Answer 61

ANS: C

Hematopoiesis occurs in the red marrow, which is part of the cancellous tissues containing both types of bone marrow.

Question 62

7. A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education?

a. High school football team
b. High school homeroom class
c. Middle-aged men
d. Older adult women

Answer 62

ANS: A

Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group.

Question 63

8. A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate?

a. Bending forward from the hips
b. Sitting upright with arms outstretched
c. Walking across the room and back
d. Walking with both eyes closed

Answer 63

ANS: A

To assess for scoliosis, a spinal deformity, the student should bend forward at the hips. Standing behind the student, the nurse looks for a lateral curve in the spine. The other actions are not correct.

Question 64

9. The client’s chart indicates genu varum. What does the nurse understand this to mean?

a. Bow-legged
b. Fluid accumulation
c. Knock-kneed
d. Spinal curvature

Answer 64

ANS: A

Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis.

Question 65

10. The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first?

a. Serum alkaline phosphatase (ALP): 108 units/L
b. Serum aspartate aminotransferase (AST): 26 units/L
c. Serum calcium: 10.2 mg/dL
d. Serum phosphorus: 2 mg/dL

Answer 65

ANS: D

A normal serum phosphorus level is 3 to 4.5 mg/dL; a level of 2 mg/dL is low, and this client should be assessed first. The values for serum ALP, AST, and calcium are all within normal ranges.

Question 66

1. A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn? (Select all that apply.)

a. A lack of vitamin D can lead to rickets.
b. Calcitonin increases serum calcium levels.
c. Estrogens stimulate osteoblastic activity.
d. Parathyroid hormone stimulates osteoclastic activity.
e. Thyroxine stimulates estrogen release.

Answer 66

ANS: A, C, D

Vitamin D is needed to absorb calcium and phosphorus. A deficiency of vitamin D can lead to rickets. Estrogen stimulates osteoblastic activity. Parathyroid hormone stimulates osteoclastic activity. Calcitonin decreases serum calcium levels when they get too high. Thyroxine increases the rate of protein synthesis in all tissue types.

Question 67

2. A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.)

a. Bone changes lead to potential safety risks.
b. Increased bone density leads to stiffness.
c. Osteoarthritis occurs due to cartilage degeneration.
d. Osteoporosis is a universal occurrence.
e. Some muscle tissue atrophy occurs with aging.

Answer 67

ANS: A, C, E

Many age-related changes occur in the musculoskeletal system, including decreased bone density, degeneration of cartilage, and some degree of muscle tissue atrophy. Osteoporosis, while common, is not universal. Bone density decreases with age, not increases.

Question 68

3. An older client’s serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this result? (Select all that apply.)

a. Good dietary intake of calcium and vitamin D
b. Normal age-related decrease in serum calcium
c. Possible occurrence of osteoporosis or osteomalacia
d. Potential for metastatic cancer or Paget’s disease
e. Recent bone fracture in a healing stage

Answer 68

ANS: B, C

This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease such as osteoporosis or osteomalacia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Paget’s disease, or healing bone fractures will elevate calcium.

Question 69

4. When assessing gait, what features does the nurse inspect? (Select all that apply.)

a. Balance
b. Ease of stride
c. Goniometer readings
d. Length of stride
e. Steadiness

Answer 69

ANS: A, B, D, E

To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings assess flexion and extension or joint range of motion.