Wound Healing & Complications: Oxygen Saturation, Pulmonary Function, Arterial Blood Gases, Exams of Nursing

Download Wound Healing & Complications: Oxygen Saturation, Pulmonary Function, Arterial Blood Gases and more Exams Nursing in PDF only on Docsity!

NUR 280 EXAM 2 WITH ACTUAL CORRECT

QUESTIONS AND VERIFIED DETAILED

RATIONALES ANSWERS BY EXPERTS |

FREQUENTLY TESTED QUESTIONS AND

SOLUTIONS |ALREADY GRADED A+ |LATEST

UPDATE | GUARANTEED PASS

The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? A) Risk for disuse syndrome B) Ineffective health maintenance C) Sedentary lifestyle D) Imbalanced nutrition: less than body requirements

D

How should the nurse best position a patient who has leg ulcers that are venous in origin? a. keep the patient legs flat and straight b. keep the patients knees bent to 45- degree angle and supported with pillows c. elevate the patients lower extremities d. dangle the patient legs over the side of the bed

C

A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patients lower extremities? A) Ensure that the patients heels are protected and supported. B) Closely monitor the patients serum albumin and prealbumin levels. C) Perform gentle massage of the patients lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift.

A

The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patients legs E) Identification of mobility limitations

A, C, D, E

The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of the patients blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels

A, B, E

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patients left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.

D

An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins

D

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A) Raynauds phenomenon b. CAD c. Arterial insufficiency d. Varicose veins

c

When assessing venous disease in a patients lower extremities, the nurse knows that what test will most likely be ordered? a. Duplex ultrasonography

b. Echocardiography c. Positron emission tomography (PET) d. Radiography

A

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? A) Watery with blood and mucus B) Hard and black or tarry C) Dry and streaked with blood D) Loose with visible fatty streaks

A

A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting? A) Apply antibiotic ointment as ordered after cleaning the stoma. B) Apply a skin barrier to the peristomal skin prior to applying the pouch. C) Dispose of the clamp with each bag change. D) Cleanse the area surrounding the stoma with alcohol or chlorhexidine.

B

A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient? a. Spinach b. Tofu c. Multigrain bagel d. Blueberries

b

A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patients care, which of the following nursing diagnoses should the nurse prioritize? a. Ineffective Tissue Perfusion Related to Bowel Ischemia b. Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption c. Anxiety Related to Bowel Obstruction and Subsequent Hospitalization d. Impaired Skin Integrity Related to Bowel Obstruction

A

A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge? A) The familys ability to take care of the patients special diet needs B) The familys ability to monitor the patients changing health status C) The familys ability to provide emotional support D) The familys ability to manage the patients medication regimen

C

A nurse is caring for a patient with constipation whose primary care provider has recommended senna (Senokot) for the management of this condition. The nurse should provide which of the following education points? A) Limit your fluid intake temporarily so you dont get diarrhea. B) Avoid taking the drug on a long-term basis. C) Make sure to take a multivitamin with each dose. D) Take this on an empty stomach to ensure maximum effect.

B

A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms? A) A pattern of distinct exacerbations and remissions B) Severe diarrhea C) An absence of blood in stool D) Involvement of the rectal mucosa

C

The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patients medication regimen? A) Anticholinergic medications 30 minutes before a meal B) Antiemetics on a PRN basis C) Vitamin B12 injections to prevent pernicious anemia D) Beta adrenergic blockers to reduce bowel motility

A

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? A) Taking a hot bath at least once daily B) Resting in an air-conditioned room whenever possible C) Increasing the dose of muscle relaxants d. Avoiding naps during the day

b

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient? MS is a progressive demyelinating disease of the nervous system. A) B) MS usually occurs more frequently in men. C) MS typically has an acute onset. D) MS is sometimes caused by a bacterial infection.

A

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patients care plan? A) Encourage patient to void every hour. B) Order a low-residue diet. C) Provide total assistance with all ADLs. d. Instruct the patient on daily muscle stretching.

D

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? A) Cognitive declines B) Personality changes C) Contractures D) Difficulty in coordination

D

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patients safety, what nursing action should be performed? A) Ensure that suction apparatus is set up at the bedside. B) Pad the patients bed rails. C) Maintain bed rest whenever possible. D) Provide several small meals each day.

A

A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinskis reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

c

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply. A) Possible nursing home placement B) Pain associated with physical therapy C) Increasing disability D) Becoming a burden on the family E) Loss of appetite

A, C, D

A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Decreased severity and duration of exacerbations

B

A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patients care, the nurse addresses the need to enhance the patients bladder control. What aspect of nursing care is most likely to meet this goal? A) Establish a timed voiding schedule. B) Avoid foods that change the pH of urine. C) Perform intermittent catheterization q6h. D) Administer anticholinergic drugs as ordered.

A

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A) Arrange for the patient to receive a low residue diet. B) Position the patient upright during feeding. C) Suction the patient following each meal. D) Withhold liquids until the patient has finished eating.

B

A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A) The patient will likely require lifelong treatment with anticholinergic medications. B) The patient has a disproportionate risk of developing myasthenia gravis later in life. c. the patient needs to be assessed for MS. D) The disease is self-limiting and the patient will achieve pain relief over time.

c

The nurse who is a member of the palliative care team is assessing a patient. The patient indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this patient? A) Medication should be taken when pain levels are low so the pain is easier to reduce. B) Pain medication can be increased when the pain becomes intense. C) It is difficult to control chronic pain, so this is an inevitable part of the disease process. D) The patient will likely benefit more from distraction than pharmacologic interventions.

A

Two patients on your unit have recently returned to the postsurgical unit after knee arthroplasty. One patient is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other patient is reporting a pain level of 3 to 4 on the same pain scale. What is the nurses most plausible rationale for understanding the patients different perceptions of pain? A) Endorphin levels may vary between patients, affecting the perception of pain. B) One of the patients is exaggerating his or her sense of pain. C) The patients are likely experiencing a variance in vasoconstriction. D) One of the patients may be experiencing opioid tolerance.

A

You are frequently assessing an 84-year-old womans pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a patient of this age, what principle should you best apply? A) Monitor for signs of drug toxicity due to a decrease in metabolism. B) Monitor for an increase in absorption of the drug due to age-related changes. C) Monitor for a paradoxical increase in pain with opioid administration. D) Administer analgesics every 4 to 6 hours as ordered to control pain.

A

The nurse is assessing a patients pain while the patient awaits a cholecystectomy. The patient is tearful, hesitant to move, and grimacing. When asked, the patient rates his pain as a 2 at this time using a 0-to- 10 pain scale. How should the nurse best respond to this assessment finding? A) Remind the patient that he is indeed experiencing pain. B) Reinforce teaching about the pain scale number system. C) Reassess the patients pain in 30 minutes. D) Administer an analgesic and then reassess.

B

You are creating a nursing care plan for a patient with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of patients who live with chronic pain should inform your care planning? A) They are typically more comfortable with underlying pain than patients without chronic pain. B) They often have a lower pain threshold than patients without chronic pain. C) They often have an increased tolerance of pain. D) They can experience acute pain in addition to chronic pain.

D

The nurse is caring for a 51-year-old female patient whose medical history includes chronic fatigue and poorly controlled back pain. These medical diagnoses should alert the nurse to the possibility of what consequent health problem? A) Anxiety B) Skin breakdown C) Depression D) Hallucinations

C

Your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to administer the patients first scheduled dose of hydromorphone (Dilaudid). Prior to administering the drug, you would prioritize which of the following assessments? A) The patients electrolyte levels B) The patients blood pressure C) The patients allergy status D) The patients hydration status

c

Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patients orders specify an initial bolus dose. What is your priority assessment? A) Assessment for decreased level of consciousness (LOC) B) Assessment for respiratory depression C) Assessment for fluid overload D) Assessment for paradoxical increase in pain

B

Your patient is 12-hours post ORIF right ankle. The patient is asking for a breakthrough dose of analgesia. The pain-medication orders are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? A) To prevent respiratory depression from the opioid B) To eliminate the need for additional medication during the night C) To achieve better pain control than with one medication alone D) To eliminate the potentially adverse effects of the opioid

C

The nurse is caring for a patient with metastatic bone cancer. The patient asks the nurse why he has had to keep getting larger doses of his pain medication, although they do not seem to affect him. What is the nurses best response? A) Over time you become more tolerant of the drug. B) You may have become immune to the effects of the drug. C) You may be developing a mild addiction to the drug. D) Your body absorbs less of the drug due to the cancer.

A

A 52-year-old female patient is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the patients pain in her plan of nursing care, the nurse should consider what characteristic of cancer pain? A) Cancer pain is often related to the stress of the patient knowing she has cancer and requires relatively low doses of pain medications along with a high dose of anti-anxiety medications.

B) Cancer pain is always chronic and challenging to treat, so distraction is often the best intervention. C) Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications. D) Cancer pain is often misreported by patients because of confusion related to their disease process.

C

The nurse caring for a 79-year-old man who has just returned to the medicalsurgical unit following surgery for a total knee replacement received report from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that he has been agitated in the past following opioid administration. What principle should guide the nurses management of the patients pain? a. The elderly may require lower doses of medication and are easily confused with new medications. b. The elderly may have altered absorption and metabolism, which prohibits the use of opioids. c. The elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication. d. The elderly may require a higher initial dose of pain medication followed by a tapered dose.

a

You are the nurse in a pain clinic caring for an 88-year-old man who is suffering from long-term, intractable pain. At this point, the pain team feels that first-line pharmacological and nonpharmacological methods of pain relief have been ineffective. What recommendation should guide this patients subsequent care? a. The patient may want to investigate new alternative pain management options that are outside the United States. b. The patient may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options. c. The patient may want to increase his exercise and activities significantly to create distractions. d. The patient may want to relocate to long-term care in order to have his ADL needs met.

b

You are the home health nurse caring for a homebound client who is terminally ill. You are delivering a patient-controlled analgesia (PCA) pump to the patient at your visit today. The family members will be taking care of the patient. What would your priority nursing interventions be for this visit? a. Teach the family the theory of pain management and the use of alternative therapies. b. Provide psychosocial family support during this emotional experience. c. Provide patient and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication. d. Provide family teaching regarding use of morphine, recognizing morphine overdose, and offering spiritual guidance.

c

The mother of a cancer patient comes to the nurse concerned with her daughters safety. She states that her daughters morphine dose that she needs to control her pain is getting higher and higher. As a result, the mother is afraid that her daughter will overdose. The nurse educates the mother about what aspect of her pain management?

A) The dose range is higher with cancer patients, and the medical team will be very careful to prevent addiction. B) Frequently, female patients and younger patients need higher doses of opioids to be comfortable. C) The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment. D) There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

d

You have just received report on a 27-year-old woman who is coming to your unit from the emergency department with a torn meniscus. You review her PRN medications and see that she has an NSAID (ibuprofen) ordered every 6 hours. If you wanted to implement preventive pain measures when the patient arrives to your unit, what would you do? A) Use a pain scale to assess the patients pain, and let the patient know ibuprofen is available every 6 hours if she needs it. B) Do a complete assessment, and give pain medication based on the patients report of pain. C) Check for allergies, use a pain scale to assess the patients pain, and offer the ibuprofen every 6 hours until the patient is discharged. D) Provide medication as per patient request and offer relaxation techniques to promote comfort.

c

A 60-year-old patient who has diabetes had a below-knee amputation 1 week ago. The patient asks why does it still feel like my leg is attached, and why does it still hurt? The nurse explains neuropathic pain in terms that are accessible to the patient. The nurse should describe what pathophysiologic process? A) The proliferation of nociceptors during times of stress B) Age-related deterioration of the central nervous system C) Psychosocial dependence on pain medications D) The abnormal reorganization of the nervous system

d

You are the case manager for a 35-year-old man being seen at a primary care clinic for chronic low back pain. When you meet with the patient, he says that he is having problems at work; in the past year he has been absent from work about once every 2 weeks, is short-tempered with other workers, feels tired all the time, and is worried about losing his job. You are developing this patients plan of care. On what should the goals for the plan of care focus? A) Increase the patients pain tolerance in order to achieve psychosocial benefits. B) Decrease the patients need to work and increase his sleep to 8 hours per night. C) Evaluate other work options to decrease the risk of depression and ineffective coping. D) Decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety.

d

An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurses best response?

A) Pain often comes and goes with postsurgical patients. Please ask her about pain again in about 30 minutes. B) We need to provide pain medications because it is the law, and we must always follow the law. C) Unless there is strong evidence to the contrary, we should take the patients report at face value. D) Its not unusual for patients to misreport pain to get our attention when we are busy.

c

The home health nurse is developing a plan of care for a patient who will be managing his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the patient teaching? A) Self-care and safety B) Autonomy and need C) Health promotion and exercise D) Dependence and health

a

You are the emergency department (ED) nurse caring for an adult patient who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain are you addressing when you provide care for this patient? A) Chronic B) Acute C) Intermittent D) Osteopenic

b

The wife of a patient you are caring for asks to speak with you. She tells you that she is concerned because her husband is requiring increasingly high doses of analgesia. She states, He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasnt just raised and raised. What would be the nurses best response? A) I didnt know that. I will speak to the doctor about your husbands pain control. B) Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the patient relief. C) Cancer is a chronic kind of pain so the more it hurts the patient, the more medicine we give the patient until it no longer hurts. D) Does the increasing medication dosage concern you?

b

You are part of the health care team caring for an 87-year-old woman who has been admitted to your rehabilitation facility after falling and fracturing her left hip. The patient appears to be failing to regain functional ability and may have to be readmitted to an acute-care facility. When planning this patients care, what do you know about the negative effects of the stress associated with pain? A) Stress is less pronounced in older adults because they generally have more sophisticated coping skills than younger adults B) It is particularly harmful in the elderly who have been injured or who are ill. C) It affects only those patients who are already debilitated prior to experiencing pain.

D) It has no inherent negative effects; it just alerts the person/health care team of an underlying disease process.

B

You are the nurse caring for the 25-year-old victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurses aide (NA) tells you that she is concerned because the patients resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 99.1F axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as you assess this patients physiologic status? A) The patients understanding of pain physiology B) The patients serum glucose level C) The patients white blood cell count D) The patients rating of her pain

D

You are the nurse coming on shift in a rehabilitation unit. You receive information in report about a new patient who has fibromyalgia and has difficulty with her ADLs. The off-going nurse also reports that the patient is withdrawn, refusing visitors, and has been vacillating between tears and anger all afternoon. What do you know about chronic pain syndromes that could account for your new patients behavior? A) Fibromyalgia is not a chronic pain syndrome, so further assessment is necessary. B) The patient is likely frustrated because she has to be in the hospital. C) The patient likely has an underlying psychiatric disorder. D) Chronic pain can cause intense emotional responses.

D

You are caring for a patient admitted to the medical-surgical unit after falling from a horse. The patient states I hurt so bad. I suffer from chronic pain anyway, and now it is so much worse. When planning the patients care, what variables should you consider? Select all that apply. A) How the presence of pain affects patients and families B) Resources that can assist the patient with pain management C) The influence of the patients cognition on her pain D) The advantages and disadvantages of available pain-relief strategies E) The difference between acute and intermittent pain

A, B, D

A patient is experiencing severe pain after suffering an electrical burn in a workplace accident. The nurse is applying knowledge of the pathophysiology of pain when planning this patients nursing care. What is the physiologic process by which noxious stimuli, such as burns, activate nociceptors? A) Transduction B) Transmission c. Perception d. Modulation

a

A 74-year-old woman was diagnosed with rheumatoid arthritis 1 year ago, but has achieved adequate symptom control through the regular use of celecoxib (Celebrex), a COX-2 selective NSAID. The nurse should recognize that this drug, like other NSAIDs, influences what aspect of the pathophysiology of nociceptive pain? a. Distorting the action potential that is transmitted along the A-delta (d) and C fibers b. Diverting noxious information from passing through the dorsal root ganglia and synapses in the dorsal horn of the spinal cord c. Blocking modulation by limiting the reuptake of serotonin and norepinephrine d. Inhibiting transduction by blocking the formation of prostaglandins in the periphery

d

You are the nurse caring for a postsurgical patient who is Asian-American who speaks very little English. How should you most accurately assess this patients pain? a. Use a chart with English on one side of the page and the patients native language on the other so he can rate his pain. b. Ask the patient to write down a number according to the 0-to-10 point pain scale. c. Use the Visual Analog Scale (VAS). d. Use the services of a translator each time you assess the patient so you can document the patients pain rating.

a

A patients intractable neuropathic pain is being treated on an inpatient basis using a multimodal approach to analgesia. After administering a recently increased dose of IV morphine to the patient, the nurse has returned to assess the patient and finds the patient unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug? A) Acetylcysteine B) Naloxone C) Celecoxib D) Acetylsalicylic acid

B

You are assessing an 86-year-old postoperative patient who has an unexpressive, stoic demeanor. When you enter the room, the patient is curled into the fetal position and your assessment reveals that his vital signs are elevated and he is diaphoretic. You ask the patient what his pain level is on a 0-to-10 scale that you explained to the patient prior to surgery. The patient indicates a pain level of three or so. You review your pain-management orders and find that all medications are ordered PRN. How would you treat this patients pain? A) Treat the patient on the basis of objective signs of pain and reassess him frequently. B) Call the physician for new orders because it is apparent that the pain medicine is not working. C) Believe what the patient says, reinforce education, and reassess often. D) Ask the family what they think and treat the patient accordingly.

c

The nurse caring for a 91-year-old patient with osteoarthritis is reviewing the patients chart. This patient is on a variety of medications prescribed by different care providers in the community. In light of the QSEN competency of safety, what is the nurse most concerned about with this patient? A) Depression B) Chronic illness C) Inadequate pain control D) Drug interactions

d

You are caring for a patient with sickle cell disease in her home. Over the years, there has been joint damage, and the patient is in chronic pain. The patient has developed a tolerance to her usual pain medication. When does the tolerance to pain medication become the most significant problem? A) When it results in inadequate relief from pain B) When dealing with withdrawal symptoms resulting from the tolerance C) When having to report the patients addiction to her physician D) When the family becomes concerned about increasing dosage

a

You are admitting a patient to your rehabilitation unit who has a diagnosis of persistent, severe pain. According to the patients history, the patients pain has not responded to conventional approaches to pain management. What treatment would you expect might be tried with this patient? A) Intravenous analgesia B) Long-term intrathecal or epidural catheter C) Oral analgesia D) Intramuscular analgesia

b

You are caring for a 20-year-old patient with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this patient, what variables should the nurse consider? Select all that apply. a. Patients gender b. Patients comorbid conditions c. Type of procedure be performed d. Changes in neurologic function due to the procedure d. Prior effectiveness in relieving the pain

b, c, d, e

The nurse is caring for a male patient whose diagnosis of bone cancer is causing severe and increasing pain. Before introducing nonpharmacological pain control interventions into the patients plan of care, the nurse should teach the patient which of the following? A) Nonpharmacological interventions must be provided by individuals other than members of the healthcare team. B) These interventions will not directly reduce pain, but will refocus him on positive stimuli. C) These interventions carry similar risks of adverse effects as analgesics. D) Reducing his use of analgesics is not the purpose of these interventions.

D

A nurse on an oncology unit has arranged for an individual to lead meditation exercises for patients who are interested in this nonpharmacological method of pain control. The nurse should recognize the use of what category of nonpharmacological intervention? a. A body-based modality b. A mind-body method c. A biologically based therapy d. An energy therapy

b

A medical nurse is appraising the effectiveness of a patients current pain control regimen. The nurse is aware that if an intervention is deemed ineffective, goals need to be reassessed and other measures need to be considered. What is the role of the nurse in obtaining additional pain relief for the patient? A) Primary caregiver B) Patient advocate c. Team leader d. Case manager

b

A nurse has cited a research study that highlights the clinical effectiveness of using placebos in the management of postsurgical patients pain. What principle should guide the nurses use of placebos in pain management? a. Placebos require a higher level of informed consent than conventional care. b. Placebos are an acceptable, but unconventional, form of nonpharmacological pain management. c. Placebos are never recommended in the treatment of pain. d. Placebos require the active participation of the patients family.

c

The nurse is accepting care of an adult patient who has been experiencing severe and intractable pain. When reviewing the patients medication administration record, the nurse notes the presence of gabapentin (Neurontin). The nurse is justified in suspecting what phenomenon in the etiology of the patients pain? a. Neuroplasticity b. Misperception c. Psychosomatic processes d.Neuropathy

D

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when 1. the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis

C) Inflammatory phase D) Maturation phase

A

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing 2. management includes calling the physician and doing which of the following? A) Covering the wound area with sterile towels moistened with sterile 0.9% saline B) Closing the wound area with Steri-Strips C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze D) Holding the wound together until the physician arrives

A

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this 3. wound? A) Stage I pressure ulcer B) Stage II pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

c

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse 4. perform first? A) Perform hand hygiene. B) Insert a swab into the wound at 90 degrees. C) Measure the width of the wound with a disposable ruler. D) Assess the condition of the visible wound bed.

A

The nurse would recognize which of these devices as an open drainage system? A) Penrose drain B) Jackson-Pratt drain C) Hemovac D) Negative pressure dressing

a

Which is an example of a closed wound? A) Abrasion B) Ecchymosis C) Incision D) Puncture wound

b

What are the two major processes involved in the inflammatory phase of wound healing? A) Bleeding is stimulated, epithelial cells are deposited B) Granulation tissue is formed, collagen is deposited C) Collagen is remodeled, avascular scar forms D) Blood clotting is initiated, WBCs move into the wound

d

A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would 8. be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the client that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement.

b

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer 9. period of care? A) An infant B) A young adult C) A middle adult D) An older adult

d

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate 10. a need for more information? A) "I will drink a lot of orange juice and drink milk, too." B) "I will take the zinc supplement the doctor recommended." C) "I will restrict my diet to fats and carbohydrates." D) "I will drink 8 to 10 glasses of water every day."

c

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is 11. taking corticosteroid medications? A) Self-care Deficit B) Risk for Imbalanced Nutrition C) Anxiety D) Risk for Infection

d

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one 12. would be most at risk? A) A client 83 years of age who is mobile B) A client 92 years of age who uses a walker

C) A client 75 years of age who uses a cane D) A client 86 years of age who is bedfast

d

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? A) Change position at least once each shift. B) Implement a turning schedule every two hours. C) Use ring cushions for heels and elbows. D) Do not turn; use pressure-relieving support surface.

b

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) Full-thickness skin loss B) Skin pallor C) Blister formation D) Eschar formation

a

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse 15. do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers. C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery.

d

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of 16. drainage? A) Clear, watery blood B) Large numbers of red blood cells C) Mixture of serum and red blood cells D) White blood cells, debris, bacteria

d

The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the 17. wound. What should the nurse do after reading this information? A) Question the physician about the accuracy of this agent. B) Refuse to use 0.9% normal saline on a wound. C) Document the rationale for not changing the dressing. D) Continue with the dressing change as planned.

d

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during 18. dressing changes. Which response by the nurse is appropriate? A) "Oh, for gosh sakes...it doesn't look that bad!" B) "I understand, but you are going to have to look someday." C) "I respect your wish not to look at it right now." D) "You won't be able to go home until you look at it."

c

A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the 19. client indicates the need for further education? A) "I understand the rebound effect of heat." B) "I will put the heat packs only on the sore on my leg." C) "I will only leave the heat packs on for 20 minutes." D) "I will leave the heat packs on for an hour."

d

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant 20. in preventing wound infections? A) Taking medications as prescribed B) Proper intake of food and fluids C) Thorough hand hygiene D) Adequate sleep and rest

c

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client? A) Secure the heating pad to the client's clothing with safety pins. B) Place a heavy towel or blanket over the heating pad to maximize heat effects. C) Use a heating pad with a selector switch that can be turned up by the client if needed. D) Place a heating pad anteriorly or laterally to, not under, the body part.

d

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? A) A clean separation of skin and tissue with a smooth, even edge B) A separation of skin and tissue in which the edges are torn and irregular C) A wound in which the surface layers of skin are scraped away D) A shallow crater in which skin or mucous membrane is missing

b

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The 23. drainage is thin with a pale pink-yellow color. The nurse documents the drainage as

which of the following? A) Serous B) Sanguineous C) Serosanguineous D) Purulent

c

An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related 24. to what? A) Beta-hemolytic streptococcus B) Age C) V enous insufficiency D) Hemangioma

c

Which of the following clients would be considered at risk for skin alterations? Select all that apply. A) A teenager with multiple body piercings B) A homosexual in a monogamous relationship C) A client receiving radiation therapy D) A client undergoing cardiac monitoring E) A client with diabetes

a, c, e

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold 26. therapy? Select all that apply. A) Constricts peripheral blood vessels B) Reduces muscle spasms C) Increases blood flow to tissues D) Increases the local release of pain-producing substances E) Reduces the formation of edema and inflammation

a, b, e

Which of the following are functions of the skin? Select all that apply. A) Protection B) Temperature regulation C) Sensation D) Vitamin C production E) Immunological

a, b, c, e

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the 28. correct name of this wound?

A) Stage II pressure ulcer B) Stage I pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

a

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in 29. this client? A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin. Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or B) shear. Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or C) cooler as compared with adjacent tissue. Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink D) wound bed, without slough.

c

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; 30. bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages? A) Stage I B) Stage II C) Stage III D) Stage IV

c

Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound? A) Do not use irrigation to clean the wound before changing the dressing. B) Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it. C) Exert light pressure to pack the wound tightly with moistened dressing. D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.

d

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of 32. dressing for this wound? A) Saline-moistened dressing B) Dressing secured with Montgomery straps C) Hydrocolloid dressing D) Foam dressing

c

Which of the following is an indication for the use of negative pressure wound therapy? A) Bone infections B) Malignant wounds C) Wounds with fistulas to body cavities D) Pressure ulcers

d

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client 34. requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom D) Provide supplies and assist with hard-to-reach areas

d

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is 1. worse with ambulation. The nurse will document this type of pain as which of the following? A) Somatic pain B) Cutaneous pain C) Visceral pain D) Phantom pain

a

Which statement accurately describes pain experienced by the older adult? A) Boredom and depression may affect an older person's perception of pain. B) Residents in long-term care facilities have a minimal level of pain. C) The older client has decreased sensitivity to pain. d. a heightned pain tolerance occurs in the older adult

a

Pet therapy is commonly used in long-term facilities for distraction. If a client is experiencing pain and the pain is 3. temporarily decreased while petting a visiting dog or cat, this is an example of which type of distraction technique? A) Tactile kinesthetic distraction B) Visual distraction C) Auditory distraction D) Project distraction

a

Of the following individuals, who can best determine the experience of pain? A) The person who has the pain

B) The person's immediate family C) The nurse caring for the client D) The physician diagnosing the cause

a

A client who has breast cancer is said to be in remission. What does this term signify? A) The client is experiencing symptoms of the disease. B) The client has end-stage cancer. C) The client is experiencing unremitting pain. D) The disease is present but the client is not experiencing symptoms.

d

Which of the following clients would be classified as having chronic pain? A) A client with rheumatoid arthritis B) A client with pneumonia C) A client with controlled hypertension D) A client with the flu

a

A client has a severe abdominal injury with damage to the liver and colon from a motorcycle crash. What type of pain 7. will predominate? A) Psychogenic pain B) Neuropathic pain C) Cutaneous pain D) Visceral pain

d

A client in the emergency department is diagnosed with a myocardial infarction (heart attack). The client describes pain 8. in his left arm and shoulder. What name is given to this type of pain? A) Cutaneous pain B) Referred pain C) Allodynia D) Nociceptive

b

Why is acute pain said to be protective in nature? A) It warns an individual of tissue damage or disease. B) It enables the person to increase personal strength. C) As a subjective experience, it serves no purpose. d. as an objective experience, it aids diagnosis

a

A client tells the nurse that she is experiencing stabbing pain in her mouth, gums, teeth, and chin following brushing her 10. teeth. These are symptoms of which of the following pain syndromes?

A) Complex regional pain syndrome B) Postherpetic neuralgia C) Trigeminal neuralgia D) Diabetic neuropathy

c

A nurse implements a back massage as an intervention to relieve pain. What theory is the motivation for this 11. intervention? A) Gate control theory B) Neuromodulation C) Large/small fiber theory D) Prostaglandin stimulation

a

A client has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be 12. released in the body during relaxation to relieve pain? A) Narcotics B) Sedatives C) A-delta fibers D) Endorphins

d

How may a nurse demonstrate cultural competence when responding to clients in pain? A) Treat every client exactly the same, regardless of culture. B) Be knowledgeable and skilled in medication administration. C) Know the action and side effects of all pain medications. D) Avoid stereotyping responses to pain by clients.

d

Which client would be most likely to have decreased anxiety about, and response to, pain as a result of past experiences? A) One who had pain but got adequate relief B) One who had pain but did not get relief C) One who has had chronic pain for years D) One who has had multiple pain experiences

a

Which misconception is common in clients in pain? A) "I will get addicted to pain medications." B) "I need to ask for pain medications." C) "The nurses are here to help relieve the pain." D) "I do not have to fight the pain without help."

a

What is the term used to describe a pharmaceutical agent that relieves pain? A) Antacid B) Antihistamine C) Analgesic D) Antibiotic

c

A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would 17. the nurse recommend to the client? A) "Only take morphine when you have the most severe pain." B) "Increase fluids and high-fiber foods, and use a mild laxative." C) "Administer an enema to yourself every third day." D) "Constipation is nothing to worry about; take your medicine."

b

Which client would benefit from a p.r.n. drug regimen? A) One who had thoracic surgery 12 hours ago B) One who had thoracic surgery four days ago C) One who has intractable pain D) One who has chronic pain

b

A nurse is teaching an alert client how to use a PCA system in the home. How will she explain to the client what he must 19. do to self-manage pain? A) "You don't have to do anything. The machine does it all." B) "I will teach your family what they need to do." C) "When you push the button, you will get the medicine." D) "The medicine is going into your body all the time."

c

A middle-age client is complaining of acute joint pain to a nurse who is assessing the client's pain in a clinic. Which of 20. the following questions related to pain assessment should the nurse ask the client? A) Does your diet include red meat and poultry products? B) Does your pain level change after taking medications? C) Are your family members aware of your pain? D) Have you thought of the effects of your condition on your family?

b

A client having acute pain tells the nurse that her pain has gradually reduced, but that she fears it could recur and 21. become chronic. What is a characteristic of chronic pain? A) Chronic pain will lead to psychological imbalance. B) Chronic pain has far-reaching effects on the client. C) Chronic pain can be severe in its initial stages. D) Chronic pain eases with healing and eventually disappears.