Nursing Considerations for Pain Management, Exams of Nursing

Download Nursing Considerations for Pain Management and more Exams Nursing in PDF only on Docsity! 1 | P a g e NURS 215 EXAM 2 (ARIZONA COLLEGE OF NURSING) 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST|LATEST UPDATE |GUARANTEED PASS a nurse is discussing the care of a group of clients with a newly licensed nurse. which of the following clients should the newly licensed nurse identify has experiencing chronic pain? a. a client who has a broken femur and reports hip pain b. a client who has incisional pain 72 hr following pacemaker insertion c.a client who has food poisoning and reports abdominal cramping d. a client who has episodic back pain following a fall 2 years ago d. a client who has episodic back pain following a fall 2 years ago a nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. which of the following effects should the nurse anticipate? select all that apply a. urinary incontinence b. diarrhea c. bradypnea d. orthostatic hypotension e. nausea c. bradypnea d. orthostatic hypotension e. nausea a nurse is caring for a client who is receiving morphine via a Patient controlled analgesia infusion device after abdominal surgery. which of the following statements indicates that the client knows how to use the device? 2 | P a g e a. i'll wait to use the device until it's absolutely necessary b. i'll be careful about pushing the button too much so i don't get an overdose c. i should tell the nurse if the pain does't stop while i am using the device d. i will ask my adult child to push the dose button when i am sleeping c. i should tell the nurse if the pain does't stop while i am using the device A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? a. Offer information on a relaxation technique and ask the client if he is interested in trying it. b. Request a social worker to see the client to discuss meditation. c. Attempt to use biofeedback techniques with the client d. Tell the client many people feel the same way before surgery and to think of something else a. Offer information on a relaxation technique and ask the client if he is interested in trying it. A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. The nurse should suspect the tea includes which of the following ingredients? a. Chamomile b. Ginseng c. Ginger d. Echinacea a. chamomile A nurse is reviewing complementary and alternative therapies with a group of nursing students. The nurse should classify which of the following interventions as a mind-body therapy? (Select all that apply.) a. Art therapy b. Acupressure c. Yoga d. Therapeutic touch e. Biofeedback a. Art therapy c. Yoga e. Biofeedback A nurse is teaching a group of nursing students on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (Select all that apply.) a. Guided imagery b. Massage therapy c. Meditation 5 | P a g e reduced sensory input from the internal or external environment Can result from illness or trauma, or isolation sensory deficit a change in reception and or perception, can affect any of the senses factors the affect sensory stimulation Neurologic deficit Stroke Environment fear/anxiety Aging A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professional are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (select all the apply) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A. Planning and evaluating control and prevention strategies B. Determining public health priorities D. Identifying endemic disease E. Monitoring for common-source outbreaks A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? A. allergic reaction B. ringworm C. systemic lupus erythematosus D. Tuberculosis D. Tuberculosis A nurse is caring for a client who repots a severe throat, pain when swallowing, and swollen lymph nodes. The client has manifestations of which of the following conditions? 6 | P a g e A. prodromal B. ringworm C. convalescence D. Illness illness A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized vs a systemic infection. Which of the following are manifestations of a systemic infection. (select all that apply) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate A. Fever B. Malaise E. Increase in pulse and respiratory rate A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all. A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when preforming care that may result in contamination from secretions B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable E. Wear a gown when preforming care that may result in contamination from secretions What is an infection? occurs when a pathogen is present and leads to a chain of events What is the best prevention against HAIs? Hand hygiene iatrogenic infections result from diagnostic or therapeutic procedures Transmission Chain of Infection 1. Causative agent 2. Reservoir 3. Portal of exit 7 | P a g e 4. Mode of transmission 5. Portal of entry 6. Susceptible host Transmission chain of infection example of MRSA and the Wrestler 1. Causative agent- MRSA 2. Reservoir- Athlete 3. Portal of exit- Contact w/ mat 4. Mode of transmission- skin contact w/ gear 5. Portal of entry- nose, skin lesion, mouth 6. Susceptible host- broken skin, compromised, brewed skin What is the reservoir in the chain of infection? where pathogens can live and multiply, ex. human, animal, food, or organic matter what is the portal of exit in the chain of infection? where the pathogen can leave the reservoir and spread ex body fluids, respiratory, GI tract, skin, MM What are the stages of an infection? 1. Incubation-Interval between the pathogen entering the body and presentation of the first finding 2. Prodromal stage-Interval from onset to more distinct findings, the pathogen multiples during this time 3. Illness stage- Interval when findings specific to the infection occur 4. Convalescence- Interval when acute findings disappear, total recovery taking days to months Lab values associate with infections Leukocytosis- WBC greater than 10,000 Left shift- increase neutrophils Elevated Erythrocyte sedimentation over 20mm/hr Positive culture Contact transmission examples D+, CDF, open wounds, and MRSA Droplet Transmission examples Pneumonia, pertussis, strep, COVID-larger than 5cmg, and RSV Airborne examples Covid-smaller than 5mcg, measles, TB, Varicella 10 | P a g e A. Turn the clients head to the side B. place two fingers in the client's mouth to open it C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the clients mouth A. Turn the clients head to the side A nurse is instructing a client who has diabetes mellitus about footsore. Which of the following guidelines should the nurse include. Select all that apply A. Inspect the feet daily B. Use moisturizing lotion on the feet C. Wash the feet with warm water and let them air dry D. Use over-the-counter products to treat abrasions E. Wear cotton socks A. Inspect the feet daily B. Use moisturizing lotion on the feet (not in-between toes) E. Wear cotton socks A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following guidelines should the nurse include. Select all that apply A. Schedule rest periods during morning care B. Discontinue morning care for 2 days C. Perform all care as quickly as possible D. Ask a family member to come in to bathe the client A. Schedule rest periods during morning care A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. face B. feet C. chest D. arms A. face A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove B. Brush the dentures with a toothbrush and denture cleaner C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storage container after cleaning them 11 | P a g e B. Brush the dentures with a toothbrush and denture cleaner What are 5 benefits of good hygiene? 1. promotes comfort 2. improves self body image 3. decreases infection and disease 4. promotes autonomy 5. social interaction or relaxation What roles does a nurse play in hygiene? Assess self care abilities Provide assistance with ADLS Promote self care in ADLS Delegate appropriate parts for hygiene care What factors can affect a clients view on hygiene? Cultural preferences Socioeconomic status Knowledge level Physical factors include pain, limited mobility, sensory, cognitive or emotional impairments When is hygiene routinely done? Hourly rounds-Offer help with self-care needs Early morning care-On awakening, wash face, hands and mouth care AM care-After breakfast, bathing, toileting, hair, skin and bed making PM care-Toileting, handwashing, oral care, readying for visitors HS care-Prior to sleep, relaxation, activism reading environment to facilitate sleep What are the different types of baths administered in the hospital setting? Assist bath- Areas hard to reach Complete bath Partial bath-Bathe only areas absolutely necessary include peritoneal, a complete bath may be too stressful Towel bath Bag/ package 12 | P a g e Shower Tub bath Therapeutic bath-Eczema, diaper rash important factors to remember while preforming oral care Decreases risk of infection that causes pneumonia, risk for aspiration, impaired swallowing or decreased gag reflex important factors to remember when performing oral care on altered patient have suction ready, do not place fingers in the mouth, keep head turned to one side important factors of foot care Prevents skin breakdown, pain, and infection that could interfere with gait Avoid applying moisturizer in between toes Avoid alcohol products Diabetes-Should be cared for by a qualified personnel to prevent injury and evaluate feet important factors while preforming scalp care Essential component of personal hygiene brushing/combing hair- Removes tangles, stimulates the scalp and circulation Use of soft bristle to prevent trauma important factors of nail care Observe size, shape, and condition of nails and nail beds Check from cracking, clubbing, and fungus Do not soak due to infection File nails instead of cutting Acute pain characteristics protective, temporary, usually self-limiting has a direct cause 15 | P a g e TENS stimulation Distraction-TV or visitors Acupuncture Ice/ heat elevation Reposition Music Humor Check bed linens/hygiene exercise a nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. the nurse asks the client whether he has nausea and has been vomiting. which of the following pain characteristics is the nurse attempting to determine? a. presence of associated manifestations b. location of the pain c. pain quality d. aggravating and relieving factors a. presence of associate manifestations a nurse is collecting data from a client who is reporting pain despite taking analgesia. which of the following actions should the nurse take to determine the intensity of the client's pain? a. ask the client what precipitates the pain b. question the client about the location of the pain c. offer the client a pain scale to measure his pain d. use open- ended questions to identify the client's pain sensations c. offer the client a pain scale to measure his pain Which data, if assessed on a client, would be the most indicative of peripheral arterial disease? Select all that apply. 1. absence of hair on the big toe bilaterally 2. bilateral brown pigmentation around the ankles 16 | P a g e 3. pain that decreased with elevation of lower extremities 4. weak dorsalis pedal pulses bilaterally 5. lower extremities cool bilaterally 1, 4, & 5 Which, data is assessed on a client, would be the most indicative of peripheral venous disease? Select all that apply. 1. absence of hair on the big toe bilaterally 2. bilateral brown pigmentation around the ankles 3. pain that decreased with elevation of lower extremities 4. weak dorsalis pedal pulses bilaterally 5. lower extremities cool bilaterally 2 & 3 Which anatomical position would be most accurate for the nurse to use when assessing the dorsalis pedis pulse? 1. behind the knee 2. over the lateral malleolus 3. in the groove behind the medial malleolus 4. lateral to the extensor tendon of the great toe 4 A client reports the new onset of pain in the left calf after climbing approximately 10 stairs that is relieved after sitting for 2 minutes. What is the best term for the RN to document his finding as? 1. intermittent claudication 2. DVT 3. Raynaud's pnenomenon 4. Lymphedema 1 Which principle(s) are most important to incorporate when completing a peripheral vascular assessment of the upper and lower extremities? Select all that apply. 1. look for symmetry bilaterally 2. palpate and grade pulses 3. omit palpation of the lymph nodes 4. utilize Homan's sign to rule out DVT 5. Assess for sensory and motor function 1, 2, & 5 Where are bronchial sounds heard when auscultating the lungs? neck 17 | P a g e The nurse is assessing a 69-year-old client's risks for lung disease. The client states, "It shouldn't be a problem for me. My spouse smokes quite heavily but I've been a lifelong nonsmoker." the nurse should recognize the need to teach the client about what topic? health risks of second hand smoke The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs? right lung has 3 lobes left lung has 2 lobes Which action by a nurse demonstrates the proper sequence for auscultation of the lungs? listen at each site for at least one complete respiratory cycle What characteristic nail color should the nurse recognize as an indication of hypoxia? cyanotic What are the signs of hypoxia? Select all that apply. 1. Respiratory rate > 30 2. Cyanosis 3. Retractions 4. Use of accessory muscles to breathe 5. Oxygen saturation of 90% 6. Increased level of consciousness 1, 2, 3, & 4 Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. What position is the client in? tripod position Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder? chronic obstructive pulmonary disorder (COPD) A nurse performs a respiratory assessment on a client and notes the respiratory rate was 10 breaths/min. the nurse knows the proper term for this rate is what? bradypnea Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first? 1.document findings as normal 2. wait 5 minutes and listen again 20 | P a g e - lessens with limb elevation - worsens with limb dependence Regarding placement of leg, what does dependent mean? when it's positioned below the level of the heart, allowing blood to flow into the limb by gravity Characteristics of bronchial breath sounds? - inspiration < expiration - harsh, hollow, tubular - heard over trachea and larynx Characteristics of bronchovesicular breath sounds? - inspiration = expiration - over major bronchi (fewer alveoli) - posterior between scapulae especially on right - anterior around sternum in 1st & 2nd intercostal spaces Characteristics of vesicular breath sounds? - inspiration > expiration - rustling (wind in trees) - over the peripheral lung fields where air flows through smaller bronchioles and alveoli Where is S1 louder than S2? apex of heart Where is S2 louder than S1? base of heart Is S3 a normal heart sound and where can you hear it best? - may be normal finding in children and young adults - heard best at mitral area Is S4 a normal heart sound and where can you hear it best? - may be normal in the elderly - heard best at tricuspid area Characteristics of heave or lift during cardiac assessment? - seen on inspection - sustained forceful thrusting of the ventricle during systole - occurs with ventricular hypertrophy - RIGHT ventricular heave seen at sternal border - LEFT ventricular heave seen at apex Characteristics of thrill during cardiac assessment? 21 | P a g e - felt upon palpation - signifies turbulent blood flow - directs you to the origin of murmur * absence of thrill does not rule out a murmur* What is a pulse deficit? check when you have an irregular pulse apical - radial pulse: record the remainder as the pulse deficit signals a weak contraction of ventricles occurs with atrial fibrillation, premature beats, and HF What are some symptoms of hypoxemia? - confusion - irritability - restlessness - memory loss - decrease exercise tolerance What is PND (paroxysmal nocturnal dyspnea)? awakening from sleep with SOB and need to be upright When observing sputum production, what does the acronym COCA stand for? Color Odor Consistency Amount What occurs during inspiration to anatomy of body? 1. Diaphragm contracts 2. Ribs move upward and outward 3. Sternum moves outward 4. Thorax enlarges 5. Permits lungs to expand and fill with air What occurs during expiration to anatomy of body? 1. Diaphragm relaxes 2. Ribs move downward and inward 3. Sternum moves inward 4. Thorax decreases What are the 5 A's when obtaining a health history of smoking? Ask Advise Assess 22 | P a g e Assist Arrange What equipment is used when examining the lungs? Stethoscope What is a normal respiratory rate and what should you do if it is irregular/dyspneic/labored? Normal rate: 12-20 Measure for full 60 seconds What is a normal AP:T ratio? 2:1 What does an AP:T ratio of 1:1 indicate? barrel chest When palpating the lungs what is it called when you feel a coarse, crackling sensation? Crepitus When palpating the lungs, what is it called when you're comparing vibrations (having pt repeat 99)? Tactile Fremitus Where are the different lung sounds heard? - Bronchial - Bronchovesicular - Vesicular When auscultating the lungs, what does crackles sound like? Popping sound When auscultating the lungs, what does atelectatic crackles sound like? Popping sounds that clear after a few breaths or coughing When auscultating the lungs, what does wheezing sound like? Musical sounds When auscultating the lungs, what does stridor sound like? Noisy, high-pitched sound 25 | P a g e When assessing Raynaud's disease what occurs to the clients skin? 1. Fingers can become white due to lack of blood flow 2. Fingers may turn blue as blood vessels dilate to keep the blood in tissues 3. Finally, fingers may turn red as blood begins to return What is brawny edema? 1. tissue is firm 2. no pitting 3. skin surface is hard, shiny, moist What is +1 edema? 1. slight indentation 2. normal contours What is +2 edema? 1. pitting lasts longer than +1 2. deeper pitting 3. fairly normal contour What is +3 edema? 26 | P a g e 1. deep pit 2. remains several seconds after palpation 3. skin swelling obvious at inspection What is +4 edema? 1. very deep pit 2. remains for a prolonged time after palpation (minutes) 3. frank swelling If DVT is expected, what should the nurse do? Measure calf circumference