Fundamental Nursing Skills and Concept 10th Edition Timby -Test Bank

<< Foundations of Mental Health Care 5th Ed By Michelle Morrison Valfre-Test Bank Health Promotion Throughout The Life Span 7th Edition by Carole Lium Edelman -Test Bank >>
Product Code: 222
Availability: In Stock
Price: $24.99
Qty:     - OR -   Add to Wish List
Add to Compare

Fundamental Nursing Skills and Concept 10th Edition Timby -Test Bank

Description

WITH ANSWERS
Fundamental Nursing Skills and Concept 10th Edition Timby -Test Bank
Chapter 2- Nursing Process
1. A client reports to a health care facility with complaints of abdominal pain and vomiting. The clients wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?
  A) Clients friends
  B) Clients wife
  C) Client himself
  D) Test reports
  Ans: C
  Feedback:
  As the client is in a conscious state, he himself is the primary source of information since he can give firsthand information. The clients wife, friends, and test results would be the secondary sources of data.

 

 

2. A client with HIV has been admitted to a health care facility. Which of the following nursing diagnoses should be of the highest priority, keeping in mind the clients condition?
  A) Risk for activity intolerance
  B) Risk for ineffective coping
  C) Risk for infection
  D) Risk for imbalanced nutrition
  Ans: C
  Feedback:
  Clients with HIV have decreased immunity and are prone to infections. Infection in a client with HIV is life-threatening, because it makes the client vulnerable to other infections, and also impairs his or her already weakened immune functions. Clients with HIV may not have problems with other activities and food. They may often feel depressed, but this is not the highest priority.

 

 

3. A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data?
  A) Blood pressure
  B) Nausea
  C) Heart rate
  D) Respiratory rate
  Ans: B
  Feedback:
  Subjective data are those that the client can feel and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.

 

 

4. A client who has to undergo a thyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
  A) Risk for impaired physical mobility due to surgery
  B) Ineffective denial related to poor coping mechanisms
  C) Disturbed body image related to the incision scar
  D) Risk of injury related to surgical outcomes
  Ans: C
  Feedback:
  The client is concerned about the surgery scar on his neck, which would disturb his body image; therefore, the appropriate diagnosis should be disturbed body image related to the incision scar. Risk for impaired physical mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, ineffective denial related to poor coping mechanisms and injury related to surgical outcomes are also not related to the clients concern.

 

 

5. A nurse is giving postoperative care to a client after knee arthroplasty. Which of the following is a possible short-term goal for this client?
  A) To ambulate the client to a bedside chair
  B) To help the client return to activities of daily life
  C) To maintain a healthy and active lifestyle
  D) To prevent repeat surgery in the client
  Ans: A
  Feedback:
  The short-term goal in this case is to help the client ambulate to the bedside chair. The other goals, such as helping the client return to activities of daily life, to maintain a healthy and active lifestyle, and to prevent repeat surgery in the client are long-term goals and may take weeks or months to achieve. On the other hand, short-term goals can be achieved in a day or a week.

 

 

6. A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which of the following nursing diagnoses is the highest priority for this client?
  A) Impaired comfort
  B) Disturbed body image
  C) Disturbed sleep pattern
  D) Activity intolerance
  Ans: A
  Feedback:
  Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurses first priority. According to Maslow, physiologic needs are the highest priority. The client may have disturbed body image, disturbed sleep patterns, or activity intolerance, but all these are secondary to pain.

 

 

7. The nurse is performing an assessment of a client diagnosed with excess fluid volume due to renal failure. Which of the following assessment data is the nurse likely to find?
  A) Hypotension
  B) Feeble pulse
  C) Crackles
  D) Drowsiness
  Ans: C
  Feedback:
  Crackles are the most important sign found in excess fluid volume. The client has the nursing diagnosis of excess fluid volume. The signs of increased fluid volume are adventitious lung sounds, a bounding pulse, and high blood pressure; therefore, a diagnosis of hypotension or feeble pulse would be incorrect. Consciousness may become impaired at later stages when the fluid shift starts. The adventitious lung sounds indicate excess fluid volume.

 

 

8. A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. What nursing diagnosis is the priority in this clients care?
  A) Impaired gas exchange related to the disease condition
  B) Impaired verbal communication related to the breathing problem
  C) Inability to speak due to ineffective airway clearance
  D) Impaired physical mobility related to shortness of breath
  Ans: A
  Feedback:
  The client is most likely experiencing impaired gas exchange as a result of the pathophysiology of asthma. This is a priority over mobility and communication issues, though each may be valid. Inability to speak due to ineffective airway clearance is not a proper nursing diagnosis.

 

 

9. A nurse is caring for a client with Parkinson disease. Which of the following nursing diagnoses identified by the nurse should be of the highest priority?
  A) Impaired physical mobility
  B) Risk for memory loss
  C) Ineffective role performance
  D) Risk for injury
  Ans: D
  Feedback:
  Clients with Parkinson disease are at higher risk of injury due to their physical limitations and cognitive deficiencies. Therefore, it becomes important for the nurse to ensure that the environment is safe. The client may also have impaired physical mobility, risk for memory loss, and ineffective role performance, but the highest priority is to prevent injury and ensure the clients safety.

 

 

10. A nurse is caring for a client with cancer who is experiencing pain. Which of the following would be the most appropriate assessment of the clients pain?
  A) Pain relief after nursing intervention
  B) Verbal and nonverbal cues of client
  C) The nurses impression of the clients pain
  D) The clients pain based on a pain rating
  Ans: D
  Feedback:
  The clients assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 1 to 10 scale and nursing actions are then implemented to reduce the pain. The nurses impression of pain and nonverbal clues are subjective data. Pain relief after nursing intervention is appropriate, but is a part of evaluation.

 

 

11. A client is admitted to a psychiatric treatment unit with psychosis. Which of the following is the most appropriate diagnosis for this client?
  A) Dressing/grooming self-care deficit
  B) Disturbed thought process
  C) Risk for confusion
  D) Risk for imbalanced nutrition
  Ans: B
  Feedback:
  A client with psychosis is unable to recognize certain aspects of reality. The client may also experience hallucinations and delusions. Therefore, disturbed thought process is the most appropriate nursing diagnosis for such a client. The client may be at risk for confusion, have difficulty in dressing and grooming, and may not eat properly; however, the priority is the thought process because it is the main reason for all other symptoms.

 

 

12. When caring for a client, the nurse identifies and analyzes data to determine nursing diagnoses and collaborative problems. Which of the following is an important role of the nurse when caring for a client with collaborative problems?
  A) Identifying factors that place the client at risk
  B) Resolving health issues through independent nursing measures
  C) Reporting trends that suggest development of complications
  D) Managing an emerging problem with the help of the registered nurse
  Ans: C
  Feedback:
  The nurse should report trends that suggest development of complications to bring to notice the need for collaborative intervention for a client. Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. Identifying factors that place the client at risk, resolving health issues through independent nursing measures, and managing an emerging problem with the help of the registered nurse are nursing roles performed during a nursing diagnosis.

 

 

13. A nurse is documenting the plan of care for a client with AIDS. Which of the following is most important when documenting the plan of care?
  A) Avoid disclosing the clients name and address on the plan of care.
  B) Ensure that the clients medical record and nursing interventions are written.
  C) Ask one particular nurse to revise and update the plan of care daily.
  D) Ensure that the clients medical insurance number is stated on the sheet.
  Ans: B
  Feedback:
  The nurse should document the clients medical record and the planned nursing interventions in the plan of care as per the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements. To communicate the plan of care, each nurse assigned to the client refers to the sheet, reviews it, and revises it daily. Stating the medical insurance number of the client on the sheet is of secondary importance as it ensures reimbursement from insurance companies. Nurses make certain that the client is identified on the plan of care.

 

 

14. A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which of the following actions should the nurse perform before revising a plan of care?
  A) Discuss any lack of progress with the client.
  B) Collect information on expected outcomes.
  C) Identify the clients health-related problems.
  D) Select more appropriate nursing interventions.
  Ans: A
  Feedback:
  The nurse should discuss any lack of progress with the client so that both the client and the nurse can speculate on what activities need to be discontinued, added, or changed. Collecting information is done during the assessment. Identification of the clients health-related problems is done during diagnosis. Nurses select appropriate nursing interventions and document the plan of care in the planning stage of the nursing process, not during evaluation.

 

 

15. A nurse provides care in a variety of different settings but is aware of the fact that the nursing process is equally applicable to each of these settings. The nursing process is best defined as:
  A) A group of tasks that cumulatively result in the resolution of health problems
  B) A process by which diseases are cured with the full involvement of the client himself or herself
  C) An organized sequence of steps with the goal of managing a clients health problems
  D) A process for distributing finite nursing time and energy for maximum benefit to clients
  Ans: C
  Feedback:
  The nursing process is an organized sequence of problem-solving steps used to identify and to manage the health problems of clients. It is a way of thinking and not solely a group of tasks and it does not always lead to the curing of disease. The main goal of the nursing process is not the equitable distribution of finite resources, though this is often necessary.

 

 

16. A client has been admitted to the acute medical unit of the hospital after an exacerbation of chronic obstructive pulmonary disease. Which of the following aspects of this clients care exemplifies the seven characteristics of the nursing process? Select all that apply.
  A) The nurse ensures that interventions are within the legal scope of nursing.
  B) The nurse weighs treatment options in light of financial costs to the hospital.
  C) The nurse chooses interventions that can be performed without the involvement of other disciplines.
  D) The nurse applies a systematic critical thinking process when providing care to the client.
  E) The nurse seeks to involve the client in the planning and execution of care.
  Ans: A, D, E
  Feedback:
  Characteristics of the nursing process include active client involvement, critical thinking, and respect for legal parameters. The nurse does not choose interventions based on the fact that they exclude members of other health disciplines. Consideration of costs to the institution is not a primary characteristic of the nursing process.

 

 

17. A nurse is planning the nursing care of an elderly client who presented to the emergency department in respiratory distress and has been admitted to an inpatient unit. Which of the following nursing diagnoses is correctly worded?
  A) Excess fluid volume related to congestive heart failure as manifested by peripheral and pulmonary edema
  B) Exacerbation of congestive heart failure related to peripheral edema, excess fluid volume, and pulmonary edema
  C) Excess fluid volume and impaired gas exchanged related to congestive heart failure
  D) Congestive heart failure resulting ineffective airway clearance related to pulmonary edema
  Ans: A
  Feedback:
  The diagnosis, Excess fluid volume related to congestive heart failure as manifested by peripheral and pulmonary edema contains the three parts of a nursing diagnostic statement: problem, etiology, and signs and symptoms. The diagnostic statement should begin with the nursing diagnosis, not the etiology, and each statement should include only one nursing diagnosis.

 

 

18. Following the completion of a comprehensive assessment, a nurse has identified the following nursing diagnosis for a newly admitted client: Risk for aspiration related to dysphagia as evidenced by coughing during feeding. The phrase related to dysphagia constitutes what component of a nursing diagnostic statement?
  A) Etiology
  B) Pathophysiology
  C) Root cause
  D) Epidemiology
  Ans: A
  Feedback:
  The phrase related to denotes the etiology of a nursing diagnosis.

 

 

19. A nursing student has been providing care for a client at the health care facility for the past several days. The client has a number of comorbid health problems and is being simultaneously treated for many of these. The student has chosen to create a concept map because concept mapping allows the student to:
  A) Identify the health problem that is most deserving of the students care and attention
  B) Identify the relationships between the various aspects of the clients health circumstances
  C) Create a plan that differentiates between nursing diagnoses and medical diagnoses
  D) Evaluate the applicability of nursing diagnoses and the effectiveness of nursing interventions
  Ans: B
  Feedback:
  A concept map is primarily a tool for organizing data and identifying relationships. It is not primarily a tool for prioritizing particular health problems or facilitating evaluation of interventions. Concept mapping can be used to inform care planning, but the two processes are not synonymous.

 

Chapter 20- Pain Management

1. A nurse is caring for a client who was administered opioids. The client complains of constipation. What other potential side effect of opioids should the nurse assess for?
  A) Sedation
  B) Anxiety
  C) Diarrhea
  D) Insomnia
  Ans: A
  Feedback:
  Opioids and opiates cause sedation, nausea, constipation, and respiratory depression, which are the main side effects to watch for with narcotics. Opioids and opiates do not as commonly lead to anxiety, diarrhea, or insomnia in clients.

 

 

2. A nurse is caring for a client who has undergone a surgical intervention in which the pain pathways in his spinal cord have been interrupted to control pain in his back. Which of the following treatments does the nurse know that the client has undergone?
  A) Cordotomy
  B) Tubectomy
  C) Rhizotomy
  D) Osteotomy
  Ans: A
  Feedback:
  The client has undergone a cordotomy, which is the surgical interruption of pain pathways in the spinal cord to control pain. A tubectomy, in general terms, means the cutting of the fallopian tubes. A rhizotomy is the surgical sectioning of a nerve root close to the spinal cord. It prevents sensory impulses from entering the spinal cord and traveling to the brain. An osteotomy is a surgical operation whereby a bone is cut to shorten, lengthen, or change its alignment.

 

 

3. A nurse is caring for a middle-aged client with acute abdominal pain at a health care facility. The physician has ordered a regimen of narcotics but the client is unable to take the medication orally due to a tracheostomy. What other delivery route might the physician prescribe?
  A) Sublingual route
  B) Inhaled route
  C) Dermal route
  D) Transdermal route
  Ans: D
  Feedback:
  Opioids are available for administration by the transdermal, oral, rectal, or parenteral route. Dermal, inhaled, and sublingual administration are not typically used for opioids.

 

 

4. A nurse is caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?
  A) Transduction
  B) Transmission
  C) Modulation
  D) Perception
  Ans: A
  Feedback:
  The client is going through the transduction phase, which is the first phase of pain in which injured cells release chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. The client is not going through the transmission, perception, or modulation phase of pain. Transmission is the phase during which stimuli move from the peripheral nervous system toward the brain. Perception occurs when the pain threshold is reached. Modulation is the last phase of pain impulse transmission, during which the brain interacts with the spinal nerves to alter the pain experience.

 

 

5. A middle-aged client is complaining of acute joint pain to a nurse who is assessing the clients pain in a clinic. Which of the following questions related to pain assessment should the nurse prioritize?
  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 those around you?
  Ans: B
  Feedback:
  The nurse should ask direct and specific questions about the nature of the pain and whether it changes with medication, as this helps the nurse to quickly gather objective data about the clients pain. The nurse should avoid asking irrelevant and closed-ended questions, such as whether the clients diet includes red meat and poultry products or whether the client has thought about the effects of his condition on the rest of his family. These types of questions do not add any value to pain assessment but could make the client feel more depressed and uncomfortable.

 

 

6. A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client most likely experiencing?
  A) Visceral pain
  B) Cutaneous pain
  C) Somatic pain
  D) Neuropathic pain
  Ans: A
  Feedback:
  The client is experiencing visceral pain, which is associated with disease or injury. It is sometimes referred or poorly localized as it is not experienced in the exact site where an organ is located. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

 

 

7. A middle-aged client with cancer has been prescribed patient-controlled analgesia PCA. The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?
  A) The client obtains pain relief slowly and steadily.
  B) The client determines the maximum daily dose.
  C) The client is able to have long hours of rest.
  D) The client is actively involved in pain management.
  Ans: D
  Feedback:
  PCA gives the client the advantage of playing an active role in pain management, as the client is allowed to self-administer medication. Pain relief is rapid, not slow and steady, because the drug is delivered intravenously. The client cannot administer the pain medication as needed because the nurse programs the infusion device to control doses.

 

 

8. A physician is explaining to the client the role of endogenous opioids in the transmission of pain. What happens when endogenous opioids are released?
  A) They bind to sites on the nerve cells membrane.
  B) They react with acetylcholine and serotonin.
  C) They occupy cell receptors for neurotransmitters.
  D) They block glutamate receptors and peptides.
  Ans: A
  Feedback:
  When endogenous opioids are released, they are thought to bind to sites on the nerve cells membrane that block the transmission of pain-conducting neurotransmitters such as substance P and prostaglandins. Endogenous opioids do not occupy cell receptors for neurotransmitters like acetylcholine and serotonin, but efforts are being made to develop pain-modulating drugs that will do so and will also block glutamate receptors and peptides.

 

 

9. A client having acute pain tells the nurse that her pain has gradually reduced, but that she fears it could recur and 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.
  Ans: B
  Feedback:
  Chronic pain has far-reaching effects on the client because the discomfort lasts longer than 6 months. Chronic pain is not as severe in the initial stage as acute pain, but does not disappear eventually with pain medication. Chronic pain need not always lead to psychological imbalance.

 

 

10. A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. Which of the following scales should the nurse use to assess the clients pain?
  A) Numeric scale
  B) Word scale
  C) Linear scale
  D) Faces scale
  Ans: D
  Feedback:
  The nurse should use the Wong-Baker FACES scale, which is best for children and clients who are culturally diverse or mentally challenged. Nurses generally use a numeric scale, a word scale, or a linear scale to quantify the pain intensity of adult clients who can express their pain intensity in words, numbers, or linear fashion with the help of the respective scales.

 

 

11. A neurosurgeon has performed a cordotomy on a client having intractable pain. Which of the following procedures is involved in a cordotomy?
  A) Surgical sectioning of a nerve root close to the spinal cord
  B) Delivering bursts of electricity to the skin and underlying nerves
  C) Surgical interruption of pain pathways in the spinal cord
  D) Connecting electromyography machine to control pain
  Ans: C
  Feedback:
  In cordotomy surgery, the neurosurgeon surgically interrupts the pain pathways in the spinal cord by cutting bundles of nerves. A rhizotomy involves the surgical sectioning of a nerve root close to the spinal cord. In TENS, the client is given bursts of electricity to the skin and underlying nerves, whereas in biofeedback, the client is connected to an electromyography machine to control pain.

 

 

12. A nurse is caring for a client with neck pain. The nurse is explaining neck pain and some basic methods for pain management to the client. Which of the following pain-management facts should the nurse teach to the client and the clients family?
  A) Take pain-relieving medication at regular intervals around the clock.
  B) Avoid performing abdominal breathing techniques.
  C) Perform neck exercises to enhance pain control.
  D) Discuss pain-control methods with the physician.
  Ans: D
  Feedback:
  The nurse should explain to the client the importance of discussing pain-control methods that have been effective and not effective with the physician. The nurse should ask the client to perform simple techniques such as abdominal breathing and jaw relaxation to increase comfort. The client should not normally take pain-relieving medication regularly regardless of pain. Instead, the client should ask for or take pain-relieving drugs when pain begins or before an activity that causes pain. Neck exercises may exacerbate pain or cause injury.

 

 

13. A physician has ordered transcutaneous electrical nerve stimulation (TENS) for a client with back pain. Which of the following candidates is most suitable for TENS?
  A) Client who is an athlete
  B) Client who is pregnant
  C) Client with a cardiac pacemaker
  D) Client with atrial fibrillation
  Ans: A
  Feedback:
  Clients involved in sports activities are most suitable for TENS. Several athletes undergo TENS when they are in acute pain. TENS is a nonnarcotic, noninvasive method, and has no toxic side effects. However, TENS is contraindicated in pregnant women because its effect on the unborn fetus has not been determined. Clients with cardiac pacemakers, especially the demand type; clients prone to irregular heartbeats; and clients with previous heart attacks are not candidates for TENS.

 

 

14. A nurse is assessing a client with severe pain in his lower back. The clients breathing becomes shallow when he is in pain. Which of the following autonomic nervous system responses should the nurse look for in the client?
  A) Headache
  B) Lethargy
  C) Dilated pupils
  D) Irritation
  Ans: C
  Feedback:
  When dealing with clients whose pain is poorly controlled, the nurse should look for autonomic nervous system responses such as tachycardia, hypertension, dilated pupils, perspiration, pallor, rapid and shallow breathing, urinary retention, reduced bowel motility, and elevated blood glucose levels. Headaches, lethargy, and irritation are not autonomic nervous system responses.

 

 

15. A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?
  A) Referred pain
  B) Phantom pain
  C) Visceral pain
  D) Cutaneous pain
  Ans: B
  Feedback:
  The nurse should document the pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client perceives that the amputated limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed. The client is not experiencing referred pain, visceral pain, or cutaneous pain. Visceral pain is associated with disease or injury. Referred pain is not experienced in the exact site where an organ is located. Cutaneous pain originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma.

 

 

16. As per the physicians orders, a nurse is placing two electrodes on a clients lower back to perform transcutaneous electrical nerve stimulation (TENS). The nurse spaces the electrodes at least the width of one from the other on the clients skin. Which of the following reasons explains the nurses action?
  A) Prevents the potential for burning the skin
  B) Promotes the integrity of the skin
  C) Prevents premature stimulation of the skin
  D) Provides wider and deeper stimulation
  Ans: A
  Feedback:
  When performing TENS, the nurse spaces the electrodes at least the width of one from the other in order to prevent the potential for burning caused by close proximity of the electrodes. To promote skin integrity, the nurse changes the position of the electrodes slightly if skin irritation develops. To prevent premature stimulation of the skin, the nurse ensures the TENS unit is set to off. To provide wider and deeper stimulation as the pulse width increases, the nurse should set the pulse width of the TENS.

 

 

17. A nurse is assessing a client with arthritis. Which of the following should the nurse prioritize in the initial assessment of the client?
  A) Blood group
  B) Anxiety level
  C) Pain level
  D) Glucose level
  Ans: C
  Feedback:
  The nurse should first assess the clients pain level since the client has arthritis. Anxiety level, blood group, and glucose level are not vital signs which will help the nurse assess the clients pain during the initial assessment.

 

 

18. A nurse is caring for an elderly client who is unable to walk without a support due to knee pain. During his initial assessment, however, the client does not mention pain. Which of the following beliefs common in elderly clients may cause them to underreport their pain?
  A) Pain is harmless.
  B) Pain is a normal part of aging.
  C) Pain can be eliminated with medication.
  D) Pain will draw their families closer to them.
  Ans: B
  Feedback:
  When assessing elderly clients, the nurse should remember that they often underreport pain. Many elderly people believe that pain is a normal part of aging, may be a punishment for past actions, may result in a loss of independence, and may indicate that death is near. Elderly clients usually do not believe that pain is harmless, that medicine will eliminate pain, or that pain will draw the family closer to the elderly client.

 

 

19. A nurse is caring for a client with acute back pain. When should the nurse assess the clients pain?
  A) Six hours after administering a prescribed analgesic
  B) After the client is discharged from the health care facility
  C) Once per day when the pain is a potential problem
  D) Whenever the vital signs are measured and documented
  Ans: D
  Feedback:
  As per JCAHO pain assessment standards, the nurse should assess the clients pain whenever the nurse measures and documents vital signs. When administering a prescribed analgesic, the nurse should assess pain before implementing a pain-management intervention and again 30 minutes later. The nurse should assess the clients pain when the client is admitted to, not discharged from, the health care facility. Similarly, the nurse should assess pain once per shift when pain is an actual or potential problem.

 

 

20. A middle-aged client tells the nurse that her neck pain reduced considerably after she underwent a treatment in which thin needles were inserted into her skin. What kind of pain relief treatment did the client undergo?
  A) Transcutaneous electrical nerve stimulation
  B) Rhizotomy
  C) Acupuncture
  D) Biofeedback
  Ans: C
  Feedback:
  The client underwent acupuncture. Acupuncture is a pain-management technique in which long, thin needles are inserted into the skin. Transcutaneous electrical nerve stimulation (TENS) and biofeedback are nonsurgical and nondrug procedures used to treat pain. TENS is a medically prescribed pain-management technique that delivers bursts of electricity to the skin and underlying nerves. In biofeedback, a client learns to control or alter a physiologic phenomenon. Rhizotomy involves the surgical sectioning of a nerve root close to the spinal cord.

 

 

21. A nurse who works in a high-acuity setting is conscious of ensuring that clients pain assessments and pain control regimens are highly individualized. Which of the following statements about pain threshold is most accurate?
  A) Pain thresholds are culturally bound concepts that vary geographically.
  B) Pain thresholds are significantly higher among females than males.
  C) Pain thresholds tend to be highest among older adults.
  D) Pain thresholds tend to be the same among healthy people.
  Ans: D
  Feedback:
  Pain thresholds tend to be the same among healthy people, but each person tolerates or bears the sensation of pain differently. Pain tolerance, however, is more subjective and variable between groups and individuals.

 

 

22. A male client who is recovering in the hospital from complications of total hip arthroplasty has orders for 5 to 10 mg of oxycodone as needed that can be administered q4h. In previous days, the client claimed relief with 5 mg doses but for the past 24 hours he has requested 10 mg doses. What is the most likely explanation for this phenomenon?
  A) The client is seeking the pleasurable effects of this opioid.
  B) The client is adopting a dependent role in his recovery.
  C) The client is developing a tolerance to the drug.
  D) The client is becoming increasingly anxious about his lack of recovery.
  Ans: C
  Feedback:
  Nurses often assume that a clients desire to experience the drugs pleasant effects motivates his or her desire for frequent doses of narcotics. What may be happening is that the prescribed dose or frequency of administration is not controlling the pain, a phenomenon that occurs as clients develop drug tolerance. This is more likely than the clients adoption of a dependent role or development of anxiety.

 

 

23. A client who suffered multiple trauma in a motor vehicle accident is receiving care in an orthopedic trauma unit. The client has a documented history or opioid addiction and the hospitals advanced pain control team has become involved in his pain control plan. Which of the following are aspects of addiction? Select all that apply.
  A) Compulsive use of a particular drug
  B) Presence of an unusually low pain threshold
  C) The need to use opioids for purposes other than pain relief
  D) The need for increasing size or frequency of opioid doses to achieve pain relief
  E) The use of more than 30 mg of morphine or 15 mg of hydromorphone in a 24 hour period
  Ans: A, C
  Feedback:
  The American Pain Society (2008) defines addiction as a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief. Drug tolerance is not synonymous with addiction and increased tolerance does not lead to addiction. Addiction is not defined in absolute terms of opioid doses and it is not related to a low pain threshold.

 

 

24. A nurse has attended a pain control workshop and learned about the psychological and physiological basis of placebos. What principle should guide the use of placebos in the treatment of pain?
  A) Placebos can effectively treat pain while avoiding unpleasant side effects of opioids.
  B) Placebos may be used in the treatment of pain in clients who have allergies or addictions.
  C) Placebos involve the use or deception and are considered unethical in most circumstances.
  D) Placebos should be used if the client provides written consent for their use.
  Ans: C
  Feedback:
  Placebos have been shown to have some efficacy in the control of pain. However, because they involve deception they are usually considered unethical. In most circumstances, this fact overrides their possible efficacy. When a client is informed that a pill is a placebo, it loses the essential characteristic of a placebo.

 

 

25. A female client with a long and complex history of chronic pain has begun a program of biofeedback with an advanced practice nurse. Together, the nurse and the client would identify what goal of this program?
  A) The client will be able to lessen her pain through the use of massage.
  B) The client will learn to alter her physiological responses to her pain.
  C) The client will learn to cope more effectively and constructively with her pain.
  D) The client will learn to identify the signs of impending pain more clearly.
  Ans: B
  Feedback:
  With biofeedback, a client learns to control or alter a physiologic phenomenon (eg, pain, blood pressure, headache, heart rate and rhythm, seizures) as an adjunct to traditional pain management. Bio

Write a review

Your Name:


Your Review: Note: HTML is not translated!

Rating: Bad           Good

Enter the code in the box below:



 

Once the order is placed, the order will be delivered to your email less than 24 hours, mostly within 4 hours. 

If you have questions, you can contact us here