Skills in Clinical Nursing 8th Edition by Audrey J. Berman Shirlee Snyder Test Bank

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Skills in Clinical Nursing 8th Edition by Audrey J. Berman Shirlee Snyder Test Bank

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Exam Name___________________________________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.
1) The client with a sprained ankle is complaining of pain in the injured area. The nurse would 1) classify this pain most specifically as:
A) Visceral pain. B) Somatic pain.
C) Physiologic pain. D) Neuropathic pain.
Answer: B Explanation:
A) Somatic pain originates in the skin, muscles, bone, or connective tissue, and would best describe this clients pain. Somatic pain is a subclassification of physiological pain, so it would be less specific to call it physiological as opposed to somatic. Visceral pain tends to be poorly located, resulting from activation of pain receptors in the organs and/or hollow viscera. Neuropathic pain results from damaged or malfunctioning nerves.
Cognitive Level: Knowledge
Client Need: Physiological Integrity Nursing Process: Assessment
B) Somatic pain originates in the skin, muscles, bone, or connective tissue, and would best describe this clients pain. Somatic pain is a subclassification of physiological pain, so it would be less specific to call it physiological as opposed to somatic. Visceral pain tends to be poorly located, resulting from activation of pain receptors in the organs and/or hollow viscera. Neuropathic pain results from damaged or malfunctioning nerves.
Cognitive Level: Knowledge
Client Need: Physiological Integrity Nursing Process: Assessment
C) Somatic pain originates in the skin, muscles, bone, or connective tissue, and would best describe this clients pain. Somatic pain is a subclassification of physiological pain, so it would be less specific to call it physiological as opposed to somatic. Visceral pain tends to be poorly located, resulting from activation of pain receptors in the organs and/or hollow viscera. Neuropathic pain results from damaged or malfunctioning nerves.
Cognitive Level: Knowledge
Client Need: Physiological Integrity Nursing Process: Assessment
D) Somatic pain originates in the skin, muscles, bone, or connective tissue, and would best describe this clients pain. Somatic pain is a subclassification of physiological pain, so it would be less specific to call it physiological as opposed to somatic. Visceral pain tends to be poorly located, resulting from activation of pain receptors in the organs and/or hollow viscera. Neuropathic pain results from damaged or malfunctioning nerves.
Cognitive Level: Knowledge
Client Need: Physiological Integrity Nursing Process: Assessment
Objective: Learning Outcome 9-1: Define the key terms used in the skills of pain management.
1
2) The nurse documents the maximum amount of pain the client can tolerate as: 2)
A) Pain threshold. B) Hyperalgesia. C) Pain tolerance. D) Allodynia.
Answer: C Explanation:
A) Pain tolerance is the maximum amount of pain a client can tolerate. Pain threshold is the lowest amount of stimuli needed for a person to label a sensation as pain. Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of wind to the area.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Pain tolerance is the maximum amount of pain a client can tolerate. Pain threshold is the lowest amount of stimuli needed for a person to label a sensation as pain. Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of wind to the area.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
C) Pain tolerance is the maximum amount of pain a client can tolerate. Pain threshold is the lowest amount of stimuli needed for a person to label a sensation as pain. Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of wind to the area.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Pain tolerance is the maximum amount of pain a client can tolerate. Pain threshold is the lowest amount of stimuli needed for a person to label a sensation as pain. Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of wind to the area.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-1: Define the key terms used in the skills of pain management.
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3) The nurse is using nonpharmacological methods to manage a clients pain, and applies a unit that 3) applies low-voltage electrical stimulation directly over the pain areas specifically known as:
A) TENS unit. B) Nerve block.
C) Functional restoration. D) Cutaneous stimulation.
Answer: A Explanation:
A) The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which is a form of cutaneous stimulation. However, TENS would be the specific name of this treatment, while cutaneous stimulation would be a more general term. Nerve block is a pharmacological treatment injecting an analgesic or steroid into the site of pain. Functional restoration is a form of social therapy.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
B) The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which is a form of cutaneous stimulation. However, TENS would be the specific name of this treatment, while cutaneous stimulation would be a more general term. Nerve block is a pharmacological treatment injecting an analgesic or steroid into the site of pain. Functional restoration is a form of social therapy.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
C) The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which is a form of cutaneous stimulation. However, TENS would be the specific name of this treatment, while cutaneous stimulation would be a more general term. Nerve block is a pharmacological treatment injecting an analgesic or steroid into the site of pain. Functional restoration is a form of social therapy.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
D) The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which is a form of cutaneous stimulation. However, TENS would be the specific name of this treatment, while cutaneous stimulation would be a more general term. Nerve block is a pharmacological treatment injecting an analgesic or steroid into the site of pain. Functional restoration is a form of social therapy.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
Objective: Learning Outcome 9-1: Define the key terms used in the skills of pain management.
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4) The client has pain in the lower back that radiates down the leg as the result of a herniated disk 4) compressing the sciatic nerve that began four months ago. This pain would be described as:
A) Acute somatic pain. B) Acute visceral pain.
C) Chronic neuropathic pain. D) Acute neuropathic pain.
Answer: D Explanation:
A) The pain is considered acute because it has lasted less than six months, which is the NANDA-accepted definition of chronic pain. It is neuropathic pain because it is caused by damage to the sciatic nerve.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
B) The pain is considered acute because it has lasted less than six months, which is the
NANDA-accepted definition of chronic pain. It is neuropathic pain because it is caused by damage to the sciatic nerve.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
C) The pain is considered acute because it has lasted less than six months, which is the
NANDA-accepted definition of chronic pain. It is neuropathic pain because it is caused by damage to the sciatic nerve.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
D) The pain is considered acute because it has lasted less than six months, which is the
NANDA-accepted definition of chronic pain. It is neuropathic pain because it is caused by damage to the sciatic nerve.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-2: Describe the various types of pain.
5) The nurse working on the labor and delivery unit has noticed how differently each client responds 5) to the pain associated with labor. The nurse recognizes this is most likely due to: (Select all that
apply.)
A) Ethnic and cultural values. B) Developmental stage.
C) Past experience with pain.
D) Physiological functioning of the brain. E) Meaning of pain.
Answer: A, B, C, E
Clients with different ethnic and cultural values are socialized to respond to pain in different manners. The developmental stage determines the clients ability to cope and report the pain. Past experience, including the effectiveness of the treatment plan in the past, with pain will have an impact on how the client deals with pain. Pain has different meaning to different clients, with some clients believing it is a punishment from a higher power or an opportunity to show how strong they are. Physiological functioning affects how pain is felt but does not affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
Explanation:
A)
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B) Clients with different ethnic and cultural values are socialized to respond to pain in different manners. The developmental stage determines the clients ability to cope and report the pain. Past experience, including the effectiveness of the treatment plan in the past, with pain will have an impact on how the client deals with pain. Pain has different meaning to different clients, with some clients believing it is a punishment from a higher power or an opportunity to show how strong they are. Physiological functioning affects how pain is felt but does not affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
C) Clients with different ethnic and cultural values are socialized to respond to pain in different manners. The developmental stage determines the clients ability to cope and report the pain. Past experience, including the effectiveness of the treatment plan in the past, with pain will have an impact on how the client deals with pain. Pain has different meaning to different clients, with some clients believing it is a punishment from a higher power or an opportunity to show how strong they are. Physiological functioning affects how pain is felt but does not affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
D) Clients with different ethnic and cultural values are socialized to respond to pain in different manners. The developmental stage determines the clients ability to cope and report the pain. Past experience, including the effectiveness of the treatment plan in the past, with pain will have an impact on how the client deals with pain. Pain has different meaning to different clients, with some clients believing it is a punishment from a higher power or an opportunity to show how strong they are. Physiological functioning affects how pain is felt but does not affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
E) Clients with different ethnic and cultural values are socialized to respond to pain in different manners. The developmental stage determines the clients ability to cope and report the pain. Past experience, including the effectiveness of the treatment plan in the past, with pain will have an impact on how the client deals with pain. Pain has different meaning to different clients, with some clients believing it is a punishment from a higher power or an opportunity to show how strong they are. Physiological functioning affects how pain is felt but does not affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
Objective: Learning Outcome 9-3: Describe factors that affect the pain experience.
6) The nurse is caring for a preschool-aged child who is in pain secondary to a compound fracture 6) resulting from a motor vehicle crash. The nurse recognizes which of the following are true? Select
all that apply.
A) It is best for the nurse to reason with the child in managing the pain.
B) The child will often respond with crying and anger because he perceives pain as a threat to
security.
C) Try to avoid touching or holding the child to reduce the level of pain.
5
D) Appeal to the childs belief in magic by using a magic blanket to take away pain. E) The child might consider pain a punishment for previous misbehaviors.
Answer: B, D, E
The preschool-aged child does not have the vocabulary or logic skills to perceive pain as a physiological response, so he will often respond with crying and anger because he sees the pain as threatening his security. A child at this stage of development has a strong belief in magic, which can be used as a pain management tool. Children often perceive pain as a punishment, so it is important for the nurse to reassure the child that it is not his fault. It is not possible to reason with a child at this stage of development, because he does not have the necessary cognitive ability. Holding and comforting the child is a useful pain management tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
Explanation:
A)
B) The preschool-aged child does not have the vocabulary or logic skills to perceive pain as a physiological response, so he will often respond with crying and anger because he sees the pain as threatening his security. A child at this stage of development has a strong belief in magic, which can be used as a pain management tool. Children often perceive pain as a punishment, so it is important for the nurse to reassure the child that it is not his fault. It is not possible to reason with a child at this stage of development, because he does not have the necessary cognitive ability. Holding and comforting the child is a useful pain management tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
C) The preschool-aged child does not have the vocabulary or logic skills to perceive pain as a physiological response, so he will often respond with crying and anger because he sees the pain as threatening his security. A child at this stage of development has a strong belief in magic, which can be used as a pain management tool. Children often perceive pain as a punishment, so it is important for the nurse to reassure the child that it is not his fault. It is not possible to reason with a child at this stage of development, because he does not have the necessary cognitive ability. Holding and comforting the child is a useful pain management tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
D) The preschool-aged child does not have the vocabulary or logic skills to perceive pain as a physiological response, so he will often respond with crying and anger because he sees the pain as threatening his security. A child at this stage of development has a strong belief in magic, which can be used as a pain management tool. Children often perceive pain as a punishment, so it is important for the nurse to reassure the child that it is not his fault. It is not possible to reason with a child at this stage of development, because he does not have the necessary cognitive ability. Holding and comforting the child is a useful pain management tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
6
E) The preschool-aged child does not have the vocabulary or logic skills to perceive pain as a physiological response, so he will often respond with crying and anger because he sees the pain as threatening his security. A child at this stage of development has a strong belief in magic, which can be used as a pain management tool. Children often perceive pain as a punishment, so it is important for the nurse to reassure the child that it is not his fault. It is not possible to reason with a child at this stage of development, because he does not have the necessary cognitive ability. Holding and comforting the child is a useful pain management tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity Nursing Process: Assessment
Objective: Learning Outcome 9-3: Describe factors that affect the pain experience.
7) The nurse has a multicultural practice, seeing clients from a variety of ethnic backgrounds. The 7) nurse recognizes that people from what culture are most likely to believe that enduring pain is a
sign of strength?
A) Mexican-Americans B) Puerto Ricans
C) Asian-Americans D) African-Americans
Answer: A Explanation:
A) Mexican-Americans might tend to view pain as a part of life and as an indicator of the seriousness of an illness, believing that enduring pain is a sign of strength. Puerto Ricans tend to be loud and outspoken in their expressions of pain as a socially learned way to cope. The Chinese culture values silence, the Japanese client might have a stoic response to pain, while the Filipino client might believe pain is Gods will. African-American clients believe pain and suffering is part of life, and is to be endured.
Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment
B) Mexican-Americans might tend to view pain as a part of life and as an indicator of the seriousness of an illness, believing that enduring pain is a sign of strength. Puerto Ricans tend to be loud and outspoken in their expressions of pain as a socially learned way to cope. The Chinese culture values silence, the Japanese client might have a stoic response to pain, while the Filipino client might believe pain is Gods will. African-American clients believe pain and suffering is part of life, and is to be endured.
Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment
C) Mexican-Americans might tend to view pain as a part of life and as an indicator of the seriousness of an illness, believing that enduring pain is a sign of strength. Puerto Ricans tend to be loud and outspoken in their expressions of pain as a socially learned way to cope. The Chinese culture values silence, the Japanese client might have a stoic response to pain, while the Filipino client might believe pain is Gods will. African-American clients believe pain and suffering is part of life, and is to be endured.
Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment
7
D) Mexican-Americans might tend to view pain as a part of life and as an indicator of the seriousness of an illness, believing that enduring pain is a sign of strength. Puerto Ricans tend to be loud and outspoken in their expressions of pain as a socially learned way to cope. The Chinese culture values silence, the Japanese client might have a stoic response to pain, while the Filipino client might believe pain is Gods will. African-American clients believe pain and suffering is part of life, and is to be endured.
Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment
Objective: Learning Outcome 9-3: Describe factors that affect the pain experience.
8) The nurse is caring for a client who had extensive surgery, and is now six days postoperative and 8) getting out of bed for the first time later this morning. When the nurse assesses the client for pain,
the client responds, It hurts, but I dont want to take any more drugs. I dont want to end up
addicted. Then nurses best response would be:
A) If you dont take the pain medication on a regular schedule, you wont get addicted.
B) People who have real pain are unlikely to become addicted to analgesics provided to treat
the pain.
C) You are wise to be concerned, and after six days it is probably time to stop taking narcotics if
you can manage the pain in other ways.
D) Dont worry about getting addicted. I will make sure you dont get addicted.
Answer: B Explanation:
A) Many clients worry about becoming addicted to narcotic analgesics if they are required for more than a few days. It is important for the nurse to reassure the client by providing truthful information. Option 1 is not true. Option 3 agrees with the client and is also untrue. Option 4 takes the control away from the client, where it belongs, and puts it in the hands of the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
B) Many clients worry about becoming addicted to narcotic analgesics if they are required for more than a few days. It is important for the nurse to reassure the client by providing truthful information. Option 1 is not true. Option 3 agrees with the client and is also untrue. Option 4 takes the control away from the client, where it belongs, and puts it in the hands of the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
C) Many clients worry about becoming addicted to narcotic analgesics if they are required for more than a few days. It is important for the nurse to reassure the client by providing truthful information. Option 1 is not true. Option 3 agrees with the client and is also untrue. Option 4 takes the control away from the client, where it belongs, and puts it in the hands of the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
8
D) Many clients worry about becoming addicted to narcotic analgesics if they are required for more than a few days. It is important for the nurse to reassure the client by providing truthful information. Option 1 is not true. Option 3 agrees with the client and is also untrue. Option 4 takes the control away from the client, where it belongs, and puts it in the hands of the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
Objective: Learning Outcome 9-4: List barriers to pain management.
9) The nurse working in a surgical center is caring for a client who had an abdominal nevus removed. 9) The client is complaining of intense pain. The nurse would:
A) Administer a non-narcotic analgesic because the client had minor surgery.
B) Attempt to divert the client without administering an analgesic because the surgery was so
minor.
C) Administer the stronger analgesic ordered by the physician.
D) Notify the physician that the clients pain is excessive for the minor surgery performed.
Answer: C Explanation:
A) Pain perception is what the client says it is, and the nurse should medicate the client based on the clients description of the pain, not what the nurse anticipates. If the client reports severe pain, the nurse should administer strong analgesics. Clients who have minor surgery can still experience severe pain, and administering weaker analgesics when the client reports severe pain would not be responsible practice. Diverting the client most likely will not be effective alone, although diversion might be possible after administering the analgesic. There is no need to notify the physician unless the nurses assessment indicates there is something unusual occurring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Pain perception is what the client says it is, and the nurse should medicate the client based on the clients description of the pain, not what the nurse anticipates. If the client reports severe pain, the nurse should administer strong analgesics. Clients who have minor surgery can still experience severe pain, and administering weaker analgesics when the client reports severe pain would not be responsible practice. Diverting the client most likely will not be effective alone, although diversion might be possible after administering the analgesic. There is no need to notify the physician unless the nurses assessment indicates there is something unusual occurring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
9
C) Pain perception is what the client says it is, and the nurse should medicate the client based on the clients description of the pain, not what the nurse anticipates. If the client reports severe pain, the nurse should administer strong analgesics. Clients who have minor surgery can still experience severe pain, and administering weaker analgesics when the client reports severe pain would not be responsible practice. Diverting the client most likely will not be effective alone, although diversion might be possible after administering the analgesic. There is no need to notify the physician unless the nurses assessment indicates there is something unusual occurring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Pain perception is what the client says it is, and the nurse should medicate the client based on the clients description of the pain, not what the nurse anticipates. If the client reports severe pain, the nurse should administer strong analgesics. Clients who have minor surgery can still experience severe pain, and administering weaker analgesics when the client reports severe pain would not be responsible practice. Diverting the client most likely will not be effective alone, although diversion might be possible after administering the analgesic. There is no need to notify the physician unless the nurses assessment indicates there is something unusual occurring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-4: List barriers to pain management.
10) The nurse is working on a surgical unit, and overhears another nurse say, That client is asking for 10) pain medication again. He is constantly on the call bell, always reporting how severe his pain is,
and I think hes just drug-seeking. Im going to make him wait the full four hours before I give this medication again. The nurse:
A) Ignores the situation because the client in question is not this nurses responsibility.
B) Enters the nurses station, reprimands the nurse, and completes an incident or variance report. C) Pulls the second nurse aside and reminds him that the sensation of pain is subjective, and that
professionals have a duty to believe clients reports of their symptoms. D) Informs the charge nurse of what was overheard.
Answer: C Explanation:
A) It is every nurses responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment. However, the nurse would address the situation privately, and not in front of others at the nurses station. Informing the charge nurse would only be necessary if the nurse who was overheard did not respond constructively to the nurses correction.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) It is every nurses responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment. However, the nurse would address the situation privately, and not in front of others at the nurses station. Informing the charge nurse would only be necessary if the nurse who was overheard did not respond constructively to the nurses correction.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
10
C) It is every nurses responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment. However, the nurse would address the situation privately, and not in front of others at the nurses station. Informing the charge nurse would only be necessary if the nurse who was overheard did not respond constructively to the nurses correction.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) It is every nurses responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment. However, the nurse would address the situation privately, and not in front of others at the nurses station. Informing the charge nurse would only be necessary if the nurse who was overheard did not respond constructively to the nurses correction.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 9-5: Identify key factors in pain management.
11) The nurse is working on the orthopedic unit, and is caring for a client who complains of back pain. 11) The nurses best response includes: (Select all that apply.)
A) Im sorry youre hurting. I want to make you feel better.
B) People with back pain experience very different symptoms. Tell me more about your back. C) You had medication for your pain at 4 p.m., so I cant give you any more until 8 p.m.,
because the doctor ordered it every four hours. D) Does anything other than your back hurt?
E) Why dont you try another position to make it feel better until its time for more pain medication?
Answer: A, B, D
The nurse should inform the client that she will work to make the client feel better, seek more information about the type of pain the client is experiencing, and question any other discomforts the client may be experiencing. Allowing the client to remain in pain would not be prudent practice, and would be lacking in caring. Cognitive Level: Analysis
Client Need: Physiological Integrity
Explanation:
A)
Nursing Process: Implementation
B) The nurse should inform the client that she will work to make the client feel better,
seek more information about the type of pain the client is experiencing, and question any other discomforts the client may be experiencing. Allowing the client to remain in pain would not be prudent practice, and would be lacking in caring. Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The nurse should inform the client that she will work to make the client feel better, seek more information about the type of pain the client is experiencing, and question any other discomforts the client may be experiencing. Allowing the client to remain in pain would not be prudent practice, and would be lacking in caring. Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
11
D) The nurse should inform the client that she will work to make the client feel better, seek more information about the type of pain the client is experiencing, and question any other discomforts the client may be experiencing. Allowing the client to remain in pain would not be prudent practice, and would be lacking in caring. Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
E) The nurse should inform the client that she will work to make the client feel better,
seek more information about the type of pain the client is experiencing, and question any other discomforts the client may be experiencing. Allowing the client to remain in pain would not be prudent practice, and would be lacking in caring. Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-5: Identify key factors in pain management.
12) The hospice nurse is making a home visit to a client with terminal cancer. The client reports poor 12) pain control, and the clients spouse says, Im giving such big doses of medication, Im afraid Im
going to overdose him if I give him more. The nurses best response would be:
A) Youre wise to be concerned. These are very strong medications youre administering.
B) You want him to be comfortable but you dont want to endanger his life. Lets talk about the
medication youre giving and warning signs youll see if the dosage youre administering is
too high.
C) I hear what youre saying, but youre not giving enough pain medication, so he is in severe
pain. You need to give more.
D) You arent giving adequate pain relief, and he is in severe pain as a result.
Answer: B Explanation:
A) It is not unusual for a family caregiver to withhold medication out of fear of overdosing the cancer client. It is important for the nurse to inform the caregiver that his feelings are not unusual, and then provide him with the information he needs to make an informed and appropriate decision that will make the client more comfortable. Option 1 is untrue. Options 3 and 4 make the caregiver feel guilty, and do not provide him with the information he needs to perform better. Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) It is not unusual for a family caregiver to withhold medication out of fear of
overdosing the cancer client. It is important for the nurse to inform the caregiver that his feelings are not unusual, and then provide him with the information he needs to make an informed and appropriate decision that will make the client more comfortable. Option 1 is untrue. Options 3 and 4 make the caregiver feel guilty, and do not provide him with the information he needs to perform better. Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
12
C) It is not unusual for a family caregiver to withhold medication out of fear of overdosing the cancer client. It is important for the nurse to inform the caregiver that his feelings are not unusual, and then provide him with the information he needs to make an informed and appropriate decision that will make the client more comfortable. Option 1 is untrue. Options 3 and 4 make the caregiver feel guilty, and do not provide him with the information he needs to perform better. Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) It is not unusual for a family caregiver to withhold medication out of fear of
overdosing the cancer client. It is important for the nurse to inform the caregiver that his feelings are not unusual, and then provide him with the information he needs to make an informed and appropriate decision that will make the client more comfortable. Option 1 is untrue. Options 3 and 4 make the caregiver feel guilty, and do not provide him with the information he needs to perform better. Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-5: Identify key factors in pain management.
13) The nurse enters the postoperative clients room and finds the client perspiring with fists clenched. 13) As the nurse administers routine medications and provides care, the client is pleasant and
cooperative. The nurse:
A) Documents no complaints of pain offered and assesses that the client is comfortable. B) Asks the client if he is in pain.
C) Informs the client he looks uncomfortable and asks him to describe his pain.
D) Instructs the client to use the call bell if he experiences pain.
Answer: C Explanation:
A) It is the nurses responsibility to assess for pain and not wait for the client to mention it. Some clients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the clients apparent discomfort and asks them to describe their pain and indicates the clients apparent discomfort. The clients body language indicates the likelihood of pain, so option 1 is not correct. Option 4 puts the responsibility for pain assessment on the client instead of on the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
B) It is the nurses responsibility to assess for pain and not wait for the client to mention it. Some clients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the clients apparent discomfort and asks them to describe their pain and indicates the clients apparent discomfort. The clients body language indicates the likelihood of pain, so option 1 is not correct. Option 4 puts the responsibility for pain assessment on the client instead of on the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
13
C) It is the nurses responsibility to assess for pain and not wait for the client to mention it. Some clients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the clients apparent discomfort and asks them to describe their pain and indicates the clients apparent discomfort. The clients body language indicates the likelihood of pain, so option 1 is not correct. Option 4 puts the responsibility for pain assessment on the client instead of on the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
D) It is the nurses responsibility to assess for pain and not wait for the client to mention it. Some clients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the clients apparent discomfort and asks them to describe their pain and indicates the clients apparent discomfort. The clients body language indicates the likelihood of pain, so option 1 is not correct. Option 4 puts the responsibility for pain assessment on the client instead of on the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
Objective: Learning Outcome 9-6: Describe the two major components of pain assessment.
14) When assessing the clients pain, the nurse uses the mnemonic COLDERR, with the C representing: 14)
A) Color.
Answer: D Explanation:
B) Cardiac. C) Comfort. D) Character.
A) The C in the COLDERR mnemonic stands for character, meaning a description of what the pain feels like, such as sharp, stabbing, dull, or aching.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
B) The C in the COLDERR mnemonic stands for character, meaning a description of
what the pain feels like, such as sharp, stabbing, dull, or aching. Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
C) The C in the COLDERR mnemonic stands for character, meaning a description of what the pain feels like, such as sharp, stabbing, dull, or aching.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
D) The C in the COLDERR mnemonic stands for character, meaning a description of
what the pain feels like, such as sharp, stabbing, dull, or aching. Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-6: Describe the two major components of pain assessment.
14
15) The nurse is obtaining a pain history. The client reports pain in his right ear. The nurses best 15) response would be:
A) Is the pain minor?
B) Do you have anything else that hurts?
C) Tell me more about the pain and what you do for it when it hurts.
D) Ill note that in the record. Is there anything else I should know?
Answer: C Explanation:
A) When the client reports pain, the nurse should seek more information. The COLDERR mnemonic is effective in helping the nurse to assess all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Assessment
B) When the client reports pain, the nurse should seek more information. The COLDERR mnemonic is effective in helping the nurse to assess all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Assessment
C) When the client reports pain, the nurse should seek more information. The COLDERR mnemonic is effective in helping the nurse to assess all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Assessment
D) When the client reports pain, the nurse should seek more information. The COLDERR mnemonic is effective in helping the nurse to assess all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Assessment
Objective: Learning Outcome 9-7: Identify data to collect and analyze when obtaining a comprehensive pain history.
15
16) When conducting a pain history, the nurse should obtain data regarding all of the following except: 16)
A) Intensity, quality, and patterns.
B) Precipitating factors, alleviating factors, and associated symptoms.
C) Effects on activities of daily living, coping resources, and affective responses.
D) Significant others assessment of the pain.
Answer: D Explanation:
A) During a pain history, it is the clients description of the pain that is most important, not the significant others. The nurse should determine all of the other factors in order to put a plan of care in place that will help the client address and treat the pain effectively.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
B) During a pain history, it is the clients description of the pain that is most important, not the significant others. The nurse should determine all of the other factors in order to put a plan of care in place that will help the client address and treat the pain effectively.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
C) During a pain history, it is the clients description of the pain that is most important, not the significant others. The nurse should determine all of the other factors in order to put a plan of care in place that will help the client address and treat the pain effectively.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
D) During a pain history, it is the clients description of the pain that is most important, not the significant others. The nurse should determine all of the other factors in order to put a plan of care in place that will help the client address and treat the pain effectively.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-7: Identify data to collect and analyze when obtaining a comprehensive pain history.
17) When caring for an elderly client who does not speak English, the nurse can best assess pain using: 17) A) The FACES rating scale. B) An interpreter.
C) The clients affect. D) The clients vital signs.
Answer: A Explanation:
A) An interpreter might not always be readily available, so the FACES rating scale can be used because it is not necessary to use language. If an interpreter is available, she can be utilized to discuss the pain in more detail, but the FACES rating scale will help the nurse to respond to the clients pain appropriately and quickly without waiting for an interpreter. Affect and vital signs might not be accurate indicators of the clients discomfort.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Assessment
16
B) An interpreter might not always be readily available, so the FACES rating scale can be used because it is not necessary to use language. If an interpreter is available, she can be utilized to discuss the pain in more detail, but the FACES rating scale will help the nurse to respond to the clients pain appropriately and quickly without waiting for an interpreter. Affect and vital signs might not be accurate indicators of the clients discomfort.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Assessment
C) An interpreter might not always be readily available, so the FACES rating scale can be used because it is not necessary to use language. If an interpreter is available, she can be utilized to discuss the pain in more detail, but the FACES rating scale will help the nurse to respond to the clients pain appropriately and quickly without waiting for an interpreter. Affect and vital signs might not be accurate indicators of the clients discomfort.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Assessment
D) An interpreter might not always be readily available, so the FACES rating scale can be used because it is not necessary to use language. If an interpreter is available, she can be utilized to discuss the pain in more detail, but the FACES rating scale will help the nurse to respond to the clients pain appropriately and quickly without waiting for an interpreter. Affect and vital signs might not be accurate indicators of the clients discomfort.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Assessment
Objective: Learning Outcome 9-7: Identify data to collect and analyze when obtaining a comprehensive pain history.
17
18) The nurse uses combinations of drugs to reduce the need for high doses of any one medication and 18) to maximize pain control with a minimum of side effects or toxicity, which is called:
A) Polypharmacy. B) Rational polypharmacy.
C) Analgesia.
D) Dose-reduction pharmacology.
Answer: B Explanation:
A) This description defines rational polypharmacy, which is a multidrug strategy combined with nonpharmacological approaches to manage the clients pain. Polypharmacy is a generic term for multiple medication administration, often used with elders who are on many medications. Analgesia is a classification of medication used for pain control. Dose-reduction pharmacology is not a real term. Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
B) This description defines rational polypharmacy, which is a multidrug strategy
combined with nonpharmacological approaches to manage the clients pain. Polypharmacy is a generic term for multiple medication administration, often used with elders who are on many medications. Analgesia is a classification of medication used for pain control. Dose-reduction pharmacology is not a real term. Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
C) This description defines rational polypharmacy, which is a multidrug strategy combined with nonpharmacological approaches to manage the clients pain. Polypharmacy is a generic term for multiple medication administration, often used with elders who are on many medications. Analgesia is a classification of medication used for pain control. Dose-reduction pharmacology is not a real term. Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
D) This description defines rational polypharmacy, which is a multidrug strategy
combined with nonpharmacological approaches to manage the clients pain. Polypharmacy is a generic term for multiple medication administration, often used with elders who are on many medications. Analgesia is a classification of medication used for pain control. Dose-reduction pharmacology is not a real term. Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of medications and routes for opioid delivery.
19) According to the World Health Organization Three-Step Approach, if the nurse is caring for a 19) client complaining of mild pain that persists after using full doses of step 1 medications, the nurse
would administer: (Select all that apply.)
A) Codeine
B) Fentanyl.
C) Oxycodone with acetaminophen.
D) Hydrocodone with ibuprofen. E) Morphine.
Answer: A, C, D
18
Explanation:
A) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain persists or the pain is moderate, the second step is a weak opioids, or a combination of opioid and non-opioid medicine can be used. If moderate pain persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
B) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain persists or the pain is moderate, the second step is a weak opioids, or a combination of opioid and non-opioid medicine can be used. If moderate pain persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
C) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain persists or the pain is moderate, the second step is a weak opioids, or a combination of opioid and non-opioid medicine can be used. If moderate pain persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
D) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain persists or the pain is moderate, the second step is a weak opioids, or a combination of opioid and non-opioid medicine can be used. If moderate pain persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
E) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain persists or the pain is moderate, the second step is a weak opioids, or a combination of opioid and non-opioid medicine can be used. If moderate pain persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity Nursing Process: Implementation
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of medications and routes for opioid delivery.
20) The nurse administers a nonsteroidal antiinflammatory drug (NSAID) knowing that the effects of 20) this medication include: (Select all that apply.)
A) Anti-inflammatory effects. B) Analgesic effects.
C) Antipyretic effects.
D) Sedating effects. E) Anesthetic effects.
Answer: A, B, C
Explanation:
A)
Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have sedating or anesthetic effects in most clients, although some clients might report being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity Nursing Process: Planning
19
B) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have sedating or anesthetic effects in most clients, although some clients might report being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
C) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have
sedating or anesthetic effects in most clients, although some clients might report being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
D) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have
sedating or anesthetic effects in most clients, although some clients might report being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
E) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have
sedating or anesthetic effects in most clients, although some clients might report being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of medications and routes for opioid delivery.
20
21) The nurse would administer acetaminophen instead of ibuprofen if which of the following effects 21) were not desired?
A) Anti-inflammatory effects B) Analgesic effects
C) Antipyretic effects
D) Antipyretic and anti-inflammatory effects
Answer: A Explanation:
A) Acetaminophen, unlike ibuprofen, does not have anti-inflammatory effects. However, both acetaminophen and ibuprofen have analgesic and antipyretic effects.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
B) Acetaminophen, unlike ibuprofen, does not have anti-inflammatory effects.
However, both acetaminophen and ibuprofen have analgesic and antipyretic effects.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
C) Acetaminophen, unlike ibuprofen, does not have anti-inflammatory effects.
However, both acetaminophen and ibuprofen have analgesic and antipyretic effects.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
D) Acetaminophen, unlike ibuprofen, does not have anti-inflammatory effects.
However, both acetaminophen and ibuprofen have analgesic and antipyretic effects.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of medications and routes for opioid delivery.
21
22) After administering an opioid analgesic, the nurse assesses the client using the sedation scale and 22) finds the client sleeping and arousable, but the client drifts off to sleep during conversation. The
nurse would rate the clients level of sedation as:
A) 1.
Answer: C Explanation:
B) 2. C) 3. D) 4.
A) Level 3 is frequently drowsy, arousable, drifts off to sleep during conversation. Level 1 is awake and alert, 2 is slightly drowsy but arousable, and level 4 is somnolent, minimal-to-no response to physical stimulation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
B) Level 3 is frequently drowsy, arousable, drifts off to sleep during conversation.
Level 1 is awake and alert, 2 is slightly drowsy but arousable, and level 4 is somnolent, minimal-to-no response to physical stimulation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
C) Level 3 is frequently drowsy, arousable, drifts off to sleep during conversation.
Level 1 is awake and alert, 2 is slightly drowsy but arousable, and level 4 is somnolent, minimal-to-no response to physical stimulation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
D) Level 3 is frequently drowsy, arousable, drifts off to sleep during conversation.
Level 1 is awake and alert, 2 is slightly drowsy but arousable, and level 4 is somnolent, minimal-to-no response to physical stimulation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of medications and routes for opioid delivery.
22
23) The client reports difficulty sleeping related to anxiety. Which of the following nonpharmacologic 23) pain management interventions might the nurse consider performing in order to relax the client?
A) Acupuncture B) Acupressure C) Massage D) Distraction
Answer: C Explanation:
A) Massage is used for relaxation, and can be effective in helping the client who is anxious. Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the client cope with pain.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
B) Massage is used for relaxation, and can be effective in helping the client who is
anxious. Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the client cope with pain.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
C) Massage is used for relaxation, and can be effective in helping the client who is
anxious. Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the client cope with pain.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
D) Massage is used for relaxation, and can be effective in helping the client who is
anxious. Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the client cope with pain.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
Objective: Learning Outcome 9-9: Describe nonpharmacologic pain management interventions.
23
24) The nurse has administered an oral analgesic to a client complaining of a mild-to-moderate 24) headache. Which of the following distractions would the nurse consider to help relieve the clients discomfort until the analgesic takes effect?
A) Reading or watching TV B) Video or computer games C) Slow rhythmic breathing D) Crossword puzzles
Answer: C Explanation:
A) Slow rhythmic breathing would be an effective distraction technique for a client with a headache. Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the client with a headache is often more comfortable in a dark, low-stimuli environment.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Planning
B) Slow rhythmic breathing would be an effective distraction technique for a client with a headache. Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the client with a headache is often more comfortable in a dark, low-stimuli environment.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Planning
C) Slow rhythmic breathing would be an effective distraction technique for a client with a headache. Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the client with a headache is often more comfortable in a dark, low-stimuli environment.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Planning
D) Slow rhythmic breathing would be an effective distraction technique for a client with a headache. Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the client with a headache is often more comfortable in a dark, low-stimuli environment.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Planning
Objective: Learning Outcome 9-9: Describe nonpharmacologic pain management interventions.
24
25) Which of the following can the nurse safely delegate to the unlicensed assistive personnel (UAP)? 25)
A) Initial assessment of pain
B) Regular reassessment of pain
C) Providing a massage and repositioning the client in pain
D) Administration of an oral analgesic
Answer: C Explanation:
A) Assessment is never delegated to the client, (options 1 and 2), and UAPs cannot administer oral analgesics. The UAP can safely provide a massage and reposition the client.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
B) Assessment is never delegated to the client, (options 1 and 2), and UAPs cannot
administer oral analgesics. The UAP can safely provide a massage and reposition the client.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
C) Assessment is never delegated to the client, (options 1 and 2), and UAPs cannot
administer oral analgesics. The UAP can safely provide a massage and reposition the client.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
D) Assessment is never delegated to the client, (options 1 and 2), and UAPs cannot
administer oral analgesics. The UAP can safely provide a massage and reposition the client.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
Objective: Learning Outcome 9-10: Recognize when it is appropriate to delegate pain management skills to unlicensed assistive personnel.
26) The unlicensed assistive personnel (UAP) informs the nurse that the client is complaining of severe 26) postoperative pain and requests pain medication. Which of the following actions would be
appropriate for the nurse to perform?
A) Give the client an analgesic.
B) Assess the clients pain and respond as indicated.
C) Ask the UAP for more data regarding the clients pain.
D) Tell the UAP to inform the client that the nurse will be in as soon as possible.
Answer: B Explanation:
A) When the UAP reports a problem, the nurse should assess the client thoroughly before acting. Giving the client an analgesic without a thorough assessment by the nurse would be dangerous. Asking the UAP for more information is not efficient because the nurse should talk directly to the client. Delaying response to the clients needs would not be effective nursing practice.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
25
B) When the UAP reports a problem, the nurse should assess the client thoroughly before acting. Giving the client an analgesic without a thorough assessment by the nurse would be dangerous. Asking the UAP for more information is not efficient because the nurse should talk directly to the client. Delaying response to the clients needs would not be effective nursing practice.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
C) When the UAP reports a problem, the nurse should assess the client thoroughly before acting. Giving the client an analgesic without a thorough assessment by the nurse would be dangerous. Asking the UAP for more information is not efficient because the nurse should talk directly to the client. Delaying response to the clients needs would not be effective nursing practice.
Cognitive Level: Analysis
Client Need: Physiological Integrity Nursing Process: Implementation
D) When the UAP reports a problem, the nurse should assess the client thoroughly before acting. Giving the client an analgesic without a thorough assessment by the nurse would be dangerous. Asking the UAP for more information is not

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