Chapter 4 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 4

Question 1

Type: MCSA

A patient complains of a dull, aching sensation in the lower back after long periods of sitting. The nurse anticipates the administration of medication to suppress pain impulse transmission in which fibers to treat the patients complaint?

1. A delta fibers

2. C fibers

3. Myelinated fibers

4. Enkephalins

Correct Answer: 2

Rationale 1: A delta fibers conduct impulses rapidly. Sharp, pinprick-like pain is conducted along these fibers.

Rationale 2: C fibers have a slow conduction rate and transmit aching, throbbing sensations.

Rationale 3: Nerves termed unmyelinated C fibers transmit aching and throbbing sensations to the brain.

Rationale 4: Enkephalins are endogenous opioid peptides that participate in the modulation of pain.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-1

Question 2

Type: MCSA

A patient has received a pain medication that blocks pain signals from the spinal cord. The nurse anticipates the effects of this medication will result in which level of pain?

1. 0 on a scale from 010

2. 8 on a scale from 010

3. 5 on a scale from 010

4. 2 on a scale from 010

Correct Answer: 1

Rationale 1: Pain signals that are blocked at the spinal cord will not be transmitted to the brain so these signals will not cause pain.

Rationale 2: Since the pain signal is being blocked or interrupted at the spinal cord, the pain will not be severe.

Rationale 3: Since the pain signal is being blocked and not transmitted to the brain pain will not be moderate.

Rationale 4: Since the pain signal is blocked at the spinal cord and is not being transmitted to the brain mild pain will not be present.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1

Question 3

Type: MCSA

The intensive care nurse plans to test nociception in the patient with a closed-head injury. Which nursing action is indicated?

1. Move an object across the patients visual field.

2. Place a container of ground coffee close to the patients nostrils.

3. Ask the patient to squeeze and release the nurses hand.

4. Press the patients nail bed.

Correct Answer: 4

Rationale 1: Testing ocular movement is not associated with nociception.

Rationale 2: Observing the patients reaction when a scent is placed close to the nostril is not painful, so it does not test nociception.

Rationale 3: Squeezing and releasing the nurses hand on command provides neurological assessment data; however, this action should not be painful to the patient.

Rationale 4: Nociception refers to the activation of pain receptors to the point of pain. Pressing the patients nail bed can elicit a motor response to pain that provides evidence of nociception.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1

Question 4

Type: MCSA

The nurse observes the patient during a major abdominal dressing change. Which facets of pain can be observed by the nurse during this procedure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

1. Expressing behaviors

2. Pain

3. Nociception

4. Suffering

Correct Answer: 1

Rationale 1: The nurse can observe pain-expressing behaviors. Grimacing and crying are pain-expressing behaviors.

Rationale 2: The patient must provide subjective data to confirm the presence of pain.

Rationale 3: Nociception is the activation of pain receptors. The nurse cannot observe this during a dressing change.

Rationale 4: Suffering is a subjective experience.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1

Question 5

Type: MCSA

Admission vital signs for the mechanically ventilated patient in the neurosurgery intensive care unit are heart rate: 60 beats per minute, blood pressure: 110/82, and respiratory rate: 20 breaths per minute. Which statement by the nurse reflects an accurate understanding of the patients current pain experience?

1. This patients vital signs reflect a sympathetic nervous system response to pain.

2. Since the vital signs are normal; the patient is not experiencing pain.

3. This patient needs further assessment to determine if pain is present.

4. Since the patient is mechanically ventilated, pain is unlikely.

Correct Answer: 3

Rationale 1: The normal heart rate and blood pressure values in this scenario do not reflect a tachycardic or hypertensive sympathetic nervous system response to pain.

Rationale 2: Parasympathetic nervous system influences on vital signs can cause vital signs to be within normal limits in the presence of pain.

Rationale 3: The nurse must complete additional assessments to determine if the patient is experiencing pain.

Rationale 4: Intubation and mechanical ventilation are painful stimuli that are frequently experienced by patients in the intensive care setting.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-3

Question 6

Type: MCSA

A patient tells the nurse that his back has not bothered him for months but now that hes in the intensive care unit, his back is killing him. The nurse considers which cause of this pain when designing interventions?

1. Lack of mobility due to hospitalization

2. Worsening of the disease process that caused the hospital admission

3. An undiagnosed injury to the back

4. Tolerance to pain medication

Correct Answer: 1

Rationale 1: Forced immobility because of the serious or critical nature of an illness and attachment to multiple tubes may exacerbate more chronic conditions, such as back or arthritic pain.

Rationale 2: There is not enough information to indicate that this back pain is related to the disease process the resulted in admission.

Rationale 3: The patient indicates previous back problems so the presence of an undiagnosed injury is not the most likely reason for the patients current back pain.

Rationale 4: Tolerance to pain medication is not suggested by this scenario.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-3

Question 7

Type: MCSA

While giving an end-of-shift report, the exiting nurse describes treatment for a patients complaint of arm pain. The nurse receiving the report should question the validity of which statement?

1. The patient is resting quietly in bed.

2. The patients blood pressure is normal so the pain is gone.

3. I administered 800 mg of ibuprofen.

4. I also applied a hot pack to the arm at the patients request.

Correct Answer: 2

Rationale 1: This statement reports the patients response to treatment.

Rationale 2: Judgments regarding patients pain levels that are based solely on objective data, such as vital sign changes, can be misleading and faulty.

Rationale 3: The nurse should indicate the medication given and the amount.

Rationale 4: The nurse should report all treatments for pain, not just pain medication.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-4

Question 8

Type: MCSA

A trauma patient has just been sedated, intubated, and placed on mechanical ventilation. The nurse documents the patients pain level as 9 on the 110 scale. How should this action be interpreted?

1. The patient should receive the highest dose of analgesic medication ordered.

2. The nurse has inappropriately scaled the patients pain.

3. The nurse should wait until the patient has adapted to the mechanical ventilator before scaling the level of pain.

4. Pain will decrease now that the patient does not have to work to breathe.

Correct Answer: 2

Rationale 1: Not enough information is presented to make the determination that the highest dose of analgesic should the administered.

Rationale 2: The unidimensional pain assessment scale is not indicated for use in this patient. Unidimensional pain assessment requires input from the patient.

Rationale 3: The presence of severe pain will likely interfere with the patients ability to adapt to the mechanical ventilator.

Rationale 4: There is no evidence that pain will decrease once the patient is being mechanically ventilated.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-4

Question 9

Type: MCMA

The nurse prepares to administer a nonsteroidal anti-inflammatory drug to the patient with postoperative knee pain. The nurse should consider which pharmacological properties of NSAIDs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. NSAIDs inhibit the manufacture of bradykinins.

2. NSAIDs bind with opioid receptors throughout the nervous system.

3. NSAIDs exert peripheral effects.

4. NSAIDs inhibit the formation of prostaglandins.

5. NSAIDS exert CNS effects.

Correct Answer: 1,3,4,5

Rationale 1: One of the mechanisms by which NSAIDs relieve pain is by inhibiting bradykinin production.

Rationale 2: The opioid class of drugs, such as morphine and dilaudid, not NSAIDs, bind with opioid receptors to relieve pain.

Rationale 3: NSAIDs work peripherally at the site of injury.

Rationale 4: One of the mechanisms by which NSAIDS relieve pain is by inhibiting prostaglandin formation.

Rationale 5: NSAIDS have a CNS effect.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4-5

Question 10

Type: MCSA

A semi-conscious patient with pancreatic cancer requires pain management. After multiple attempts, the oncology nurses are unable to establish venous access. What is the best alternative route for pain medication administration until venous access can be obtained?

1. Rectal suppository

2. Injection in deltoid muscle

3. Subcutaneous injection in abdominal tissue

4. Oral liquid

Correct Answer: 1

Rationale 1: When the IV route is not possible, rectal and sublingual routes should be considered.

Rationale 2: Intramuscular routes cause additional pain and can cause tissue damage. This route is not recommended.

Rationale 3: Subcutaneous injections cause pain and, in some instances, tissue damage; therefore, this route is not recommended.

Rationale 4: Because the patient is semi-conscious there is risk of aspiration if oral liquids are administered.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-5

Question 11

Type: MCSA

A patient with a tension pneumothorax requires insertion of a pleural chest tube. The nurse assists the physician as multiple doses of a local anesthetic are administered prior to tube insertion. Which observation by the nurse warrants immediate physician attention?

1. The patients respiratory rate changes from 22 to 26 breaths per minute.

2. The patient complains of pain during anesthetic injections.

3. The patients systolic blood pressure changes from 156 to 138 mm Hg.

4. The patients heart rate changes from 100 beats per minute to 75 beats per minute.

Correct Answer: 4

Rationale 1: The change is respiratory rate should be monitored, but is not currently the most significant finding.

Rationale 2: Local injection of anesthetics is painful.

Rationale 3: This drop in blood pressure should be monitored, but is currently not the most significant finding.

Rationale 4: A 25 percent drop in baseline heart rate is a sign of systemic anesthetic toxicity. Other symptoms of this complication are tinnitus, slurred speech, thick tongue, and mental confusion. This finding should be reported to the physician to ensure appropriate treatment.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-5

Question 12

Type: MCSA

Emergency department nurses are monitoring a patient for signs of pseudoaddiction to opioid substances. Which observation about the patients behavior can help confirm the diagnosis of pseudoaddiction?

1. The patient requires increasingly larger doses of medication for pain relief.

2. The patient appears sedated.

3. The patient appears less angry after pain relief is reported.

4. The patient appears intoxicated or drugged.

Correct Answer: 3

Rationale 1: Patients who need increases in pain medication doses to relieve pain have developed a tolerance for a drug; they are not pseudoaddicts.

Rationale 2: Sedation can occur with appropriate use of pain medications or can indicate addiction. Sedation is not a finding specifically associated with pseudoaddiction.

Rationale 3: Pseudoaddiction can cause the patient to express anger toward health care providers. This anger results from the unrelieved pain characteristic of pseudoaddiction.

Rationale 4: Appearing intoxicated or drugged can indicated substance addiction.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-2

Question 13

Type: MCSA

A patient with myocardial infarction is treated with intravenous morphine sulfate for chest pain. Which nursing action has the highest priority when administering this medication?

1. Determine the patients sedation level.

2. Check breath sounds every 15 minutes.

3. Observe for signs of opioid addiction.

4. Assess for medication infiltration into tissues.

Correct Answer: 1

Rationale 1: Extreme sedation typically precedes respiratory depression; therefore, it is important to monitor the patient who receives opioid substances for oversedation.

Rationale 2: It is not necessary to assess breath sounds at frequent intervals when pulmonary pathology is not an immediate concern.

Rationale 3: Acute pain requires treatment and typically does not result in narcotic addiction.

Rationale 4: Drug infiltration into tissues is an important assessment for any intravenous therapy; however, early detection of symptoms that precede respiratory depression has a higher priority.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-6

Question 14

Type: MCSA

A 78-year-old female patient is admitted to a medicalsurgical unit with left lower extremity pain and discoloration. The patients laboratory values are as shown.

Which statement by the nurse represents a clear understanding of this patients pain management needs?

1. This patient may need more pain medication because of anemia.

2. This patient may need less pain medication because of acute renal failure.

3. This patient may need less pain medication because of diabetes mellitus.

4. This patient will need potassium replacement before pain treatment begins.

Correct Answer: 2

Rationale 1: The diagnosis of anemia is not supported by these laboratory values.

Rationale 2: The elevated BUN, creatinine, and potassium levels in this scenario strongly suggest the presence of acute renal failure. Renal failure diminishes the patients ability to eliminate opioids from the blood stream, which can precipitate overdose or drug toxicity. Also, older individuals are at higher risk for drug toxicity than younger individuals for a number of reasons. These factors support the use of lower pain medication doses in this scenario.

Rationale 3: The serum glucose level is normal, and a medical diagnosis of diabetes mellitus has not been established.

Rationale 4: The abnormally elevated potassium level contraindicates potassium replacement and is also a sign of acute renal failure.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-7

Question 15

Type: MCMA

Which actions should be considered by the nurse planning pain relief interventions for the patient with a history of substance abuse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Planning for comorbid psychiatric disorder treatment

2. Administering long-acting analgesics

3. Using oral medications in place of intravenous ones when possible

4. Treating pain with NSAIDs instead of opioid drugs

5. Avoid using drugs that are similar in action to the abuse drug

Correct Answer: 1,2,3,5

Rationale 1: Management of pain in a patient with a history of substance abuse requires a multidisciplinary approach.

Rationale 2: The use of long-acting analgesics is recommended. Short-acting opiates should be reserved for breakthrough pain.

Rationale 3: When treating patients with previous substance abuse the nurse should plan to use oral medications whenever possible.

Rationale 4: Patients with a history of substance abuse are not immune to acute pain, and they may require opioid therapy following surgery, trauma, or other painful events.

Rationale 5: The nurse should avoid using a drug that is similar to the abused drug if possible.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-7

Question 16

Type: MCSA

A patient, with a history of drug addiction, has just been admitted following abdominal surgery. The patient is complaining of aching joints and muscles, and has a sudden onset of a runny nose. The nurse realizes these symptoms are seen during withdrawal from which commonly abused substance?

1. Barbiturates

2. Opiates

3. Cocaine

4. Alcohol

Correct Answer: 2

Rationale 1: Manifestations of barbiturate withdrawal include headache, anxiety, depression, nervousness, shakiness, blank facial expression, and flat affect.

Rationale 2: Manifestations of opiate withdrawal are initially mild and become more severe to include runny nose, diarrhea, abdominal pain, chills, gooseflesh, insomnia, aching joints and muscles, nausea and vomiting, muscle twitching and tremors, and mental depression.

Rationale 3: Manifestations of cocaine withdrawal are primarily psychological and include rapid onset of depression, fatigue, sleepiness, strong craving for more cocaine, loss of pleasure, and also experiencing paranoia or agitation.

Rationale 4: Manifestations of alcohol withdrawal include headache, anxiety, depression, nervousness, shakiness, irritability, depression, fatigue, clouded thinking, and nausea, vomiting, and anorexia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-7

Question 17

Type: MCSA

A patient, receiving moderate sedation for a colonoscopy, has progressed to a state of deep anesthesia. The nurse administering this sedation has which priority intervention?

1. Monitor the heart rate.

2. Contact the rapid response team.

3. Manage the airway and provide ventilation.

4. Monitor the blood pressure.

Correct Answer: 3

Rationale 1: While monitoring the heart rate is part of all sedation procedures it is not the priority in this situation.

Rationale 2: The nurse who is administering moderate sedation must be prepared to rescue a patient who progresses to a state of deep analgesia. The nurse should be prepared to care for this patient without calling the rapid response team.

Rationale 3: The transition from moderate sedation to deep sedation compromises the airway so this is the priority intervention.

Rationale 4: Blood pressure is part of the continuous monitoring of all patients receiving moderate sedation. It is not specifically more important because of the change in level of sedation described in this question.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-8

Question 18

Type: MCMA

A nurse is providing moderate sedation for a patient having a diagnostic endoscopy. Which actions should the nurse anticipate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Bolus of a sedative

2. Using a drug with rapid onset

3. Titration of pain medication

4. Use of a combination of drugs in a single IV line

5. Monitor a slow continuous dose of medication

Correct Answer: 2,3

Rationale 1: Titration of the sedative will result in less risk for respiratory and cardiovascular depression.

Rationale 2: The use of a drug with rapid onset allows for adjustments in dose and dose interval.

Rationale 3: Medications that produce a state of sedation may not control pain.

Rationale 4: The IV medications used in this procedure should be administered through separate IV lines.

Rationale 5: Titrating the medication involve administering small intermittent doses of medication.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-8

Question 19

Type: MCMA

A patient has achieved pain control with an oral opioid and is tolerant of its sedative effects but is having severe constipation. The nurse has contacted the health care provider about prescribing a different opioid. What should the nurse anticipate regarding the new drug?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The new opioid will be administered by the intravenous route.

2. There will be an increased need to observe the patient for sedation.

3. The starting dose of the new medication will be lower than the equianalgesic dose of the original medication.

4. It will be necessary to add an adjuvant medication to achieve equal pain control.

5. The newly prescribed medication will be a pure opioid agonist.

Correct Answer: 2,3

Rationale 1: The oral route is the preferred route. The IV route is used when oral administration is no longer possible.

Rationale 2: Even if the patient was tolerant of the sedative effects of the first opioid, that tolerance may be incomplete with the new drug.

Rationale 3: The starting dose of the new medication will likely need to be lower than the equianalgesic dose of the old medication until the patients tolerance is determined.

Rationale 4: There is no reason to expect that the patient will not achieve pain control with the new medication.

Rationale 5: The choice of medication will depend upon which medications have already be used.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4-2

Question 20

Type: MCSA

A nurse is administering naloxone (Narcan) to a patient who is minimally responsive after receiving an opioid. Which nursing action is indicated?

1. Bolus the medication over 12 minutes.

2. Give the medication without dilution.

3. Discontinue the naloxone as soon as the patients respirations normalize.

4. Plan to repeat the dose every hour for the next 4 hours.

Correct Answer: 3

Rationale 1: Naloxone should be administered slowly.

Rationale 2: Naloxone should be diluted in normal saline.

Rationale 3: Naloxone may cause return of pain and opioid withdrawal, so only the amount necessary to achieve the desired results should be administered.

Rationale 4: The medication should be effective in one dose. There is no need to repeat the dose four times.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-6

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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