Chapter 46 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 46

Question 1

Type: MCSA

The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this infant?

1. FLACC scale

2. Wong-Baker FACES

3. Visual analog scale

4. Numeric rating scale

Correct Answer: 1

Rationale 1: The FLACC scale has been validated in children from 2 months to 7 years old. Options B and C are not appropriate for this age child.

Rationale 2: This pain scale would not be appropriate for a client of this age.

Rationale 3: This pain scale would not be appropriate for a client of this age.

Rationale 4: This pain scale would not be appropriate for a client of this age.

Global Rationale: Page Reference: 1216

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify subjective and objective data to collect and analyze when assessing pain.

Question 2

Type: MCSA

The nurse is preparing to discharge a client home with a prescription for ibuprofen. What should the nurse instruct as a common side effect of this medication?

1. Gastrointestinal (GI) bleeding

2. Shakiness

3. Tremors

4. Rash

Correct Answer: 1

Rationale 1: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal, such as heartburn or indigestion.

Rationale 2: Shakiness is not a common side effect of NSAIDs.

Rationale 3: Tremors are not a common side effect of NSAIDs.

Rationale 4: A rash is not a common side effect of NSAIDs.

Global Rationale: Page Reference: 1227

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Identify subjective and objective data to collect and analyze when assessing pain.

Question 3

Type: MCSA

Which of the following objective assessment data will the nurse obtain before administering a prescribed opioid medication to a client?

1. Pain level as stated by client

2. Any nausea the client may be feeling

3. Respiratory rate

4. Color of skin

Correct Answer: 3

Rationale 1: This is subjective data.

Rationale 2: This is subjective data.

Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids.

Rationale 4: This is not applicable to assess prior to administering an opioid medication to a client.

Global Rationale: Page Reference: 1229

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify subjective and objective data to collect and analyze when assessing pain.

Question 4

Type: MCSA

The duration of action for most opiates is how long?

1. 2 hours

2. 4 hours

3. 6 hours

4. 8 hours

Correct Answer: 2

Rationale 1: The duration of action for most opiates is 4 hours.

Rationale 2: The duration of action for most opiates is 4 hours.

Rationale 3: The duration of action for most opiates is 4 hours.

Rationale 4: The duration of action for most opiates is 4 hours.

Global Rationale: Page Reference: 1222

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10 Describe pharmacologic interventions for pain.

Question 5

Type: MCSA

The nurse is to administer acetaminophen (Tylenol) prn for a headache. The client has been vomiting all day. Which of the following routes should the nurse use to administer the medication?

1. Oral

2. Vaginal

3. Rectal

4. Intravenous

Correct Answer: 3

Rationale 1: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Rationale 2: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Rationale 3: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Rationale 4: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Global Rationale: Page Reference: 1232

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.

Question 6

Type: MCSA

A client recovering from a left below the knee amputation is experiencing left foot pain. The nurse realizes the client is experiencing which type of pain?

1. Phantom limb pain

2. Acute pain

3. Chronic pain

4. Narcotic-induced pain

Correct Answer: 1

Rationale 1: Phantom sensations, the feeling that a lost body part is present, occur in most people after amputation. It is important for the nurse to remember to explain the reasons for phantom limb pain, as clients may have difficulty understanding why they have pain when the limb is gone.

Rationale 2: Acute pain is directly related to tissue injury and resolves when tissue heals.

Rationale 3: Chronic pain persists beyond 3 to 6 months secondary to chronic disorders or nerve malfunctions that produce ongoing pain after healing is complete.

Rationale 4: There is no such type of pain.

Global Rationale: Page Reference: 1206-1207

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Describe factors that can affect a persons perception of and reaction to pain.

Question 7

Type: MCSA

The nurse is providing discharge instructions to a client prescribed an opioid medication. What can the nurse suggest to decrease the risk of constipation with this medication?

1. Take an antihistamine three times per day.

2. Drink 6 to 8 glasses of water per day.

3. Assess respiratory rate before taking medication.

4. Assess heart rate before taking medication.

Correct Answer: 2

Rationale 1: Antihistamines do not prevent constipation.

Rationale 2: Increasing fluid intake can help prevent constipation.

Rationale 3: Assessing respiratory rate will not help prevent constipation.

Rationale 4: Assessing heart rate will not impact the development of constipation.

Global Rationale: Page Reference: 1230

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a clients response to interventions for pain.

Question 8

Type: MCSA

The nurse is caring for a client who is using morphine through patient controlled analgesia. What medication should the nurse have readily available?

1. Naloxone hydrochloride (Narcan)

2. Acetaminophen (Tylenol)

3. Diphenhydramine hydrochloride (Benadryl)

4. Normal saline

Correct Answer: 1

Rationale 1: Narcan is an opioid antagonist and should be readily available when a client is receiving an opioid.

Rationale 2: Tylenol would not be helpful to have available for a client who is receiving morphine through PCA administration.

Rationale 3: Benadryl would not be helpful to have available for a client who is receiving morphine through PCA administration.

Rationale 4: Normal saline would not be helpful to have available for a client who is receiving morphine through PCA administration.

Global Rationale: Page Reference: 1230

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Describe pharmacologic interventions for pain.

Question 9

Type: MCSA

The client is taking meperidine (Demerol) and experiencing pruritus. Which of the following medications would the nurse expect the physician to order?

1. Naloxone hydrochloride (Narcan)

2. Acetaminophen (Tylenol)

3. Diphenhydramine hydrochloride (Benadryl)

4. Normal saline

Correct Answer: 3

Rationale 1: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

Rationale 2: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

Rationale 3: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

Rationale 4: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

Global Rationale: Page Reference: 1230

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Describe pharmacologic interventions for pain.

Question 10

Type: MCSA

The nurse is admitting a client to the emergency department with complaints of severe abdominal pain. What is the nurses first action?

1. Administer IV pain medication as ordered.

2. Start an IV line of lactated Ringers.

3. Assess pain using a scale of 1 to 10.

4. Place a Foley catheter to bedside drainage.

Correct Answer: 3

Rationale 1: This would occur after the client was assessed.

Rationale 2: This would occur after the client was assessed.

Rationale 3: Assessment should always occur before implementation.

Rationale 4: This may or may not be appropriate for the client.

Global Rationale: Page Reference: 1215

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a clients response to interventions for pain.

Question 11

Type: MCSA

A client is surprised to learn of the diagnosis of a heart attack when there was no chest pain experienced but only some left shoulder pain. What should the nurse explain to the client about the type of pain experienced?

1. Phantom pain

2. Referred pain

3. Visceral pain

4. Chronic pain

Correct Answer: 2

Rationale 1: Phantom pain is that which is experienced in a limb after an amputation.

Rationale 2: Referred pain appears to arise in different areas of the body, as may occur with cardiac pain.

Rationale 3: Visceral pain originates in an organ.

Rationale 4: Chronic pain is that which is felt for months after the pain experience should have ended.

Global Rationale: Page Reference: 1205

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Discriminate between nociceptive and neuropathic pain categories.

Question 12

Type: MCSA

A client rates pain as being 7 on a scale from 0 to 10. What will the nurse document as this clients pain intensity?

1. Mild pain

2. Moderate pain

3. Severe pain

4. Physiological pain

Correct Answer: 3

Rationale 1: Mild pain is rated as being from 1 to 3 on a 0 to 10 rating scale.

Rationale 2: Moderate pain is rated as being from 4 to 6 on a 0 to 10 pain rating scale.

Rationale 3: Severe pain is rated a 7-10 on a scale of 0 to 10.

Rationale 4: Physiological pain does not describe the intensity of the clients pain.

Global Rationale: Page Reference: 1215

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify subjective and objective data to collect and analyze when assessing pain.

Question 13

Type: MCSA

A client is experiencing pain after spraining an ankle. The nurse realizes the type of pain the client is most likely experiencing would be:

1. Mild pain

2. Severe pain

3. Somatic pain

4. Visceral pain

Correct Answer: 3

Rationale 1: Mild is not a type of pain.

Rationale 2: Severe is not a type of pain.

Rationale 3: Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain.

Rationale 4: Visceral pain is that which originates within an organ.

Global Rationale: Page Reference: 1206

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Discriminate between nociceptive and neuropathic pain categories.

Question 14

Type: MCSA

The client scheduled to undergo a minor surgery states, The physician will not give me pain medication after surgery because my surgery is only minor. The best response by the nurse is:

1. You can experience pain after minor surgery, so you can have pain medication.

2. You are correct. The physician will not order any pain medication.

3. You are correct. I will need to teach you nonpharmacologic pain relief measures.

4. You can only have about half the dose since your surgery is minor.

Correct Answer: 1

Rationale 1: Clients can experience intense pain after minor surgery, so pain medication may be ordered.

Rationale 2: This is not true. The client can have pain after minor surgery and can receive pain medication.

Rationale 3: Nonpharmacologic pain relief measures may not be enough for the pain after surgery.

Rationale 4: The nurse has no way of knowing the dose the physician will prescribe for the client.

Global Rationale: Page Reference: 1224

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a clients response to interventions for pain.

Question 15

Type: MCSA

The nurse is performing discharge teaching for a client taking an NSAID. The client states he has heard taking an antacid with this medication will help decrease the incidence of upset stomach. The nurses best response is:

1. Antacids reduce the absorption and therefore the effectiveness of the NSAID.

2. Antacids help to reduce the incidence of gastric bleeding that could occur with the use of NSAIDs.

3. Antacids should never be taken with an NSAID.

4. Antacids help to reduce the incidence of pain.

Correct Answer: 1

Rationale 1: It is documented that the use of antacids can reduce the risk of gastric distress, but can also reduce the absorption and the effectiveness of the medication.

Rationale 2: Antacids can reduce the likelihood of gastric bleeding however will interfere with the absorption of the medication in the client.

Rationale 3: This statement is not correct.

Rationale 4: Antacids may reduce the pain associated with gastric distress however antacids are not a category of pain medication.

Global Rationale: Page Reference: 1227

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Compare and contrast barriers to effective pain management affecting nurses and clients.

Question 16

Type: MCSA

The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

1. Pulse rate: 80

2. Respiratory rate: 8

3. Blood pressure: 120/80

4. Pain rating of 4 on scale of 1-10

Correct Answer: 2

Rationale 1: This is a normal pulse rate.

Rationale 2: A respiratory rate below 8 should be reported immediately.

Rationale 3: This is a blood pressure that is within normal limits.

Rationale 4: The nurse does not need to report the clients pain rating to the physician.

Global Rationale: Page Reference: 1234

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.

Question 17

Type: MCSA

The client is admitted to the emergency department with complaints of abdominal pain. The client denies any nausea or vomiting. When asked, the client states the pain started 2 hours ago and describes the pain as cramping. The client is most likely experiencing what type of pain?

1. Chronic pain

2. Phantom pain

3. Visceral pain

4. Acute pain

Correct Answer: 4

Rationale 1: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

Rationale 2: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

Rationale 3: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

Rationale 4: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

Global Rationale: Page Reference: 1205

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Discriminate between nociceptive and neuropathic pain categories.

Question 18

Type: MCMA

While conducting a pain assessment, the nurse knows to assess which of the following?

Standard Text: Select all that apply.

1. Duration

2. Location

3. Intensity

4. Etiology

5. Neurology

Correct Answer: 1,2,3,4

Rationale 1: Pain may be described in terms of location, duration, intensity, and etiology.

Rationale 2: Pain may be described in terms of location, duration, intensity, and etiology.

Rationale 3: Pain may be described in terms of location, duration, intensity, and etiology.

Rationale 4: Pain may be described in terms of location, duration, intensity, and etiology.

Rationale 5: Pain may be described in terms of location, duration, intensity, and etiology.

Global Rationale: Page Reference: 1205-1206

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify subjective and objective data to collect and analyze when assessing pain.

Question 19

Type: MCSA

A client experiencing pain has been prescribed aspirin. The nurse realizes that this medication will affect which pain process?

1. Transduction.

2. Transmission.

3. Perception.

4. Modulation.

Correct Answer: 1

Rationale 1: During the transduction phase, noxious stimuli trigger the release of biochemical mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P, that sensitize nociceptors. Noxious or painful stimulation also causes movement of ions across cell membranes, which excites nociceptors. Pain medications such as ibuprofen or aspirin can work during this phase by blocking the production of prostaglandin or by decreasing the movement of ions across the cell membrane.

Rationale 2: The transmission of pain includes three segments. During the first segment, the pain impulses travel from the peripheral nerve fibers to the spinal cord. The second segment is transmission from the spinal cord, and ascension, via spinothalamic tracts, to the brainstem and thalamus. The third segment involves transmission of signals between the thalamus to the somatic sensory cortex, where pain perception occurs. Pain control can take place during this second process of transmission. Opioids block the release of neurotransmitters, which stops the pain at the spinal level.

Rationale 3: Perception is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the CNS that can shape the character and intensity of pain perceived and ascribes meaning to the pain. The psychosocial context of the situation and the meaning of the pain based on past experiences and future hopes and dreams help to shape the behavioral response that follows.

Rationale 4: Modulation is often described as the descending system, and occurs when neurons in the thalamus and brainstem send signals back down to the dorsal horn of the spinal cord. These descending fibers release substances such as endogenous opioids, serotonin, and norepinephrine, which can inhibit the ascending painful impulses in the dorsal horn. In contrast, excitatory amino acids and the upregulation of excitatory glial cells can amplify these pain signals. The effects of excitatory amino acids and glial cells tend to persist, while the effects of the inhibitory neurotransmitters tend to be short-lived because they are reabsorbed into the nerves. Tricyclic antidepressants block the reuptake of norepinephrine and serotonin, and may be used to help diminish the pain signals.

Global Rationale: Page Reference: 1208

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Describe the four processes involved in nociception and how pain interventions can work during each process.

Question 20

Type: MCSA

A client is complaining of having the same type of pain that he experienced prior to being diagnosed with cancer. The nurse realizes that which process will influence this clients perception of pain?

1. Transmission.

2. Modulation.

3. Perception.

4. Transduction.

Correct Answer: 3

Rationale 1: Transmission is a process by which the pain signals are transmitted to the brain.

Rationale 2: Modulation is the process where signals are sent back down the spinal tracts in response to the pain.

Rationale 3: Perception is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the CNS that can shape the character and intensity of pain perceived and ascribes meaning to the pain. The psychosocial context of the situation and the meaning of the pain based on past experiences and future hopes and dreams help to shape the behavioral response that follows.

Rationale 4: Transduction is a process where chemicals are released in response to noxious stimuli.

Global Rationale: Page Reference: 1209

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Describe the four processes involved in nociception and how pain interventions can work during each process.

Question 21

Type: MCSA

A client tells the nurse that an ice pack works well to reduce the intensity of back pain. The nurse realizes that the client is implementing:

1. A placebo.

2. Distraction.

3. Guided imagery.

4. The gate control theory of pain.

Correct Answer: 4

Rationale 1: The application of ice is not a placebo.

Rationale 2: The application of ice is not a distraction.

Rationale 3: The application of ice not a use of guided imagery.

Rationale 4: In the gate control theory, signals of noxious stimuli are carried to the dorsal horn, where they are modified according to the balance of the substantia gelatinosa. By using ice, the substantia gelatinosa is calmed, reducing the pain.

Global Rationale: Page Reference: 1210

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14 Describe nonpharmacologic pain control interventions.

Question 22

Type: MCSA

A client recovering from hip surgery is reluctant to ambulate because of the amount of pain that occurred with walking prior to the surgery. What can the nurse do to help this client with pain control?

1. Provide pain medication before every ambulation session.

2. Address the clients fear of pain with walking.

3. Tell the client that the pain is now gone.

4. Explain that the client is confusing postoperative pain with the pain before the surgery.

Correct Answer: 2

Rationale 1: The client may not be prescribed pain medication before every ambulation session.

Rationale 2: When using the gate control theory, nurses can use this model to stop nociceptor firing by applying topical therapies and addressing the clients mood to reduce fear and anxiety.

Rationale 3: The nurse needs to do more than tell the client that the pain is gone.

Rationale 4: The client does not appear to be confused between the postoperative pain and the pain before the surgery.

Global Rationale: Page Reference: 1210

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Compare and contrast barriers to effective pain management affecting nurses and clients.

Question 23

Type: MCMA

The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions would be appropriate for the nurse identify to help this client?

Standard Text: Select all that apply.

1. Talk with the client about pain.

2. Provide privacy.

3. Present choices for dealing with pain.

4. Encourage distraction with music or television.

5. Allay fears and anxiety.

Correct Answer: 1,2,3,4

Rationale 1: Nursing interventions to assist with pain management for an adolescent client include talking with the client about the pain.

Rationale 2: Nursing interventions to assist with pain management for an adolescent client include providing privacy.

Rationale 3: Nursing interventions to assist with pain management for an adolescent client include presenting choices for dealing with the pain.

Rationale 4: Nursing interventions to assist with pain management for an adolescent client include encouraging distraction with music or television.

Rationale 5: Allaying fears and anxiety would be a nursing intervention to assist with pain management for an adult.

Global Rationale: Page Reference: 1213-1215

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Describe factors that can affect a persons perception of and reaction to pain.

Question 24

Type: MCMA

An older client who refuses medication for pain is irritable and unable to sleep. What should the nurse explain to the client to encourage the use of pain medication?

Standard Text: Select all that apply.

1. There are high-dose medications that will eradicate the pain.

2. The lack of pain control is causing the inability to sleep.

3. The lack of pain control is causing irritability.

4. The risks of taking pain medication are low in the older population.

5. The lack of pain control will affect mobility and activity tolerance.

Correct Answer: 2,3,5

Rationale 1: When planning pharmacologic intervention for an older client, the approach should be to start low and go slow because of the effects on renal and liver function.

Rationale 2: If pain is not effectively controlled in the older client, the ability to sleep will be affected.

Rationale 3: If pain is not effectively controlled in the older client, irritability can occur.

Rationale 4: When planning pharmacologic intervention for an older client, the nurse must assess the client for potential risks because of changes in organ and system functioning.

Rationale 5: If pain is not effectively controlled in the older client, mobility and activity tolerance will be affected.

Global Rationale: Page Reference: 1210

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Describe factors that can affect a persons perception of and reaction to pain.

Question 25

Type: MCSA

The nurse is identifying diagnoses appropriate for a client experiencing pain. The client has had previous episodes of uncontrolled pain in the past, and is worried about the current pain pattern. Which diagnosis would be appropriate for the nurse to include for this client?

1. Anxiety.

2. Ineffective Coping.

3. Deficient Knowledge.

4. Hopelessness.

Correct Answer: 1

Rationale 1: The diagnosis of Anxiety would be appropriate for the client, since the client has past experiences of poor pain control and is anticipating pain.

Rationale 2: The diagnosis of Ineffective Coping would be applicable if the client were experiencing prolonged pain because of ineffective pain management.

Rationale 3: The diagnosis of Deficient Knowledge would be applicable if the client had a lack of exposure to information regarding pain management.

Rationale 4: The diagnosis of Hopelessness would be appropriate if the client were experiencing continuous pain.

Global Rationale: Page Reference: 1220-1221

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 06 Identify examples of nursing diagnoses for clients with pain.

Question 26

Type: MCMA

From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time?

Standard Text: Select all that apply.

1. Anxiety.

2. Hopelessness.

3. Ineffective Health Maintenance.

4. Insomnia.

5. Impaired Physical Mobility.

Correct Answer: 3,4,5

Rationale 1: The diagnosis of Anxiety would not be applicable, since the client did not express past experiences of poor control of pain or anticipation of future pain events.

Rationale 2: The diagnosis of Hopelessness would not be applicable, since the client did not state that the pain is continuous.

Rationale 3: The diagnosis of Ineffective Health Maintenance would be applicable, since the client is experiencing chronic pain of arthritis and is fatigued.

Rationale 4: The diagnosis of Insomnia would be applicable, since the client is experiencing increased pain perception at night, affecting sleep.

Rationale 5: The diagnosis of Impaired Physical Mobility would be applicable, since the client is experiencing arthritic pain in the hips and knees.

Global Rationale: Page Reference: 1220-1221

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 06 Identify examples of nursing diagnoses for clients with pain.

Question 27

Type: MCSA

A client experiencing chronic pain is not getting relief with pain medication. What should the nurse do to help this client?

1. Ask the physician to change the prescribed pain medication.

2. Reassess the pain and consider another pain relief measure.

3. Limit interaction with the client.

4. Stop using alternative pain relief measures, if not effective.

Correct Answer: 2

Rationale 1: If a pain relief measure is ineffective, encourage the client to try it again before abandoning it. Medications might need repeated doses to saturate plasma proteins before sufficient free drug is available to work on the intended target.

Rationale 2: Keep trying. Do not ignore a client because pain persists despite failed attempts to alleviate the discomfort. In these circumstances, reassess the pain and consider other relief measures.

Rationale 3: The nurse should not ignore the client

Rationale 4: Many nonpharmacologic measures require practice before they are effective.

Global Rationale: Page Reference: 1222

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a clients response to interventions for pain.

Question 28

Type: MCSA

The nurse assesses a client as experiencing severe pain. Which intervention would be the most applicable for the client at this time?

1. Provide NSAID medication as prescribed.

2. Coach the client with guided imagery.

3. Suggest the client read or watch television until the pain subsides.

4. Provide opioid analgesic as prescribed.

Correct Answer: 4

Rationale 1: The selection of pain relief measures should be aligned with the clients report of the severity of the pain. If the client reports mild pain, an analgesic such as acetaminophen might be indicated.

Rationale 2: Using a technique such as guided imagery is essentially telling the client to ignore the pain, which is a misalignment of the pain severity and the intervention selected.

Rationale 3: Using a technique such as watching television is essentially telling the client to ignore the pain, which is a misalignment of the pain severity and the intervention selected.

Rationale 4: The selection of pain relief measures should be aligned with the clients report of the severity of the pain. If a client reports severe pain, a more potent pain relief measure is indicated.

Global Rationale: Page Reference: 1229

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a clients response to interventions for pain.

Question 29

Type: MCSA

A client recovering from back surgery is refusing pain medication for fear of becoming addicted. What should the nurse say to the client?

1. I understand.

2. There are ways to treat addictions to pain medications.

3. If the medication is taken to treat pain, you will not become addicted to it.

4. All pain medication causes addiction. There is nothing that can be done to prevent it.

Correct Answer: 3

Rationale 1: Stating that the nurse understands the clients concern is not sufficient. The nurse needs to explain how the pain medication will not likely lead to addiction.

Rationale 2: This response supports the clients fears of becoming addicted to pain medication.

Rationale 3: Clients are unlikely to become addicted to an analgesic provided to treat pain.

Rationale 4: Not all pain medication causes addiction. Clients are unlikely to become addicted to an analgesic that is provided to treat pain.

Global Rationale: Page Reference: 1224

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Compare and contrast barriers to effective pain management affecting nurses and clients.

Question 30

Type: MCSA

A client experiencing pain after surgery says Something must be wrong, since the pain is so severe. The best response for the nurse to make to the client would be:

1. The amount of tissue disrupted from the surgery is not related to the degree of pain you feel.

2. That could be so.

3. Taking pain medication for many years has made the medication ineffective now.

4. Are you sure the pain is as bad as you are saying it is?

Correct Answer: 1

Rationale 1: Pain is a subjective experience, and the intensity and duration of pain vary considerably among individuals. The amount of tissue damage or disrupted is not related to the amount of pain experienced.

Rationale 2: This is not true.

Rationale 3: This statement assumes the client was taking pain medication for years, and would be incorrect and inappropriate for the nurse to explain.

Rationale 4: This response is questioning the clients experience of pain, and would be incorrect and inappropriate for the nurse to make.

Global Rationale: Page Reference: 1205

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Describe the four processes involved in nociception and how pain interventions can work during each process.

Question 31

Type: MCSA

A client has been taking medication for back pain for several months, and has seen several different healthcare providers in efforts to receive pain medication. The nurse is concerned that the client is exhibiting:

1. Tolerance.

2. Addiction.

3. Physical dependence.

4. Pseudoaddiction.

Correct Answer: 2

Rationale 1: Tolerance is a state in which continued exposure to the medication causes changes that result in a reduction in the effectiveness of the medication over time.

Rationale 2: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving.

Rationale 3: Physical dependence is a state of adaptation that manifests with withdrawal symptoms when the drug is stopped or drastically reduced.

Rationale 4: Pseudoaddiction is a condition that results from the undertreatment of pain where the client can become so focused on obtaining medications for pain relief that she becomes angry and demanding, might clock watch, and might otherwise seem inappropriately drug-seeking.

Global Rationale: Page Reference: 1224

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Differentiate tolerance, physical dependence, pseudoaddiction, and addiction.

Question 32

Type: MCSA

A client repeatedly asks the nurse How much longer until I can get more pain medication? Once the medication is provided, the client stops asking for it. The nurse identifies the clients behavior as being:

1. Addiction.

2. Tolerance.

3. Pseudoaddiction.

4. Physical dependence.

Correct Answer: 3

Rationale 1: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving.

Rationale 2: Tolerance is a state in which continued exposure to the medication causes changes that result in a reduction in the effectiveness of the medication over time.

Rationale 3: Pseudoaddiction is a condition that results from the undertreatment of pain where the client can become so focused on obtaining medications for pain relief that he becomes angry and demanding, might clock watch, and might otherwise seem inappropriately drug-seeking. To differentiate between pseudoaddiction and addiction, if the clients negative behavior resolves when the pain is treated effectively, the client is exhibiting pseudoaddiction.

Rationale 4: Physical dependence is a state of adaptation that manifests with withdrawal symptoms when the drug is stopped or drastically reduced.

Global Rationale: Page Reference: 1224

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Differentiate tolerance, physical dependence, pseudoaddiction, and addiction.

Question 33

Type: MCMA

A client experiencing pain has been prescribed a coanalgesic. The nurse should prepare to administer what medications to the client?

Standard Text: Select all that apply.

1. Nortriptyline.

2. Amitriptyline.

3. Tramadol.

4. Meloxicam.

5. Gabapentin.

Correct Answer: 1,2,5

Rationale 1: Nortriptyline is a tricyclic antidepressant used as a coanalgesic to treat pain.

Rationale 2: Amitriptyline a tricyclic antidepressant used as a coanalgesic to treat pain.

Rationale 3: Tramadol is an opioid analgesic used for moderate pain.

Rationale 4: Meloxicam is a nonopioid analgesic used for mild pain.

Rationale 5: Gabapentin is an anticonvulsant used as a coanalgesic to treat pain.

Global Rationale: Page Reference: 1231

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10 Describe pharmacologic interventions for pain.

Question 34

Type: MCMA

A client reports pain as being a 2 on a scale from 0 to 10. Which pain medications would the nurse consider for the client at this time?

Standard Text: Select all that apply.

1. Acetaminophen (Tylenol).

2. Ibuprofen (Motrin).

3. Naproxen (Naprosyn).

4. Hydrocodone (Vicodin).

5. Methadone (Dolophine).

Correct Answer: 1,2,3

Rationale 1: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as acetaminophen (Tylenol).

Rationale 2: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as ibuprofen (Motrin).

Rationale 3: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as naproxen (Naprosyn).

Rationale 4: Hydrocodone (Vicodin) would be provided if the client were experiencing moderate pain.

Rationale 5: Methadone (Dolophine) would be provided if the client were experiencing severe pain.

Global Rationale: Page Reference: 1227

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10 Describe pharmacologic interventions for pain.

Question 35

Type: MCSA

After receiving medication for mild pain, the client states that the pain is getting worse. What should the nurse plan to do for this client?

1. Administer another dose of a nonopioid medication.

2. Administer an opioid for severe pain.

3. Administer an opioid for moderate pain.

4. Administer two doses of an opioid for moderate pain.

Correct Answer: 3

Rationale 1: Since the clients pain is persisting, the next step of the WHO ladder for pain control must be applied.

Rationale 2: The next step of the WHO ladder for pain indicates that an opioid for moderate pain be provided, not an opioid for severe pain.

Rationale 3: If the client has mild pain that persists or increases despite using full doses of step 1 medications, or if the pain is moderate, then a step 2 regimen is appropriate. At the second step, an opioid for moderate pain or a combination of opioid and nonopioid medicine is provided with or without coanalgesic medications.

Rationale 4: The client should not receive two doses of an opioid for moderate pain at one time.

Global Rationale: Page Reference: 1226

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Describe the World Health Organizations ladder step approach developed for cancer pain control.

Question 36

Type: MCMA

A client is prescribed a medication that is a blend of an opioid analgesic with an NSAID. The nurse realizes that this medication will have which effect on the client?

Standard Text: Select all that apply.

1. Encourage the development of tolerance.

2. Encourage the development of addiction.

3. Maximize pain control while minimizing toxicity.

4. Maximize pain control while minimizing side effects.

5. Reduce the onset of pseudoaddiction.

Correct Answer: 3,4

Rationale 1: Blended medications do not encourage the development of tolerance.

Rationale 2: Blended medications do not encourage the development of addiction.

Rationale 3: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing toxicity.

Rationale 4: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing side effects.

Rationale 5: Blended medications do not reduce the onset of pseudoaddiction.

Global Rationale: Page Reference: 1228

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12 Describe rational polypharmacy.

Question 37

Type: MCSA

A client is diagnosed with chronic low back pain syndrome. The nurse realizes that the analgesic delivery route that might be beneficial for this client would be:

1. Topical.

2. Rectal.

3. Transmucosal.

4. Transdermal.

Correct Answer: 1

Rationale 1: Topical medications work directly at the point of application on the body. They are useful for painful procedures such as lumbar punctures or bone marrow biopsies, or for injections. These products can also offer effective pain relief for chronic pain syndromes such as low back pain.

Rationale 2: The rectal route is useful for clients who have difficulty swallowing, or nausea and vomiting.

Rationale 3: The transmucosal route is helpful for breakthrough pain because the oral mucosa is well vascularized, which facilitates rapid absorption.

Rationale 4: The transdermal approach delivers a relatively stable plasma drug level, and is noninvasive. The medication, however, is systemic which might not be what is necessary for the client with chronic low back pain syndrome.

Global Rationale: Page Reference: 1232

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.

Question 38

Type: MCSA

A client tells the nurse that at home, the dog helps distract the client from chronic hip pain. The nurse realizes that the client is utilizing which form of nonpharmacologic pain control?

1. Body.

2. Mind.

3. Social interactions.

4. Spirit.

Correct Answer: 3

Rationale 1: Interventions that target the body for pain control include massage, heat, and exercise.

Rationale 2: Interventions that target the mind for pain control include relaxation and imagery.

Rationale 3: Social interactions that are used as nonpharmacologic pain control methods include pet therapy.

Rationale 4: Interventions that target the spirit for pain control include prayer, meditation, and energy work.

Global Rationale: Page Reference: 1237

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18 List three nonpharmacologic interventions directed at each of the following: the body, the mind, the spirit, and social interactions.

Question 39

Type: MCMA

The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body for pain control. What will the nurse include in these instructions?

Standard Text: Select all that apply.

1. Massage.

2. Acupressure.

3. Self-hypnosis.

4. Exercise.

5. Nutritional supplements.

Correct Answer: 1,2,4,5

Rationale 1: Massage is a nonpharmacologic intervention that targets the body for pain control.

Rationale 2: Acupressure is a nonpharmacologic intervention that targets the body for pain control.

Rationale 3: Self-hypnosis is a nonpharmacologic intervention that targets the mind for pain control.

Rationale 4: Exercise is a nonpharmacologic intervention that targets the body for pain control.

Rationale 5: Nutritional supplements are a nonpharmacologic intervention that targets the body for pain control.

Global Rationale: Page Reference: 1236-1240

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18 List three nonpharmacologic interventions directed at each of the following: the body, the mind, the spirit, and social interactions.

Question 40

Type: SEQ

The nurse is preparing to massage a clients back. Place in order the steps the nurse will follow, after conducting hand hygiene and preparing the client, to perform the back massage.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Move the hands down the sides of the back.

Choice 2. Pour lotion into the palms of the hands to warm them.

Choice 3. Massage the areas over the right and left iliac crests.

Choice 4. Move the hands up the center of the back.

Choice 5. With the palms, massage the sacral area with smooth, circular strokes.

Choice 6. Move the hands to the scapulae and massage this region using circular strokes.

Correct Answer: 2,5,4,6,1,3

Rationale 1: To perform a back massage, the nurse should: 1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; 2) with the palms, begin in the sacral area using smooth, circular strokes; 3) move the hands up the center of the back; 4) move the hands to the scapulae and massage this region using circular strokes; 5) move the hands down the sides of the back; and 6) massage the areas over the right and left iliac crests.

Rationale 2: To perform a back massage, the nurse should: 1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; 2) with the palms, begin in the sacral area using smooth, circular strokes; 3) move the hands up the center of the back; 4) move the hands to the scapulae and massage this region using circular strokes; 5) move the hands down the sides of the back; and 6) massage the areas over the right and left iliac crests.

Rationale 3: To perform a back massage, the nurse should: 1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; 2) with the palms, begin in the sacral area using smooth, circular strokes; 3) move the hands up the center of the back; 4) move the hands to the scapulae and massage this region using circular strokes; 5) move the hands down the sides of the back; and 6) massage the areas over the right and left iliac crests.

Rationale 4: To perform a back massage, the nurse should: 1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; 2) with the palms, begin in the sacral area using smooth, circular strokes; 3) move the hands up the center of the back; 4) move the hands to the scapulae and massage this region using circular strokes; 5) move the hands down the sides of the back; and 6) massage the areas over the right and left iliac crests.

Rationale 5: To perform a back massage, the nurse should: 1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; 2) with the palms, begin in the sacral area using smooth, circular strokes; 3) move the hands up the center of the back; 4) move the hands to the scapulae and massage this region using circular strokes; 5) move the hands down the sides of the back; and 6) massage the areas over the right and left iliac crests.

Rationale 6: To perform a back massage, the nurse should: 1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; 2) with the palms, begin in the sacral area using smooth, circular strokes; 3) move the hands up the center of the back; 4) move the hands to the scapulae and massage this region using circular strokes; 5) move the hands down the sides of the back; and 6) massage the areas over the right and left iliac crests.

Global Rationale: Page Reference: 1238

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15 Verbalize the steps used in performing a back massage.

Question 41

Type: MCMA

The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage?

Standard Text: Select all that apply.

1. Supine.

2. Fowlers.

3. Trendelenburg.

4. Prone.

5. Side-lying.

Correct Answer: 4,5

Rationale 1: The supine position does not expose the clients back.

Rationale 2: The Fowlers position does not expose the clients back.

Rationale 3: The Trendelenburg position does not expose the clients back.

Rationale 4: The prone position is recommended for a back rub.

Rationale 5: The side-lying position can be used if a client cannot assume the prone position for a back rub.

Global Rationale: Page Reference: 1238

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15 Verbalize the steps used in performing a back massage.

Question 42

Type: MCSA

A client who is on postoperative day one from abdominal surgery is requesting a back rub. The nurse realizes this care should be provided by:

1. The registered nurse.

2. Unlicensed assistive personnel.

3. No one since, the client cannot assume the prone position.

4. The physician.

Correct Answer: 1

Rationale 1: Since the client is day one in recovery from abdominal surgery, the clients condition might not be stable enough to have unlicensed assistive personnel perform the skill.

Rationale 2: Although unlicensed assistive personnel might be able to perform the skill, the clients condition might warrant that the nurse provide the back rub.

Rationale 3: The client can assume a side-lying position for the back rub.

Rationale 4: The nurse can provide the back rub. The physician does not need to be contacted to do this.

Global Rationale: Page Reference: 1238

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16 Recognize when it is appropriate to delegate aspects of back massage to unlicensed assistive personnel.

Question 43

Type: MCMA

The nurse wants to assign back rubs to unlicensed assistive personnel. Before doing so, the nurse should first determine whether:

Standard Text: Select all that apply.

1. Unlicensed assistive personnel know how to perform a back rub.

2. There any clients who have intravenous fluids infusing.

3. There any clients who should not have a back rub performed.

4. There any clients who are prescribed to take nothing by mouth.

5. There any clients who do not want a back rub done by unlicensed assistive personnel.

Correct Answer: 1,3,5

Rationale 1: The nurse can delegate this skill to UAP; however, the nurse first should assess for UAPs comfort and ability.

Rationale 2: An intravenous infusion is not a contraindication for a back rub.

Rationale 3: The nurse can delegate this skill to UAP; however, the nurse first should assess for client contraindications.

Rationale 4: Being prescribed nothing by mouth is not a contraindication for a back rub.

Rationale 5: The nurse can delegate this skill to UAP; however, the nurse first should assess for client willingness to participate.

Global Rationale: Page Reference: 1238

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16 Recognize when it is appropriate to delegate aspects of back massage to unlicensed assistive personnel.

Question 44

Type: MCMA

The nurse has completed a back massage for a client. What should the nurse document about this procedure?

Standard Text: Select all that apply.

1. Effectiveness of pain medication using a rating scale from 0 to 10.

2. Position to perform the massage.

3. Content of communication that occurred during the back massage.

4. Amount of lotion used during the back massage.

5. Client response.

Correct Answer: 2,5

Rationale 1: Effectiveness of pain medication is not a part of the documentation of a back massage.

Rationale 2: The nurse should document the position in which the massage was performed on the client.

Rationale 3: The content of communication that occurred during the back massage is not necessary to document.

Rationale 4: The amount of lotion used during the back massage is not necessary to document.

Rationale 5: The nurse should document the clients response to the massage.

Global Rationale: Page Reference: 1238

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17 Demonstrate appropriate documentation and reporting of back massage.

Question 45

Type: MCSA

A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client?

1. Apply ice to the knee over the cast.

2. Rub the knee of the non-casted leg.

3. Apply heat to the knee over the cast.

4. Rub the foot of the casted extremity.

Correct Answer: 2

Rationale 1: Ice will not penetrate the cast.

Rationale 2: The nurse can use contralateral stimulation, which is accomplished by stimulating the skin in an area opposite to the painful area, such as stimulating the left knee if the pain is in the right knee. The nurse should explain the rationale to the client in that nerves are crossed in the spinal cord, and that is why this technique works contralaterally.

Rationale 3: Heat will not penetrate the cast.

Rationale 4: Rubbing the foot might not be effective to reduce pain in the knee.

Global Rationale: Page Reference: 1239

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14 Describe nonpharmacologic pain control interventions.

Question 46

Type: MCSA

A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment. The nurse realizes the clients pain was influenced by which type of distraction?

1. Visual.

2. Tactile.

3. Intellectual.

4. Behavioral.

Correct Answer: 1

Rationale 1: Visual distraction includes watching television.

Rationale 2: Tactile distraction includes slow, rhythmic breathing or a massage.

Rationale 3: Intellectual distraction includes crossword puzzles or engaging in hobby.

Rationale 4: Behavioral is not a type of distraction.

Global Rationale: Page Reference: 1239

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14 Describe nonpharmacologic pain control interventions.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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