Module 3 Comfort(FREE) My Nursing Test Banks

Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

Module 3 Comfort

The Concept of Comfort

1) The nurse is preparing to assess pain level for several clients. What will the nurse assess, in addition to the clients physical experience of pain?

Select all that apply.

A) Religion

B) Friendship

C) Environment

D) Psychospirituality

E) Social interaction

Answer: C, D, E

Explanation: A) Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, social, and environmental. Religion and friendship are encompassed in psychospiritual and social.

B) Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, social, and environmental. Religion and friendship are encompassed in psychospiritual and social.

C) Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, social, and environmental. Religion and friendship are encompassed in psychospiritual and social.

D) Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, social, and environmental. Religion and friendship are encompassed in psychospiritual and social.

E) Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, social, and environmental. Religion and friendship are encompassed in psychospiritual and social.

Page Ref: 141

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Assessment

Learning Outcome: 1. Summarize the physiology of comfort.

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2) The nurse provides an in-service to peers regarding situations that can affect the comfort level of the clients on the unit. Which client statement indicates that the clients sense of well-being is negatively impacted?

A) I feel like I have no energy today.

B) I dont feel any physical pain today.

C) I was able to sleep uninterrupted last night.

D) I am so glad that playing cards takes my mind off my worries.

Answer: A

Explanation: A) When there is insufficient energy, the client is unable to focus on healing and lacks the ability to cope in stressful situations. Restful sleep, physical well-being, and appropriate diversion all promote a sense of comfort for the client.

B) When there is insufficient energy, the client is unable to focus on healing and lacks the ability to cope in stressful situations. Restful sleep, physical well-being, and appropriate diversion all promote a sense of comfort for the client.

C) When there is insufficient energy, the client is unable to focus on healing and lacks the ability to cope in stressful situations. Restful sleep, physical well-being, and appropriate diversion all promote a sense of comfort for the client.

D) When there is insufficient energy, the client is unable to focus on healing and lacks the ability to cope in stressful situations. Restful sleep, physical well-being, and appropriate diversion all promote a sense of comfort for the client.

Page Ref: 144

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Nursing Process: Evaluation

Learning Outcome: 2. Examine the relationship between comfort and other concepts/systems.

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3) A client is experiencing severe pain in the left lower quadrant of the abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing nausea, vomiting, and restlessness. Which type of pain should the nurse suspect the client is experiencing?

A) Somatic pain

B) Referred pain

C) Visceral pain

D) Chronic pain

Answer: C

Explanation: A) There are three types of acute pain: visceral pain, somatic pain, and referred pain. The client in this scenario is experiencing visceral pain, or pain that arises from body organs. Visceral pain is often associated with nausea and vomiting, hypotension, and restlessness.

B) There are three types of acute pain: visceral pain, somatic pain, and referred pain. The client in this scenario is experiencing visceral pain, or pain that arises from body organs. Visceral pain is often associated with nausea and vomiting, hypotension, and restlessness.

C) There are three types of acute pain: visceral pain, somatic pain, and referred pain. The client in this scenario is experiencing visceral pain, or pain that arises from body organs. Visceral pain is often associated with nausea and vomiting, hypotension, and restlessness.

D) There are three types of acute pain: visceral pain, somatic pain, and referred pain. The client in this scenario is experiencing visceral pain, or pain that arises from body organs. Visceral pain is often associated with nausea and vomiting, hypotension, and restlessness.

Page Ref: 155

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 3. Identify commonly occurring alterations in comfort and their related therapies.

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4) The nurse is caring for a 1-year-old child in the postoperative period. Which pain assessment tool should the nurse use when assessing pain in this child?

A) Faces Pain Rating Scale

B) FLACC Behavioral Pain Assessment Scale

C) Oucher Scale

D) Poker Chip Tool

Answer: B

Explanation: A) The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales, and can usually be used with children 3 and older.

B) The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales, and can usually be used with children 3 and older.

C) The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales, and can usually be used with children 3 and older.

D) The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales, and can usually be used with children 3 and older.

Page Ref: 169

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 4. Differentiate common assessment procedures used to examine comfort across the life span.

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5) A child with injuries from a motor vehicle crash is crying, moaning, and thrashing about on the bed. The childs assessment reveals guarding of the abdomen. The nurse suspects that the child is in severe pain and anticipates which diagnostic test will be ordered for this client?

A) Barium enema

B) Electrolyte panel

C) PET scan

D) X-rays of the limbs

Answer: A

Explanation: A) There are a few tests that can help the medical team determine the source of the clients discomfort. In this case, a barium enema will determine GI abnormalities and sources of pain. An x-ray will not help to determine the source of abdominal pain. An electrolyte panel will not help determine the source of the pain. PET is a scan that helps determine the functioning of tissues.

B) There are a few tests that can help the medical team determine the source of the clients discomfort. In this case, a barium enema will determine GI abnormalities and sources of pain. An x-ray will not help to determine the source of abdominal pain. An electrolyte panel will not help determine the source of the pain. PET is a scan that helps determine the functioning of tissues.

C) There are a few tests that can help the medical team determine the source of the clients discomfort. In this case, a barium enema will determine GI abnormalities and sources of pain. An x-ray will not help to determine the source of abdominal pain. An electrolyte panel will not help determine the source of the pain. PET is a scan that helps determine the functioning of tissues.

D) There are a few tests that can help the medical team determine the source of the clients discomfort. In this case, a barium enema will determine GI abnormalities and sources of pain. An x-ray will not help to determine the source of abdominal pain. An electrolyte panel will not help determine the source of the pain. PET is a scan that helps determine the functioning of tissues.

Page Ref: 147

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individuals comfort status.

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6) An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. What should the nurse do?

A) Allow the toddler to sit on the parents lap and begin the assessment.

B) Allow the toddler to stand on the floor until the crying stops.

C) Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddlers behavior.

D) Instruct the parent to hold the toddler down tightly to complete the examination.

Answer: A

Explanation: A) Toddlers are most comfortable when sitting with the parents. Vaccinations can be administered in this way if the parent is taught proper therapeutic holding techniques to keep everyone safe for the procedure. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the vaccinations to prevent injury from movement.

B) Toddlers are most comfortable when sitting with the parents. Vaccinations can be administered in this way if the parent is taught proper therapeutic holding techniques to keep everyone safe for the procedure. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the vaccinations to prevent injury from movement.

C) Toddlers are most comfortable when sitting with the parents. Vaccinations can be administered in this way if the parent is taught proper therapeutic holding techniques to keep everyone safe for the procedure. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the vaccinations to prevent injury from movement.

D) Toddlers are most comfortable when sitting with the parents. Vaccinations can be administered in this way if the parent is taught proper therapeutic holding techniques to keep everyone safe for the procedure. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the vaccinations to prevent injury from movement.

Page Ref: 149

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and caring interventions across the life span for individuals with common alterations of comfort.

Copyright 2015 Pearson Education, Inc.

7) The nurse is caring for a postoperative client on a medical-surgical unit. An analgesic is ordered to be given every 3-4 hours. What can occur if the nurse delays providing the client with the medication?

A) Increase in the clients pain tolerance

B) Increase in the chance of breakthrough pain

C) Decrease in the chance of withdrawal symptoms

D) Decrease in the chance of addiction

Answer: B

Explanation: A) Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain. Delaying the pain medication will not increase the clients pain tolerance, decrease the chance of addiction, or decrease the chance of withdrawal symptoms if the medication is stopped without weaning.

B) Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain. Delaying the pain medication will not increase the clients pain tolerance, decrease the chance of addiction, or decrease the chance of withdrawal symptoms if the medication is stopped without weaning.

C) Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain. Delaying the pain medication will not increase the clients pain tolerance, decrease the chance of addiction, or decrease the chance of withdrawal symptoms if the medication is stopped without weaning.

D) Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain. Delaying the pain medication will not increase the clients pain tolerance, decrease the chance of addiction, or decrease the chance of withdrawal symptoms if the medication is stopped without weaning.

Page Ref: 156

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 8. Compare and contrast common independent and collaborative interventions for clients with alterations in comfort.

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8) The nurse is designing a teaching plan for community members on ways to prevent chronic pain. Which information should the nurse include in this teaching plan?

Select all that apply.

A) Eating a healthy diet

B) Obtaining adequate sleep

C) Avoiding illicit drug use

D) Limiting smoking before going to sleep

E) Avoiding repetitive movements

Answer: A, B, C, E

Explanation: A) Lifestyle habits that predispose individuals to chronic health alterations increase an individuals risk for experiencing discomfort. Eating a healthy diet and obtaining adequate sleep can prevent the development of chronic diseases that lead to symptoms of discomfort. Using illicit drugs can cause emotional and physical withdrawal symptoms when the drug is no longer used. Smoking can cause physical and emotional withdrawal symptoms when no longer used. It is wise to not engage in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements can increase the risk of injury and fatigue, leading to discomfort.

B) Lifestyle habits that predispose individuals to chronic health alterations increase an individuals risk for experiencing discomfort. Eating a healthy diet and obtaining adequate sleep can prevent the development of chronic diseases that lead to symptoms of discomfort. Using illicit drugs can cause emotional and physical withdrawal symptoms when the drug is no longer used. Smoking can cause physical and emotional withdrawal symptoms when no longer used. It is wise to not engage in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements can increase the risk of injury and fatigue, leading to discomfort.

C) Lifestyle habits that predispose individuals to chronic health alterations increase an individuals risk for experiencing discomfort. Eating a healthy diet and obtaining adequate sleep can prevent the development of chronic diseases that lead to symptoms of discomfort. Using illicit drugs can cause emotional and physical withdrawal symptoms when the drug is no longer used. Smoking can cause physical and emotional withdrawal symptoms when no longer used. It is wise to not engage in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements can increase the risk of injury and fatigue, leading to discomfort.

D) Lifestyle habits that predispose individuals to chronic health alterations increase an individuals risk for experiencing discomfort. Eating a healthy diet and obtaining adequate sleep can prevent the development of chronic diseases that lead to symptoms of discomfort. Using illicit drugs can cause emotional and physical withdrawal symptoms when the drug is no longer used. Smoking can cause physical and emotional withdrawal symptoms when no longer used. It is wise to not engage in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements can increase the risk of injury and fatigue, leading to discomfort.

Copyright 2015 Pearson Education, Inc.

E) Lifestyle habits that predispose individuals to chronic health alterations increase an individuals risk for experiencing discomfort. Eating a healthy diet and obtaining adequate sleep can prevent the development of chronic diseases that lead to symptoms of discomfort. Using illicit drugs can cause emotional and physical withdrawal symptoms when the drug is no longer used. Smoking can cause physical and emotional withdrawal symptoms when no longer used. It is wise to not engage in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements can increase the risk of injury and fatigue, leading to discomfort.

Page Ref: 146

Cognitive Level: Creating

Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 6. Explain management of comfort and prevention of discomfort.

Copyright 2015 Pearson Education, Inc.

Exemplar 3.1 Acute and Chronic Pain

1) The nurse is teaching a class on the perception of pain. What will the nurse teach as being the second step in processing pain stimuli?

A) Thalamus

B) Reticular system

C) Limbic system

D) Cerebral cortex

Answer: D

Explanation: A) The thalamus is the main relay station for sensory information. Pain information is then transmitted to the cerebral cortex as well as the reticular and limbic systems for the processing and interpretation of pain. The cerebral cortex is the second step in processing pain stimuli. The transmission of pain moves through the limbic system after the thalamus. Transmission of pain impulses occurs in the reticular system after traveling though the thalamus as the main relay station.

B) The thalamus is the main relay station for sensory information. Pain information is then transmitted to the cerebral cortex as well as the reticular and limbic systems for the processing and interpretation of pain. The cerebral cortex is the second step in processing pain stimuli. The transmission of pain moves through the limbic system after the thalamus. Transmission of pain impulses occurs in the reticular system after traveling though the thalamus as the main relay station.

C) The thalamus is the main relay station for sensory information. Pain information is then transmitted to the cerebral cortex as well as the reticular and limbic systems for the processing and interpretation of pain. The cerebral cortex is the second step in processing pain stimuli. The transmission of pain moves through the limbic system after the thalamus. Transmission of pain impulses occurs in the reticular system after traveling though the thalamus as the main relay station.

D) The thalamus is the main relay station for sensory information. Pain information is then transmitted to the cerebral cortex as well as the reticular and limbic systems for the processing and interpretation of pain. The cerebral cortex is the second step in processing pain stimuli. The transmission of pain moves through the limbic system after the thalamus. Transmission of pain impulses occurs in the reticular system after traveling though the thalamus as the main relay station.

Page Ref: 153

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of acute and chronic pain.

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2) The nurse, caring for a 1-year-old client recovering from a tonsillectomy, assesses the child for pain. If pain level is not addressed, what additional health problem could occur?

A) Urinary retention

B) Bowel obstruction

C) Respiratory compromise

D) Bradycardia

Answer: C

Explanation: A) The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory compromise and complications. Uncontrolled pain does not lead to cardiac complications such as bradycardia. Uncontrolled pain does not frequently lead to bowel complications such as obstruction. Uncontrolled pain does not usually lead to urinary complications such as retention.

B) The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory compromise and complications. Uncontrolled pain does not lead to cardiac complications such as bradycardia. Uncontrolled pain does not frequently lead to bowel complications such as obstruction. Uncontrolled pain does not usually lead to urinary complications such as retention.

C) The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory compromise and complications. Uncontrolled pain does not lead to cardiac complications such as bradycardia. Uncontrolled pain does not frequently lead to bowel complications such as obstruction. Uncontrolled pain does not usually lead to urinary complications such as retention.

D) The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory compromise and complications. Uncontrolled pain does not lead to cardiac complications such as bradycardia. Uncontrolled pain does not frequently lead to bowel complications such as obstruction. Uncontrolled pain does not usually lead to urinary complications such as retention.

Page Ref: 157

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 2. Identify risk factors and prevention methods associated with acute and chronic pain.

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3) A client who has been undergoing treatment for chronic back pain has been considering complementary and alternative therapies to manage the pain. The nurse has assessed the clients needs and discussed the use of available methods with the client. Which client statement indicates the need for further instruction?

A) Caution is needed with alternative therapies, as they have not been tested by the FDA.

B) Chondroitin sulfate is a dietary supplement that I can get over the counter.

C) Glucosamine sulfate is a medication that must be prescribed by my physician.

D) I may have some stomach upset associated with glucosamine sulfate.

Answer: C

Explanation: A) Glucosamine sulfate is a dietary supplement. No prescription is needed to obtain it. Alternative therapies do not require the approval of the FDA to be sold. The remaining statements are correct.

B) Glucosamine sulfate is a dietary supplement. No prescription is needed to obtain it. Alternative therapies do not require the approval of the FDA to be sold. The remaining statements are correct.

C) Glucosamine sulfate is a dietary supplement. No prescription is needed to obtain it. Alternative therapies do not require the approval of the FDA to be sold. The remaining statements are correct.

D) Glucosamine sulfate is a dietary supplement. No prescription is needed to obtain it. Alternative therapies do not require the approval of the FDA to be sold. The remaining statements are correct.

Page Ref: 168

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with acute and chronic pain.

Copyright 2015 Pearson Education, Inc.

4) A 3-year-old client being prepared for a lumbar puncture begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate for the client at this time?

A) Knowledge Deficient of the procedure

B) Anxiety related to anticipated painful procedure

C) Fear related to the unfamiliar environment

D) Ineffective Coping related to an invasive procedure

Answer: B

Explanation: A) The Question Stem indicates that the child associates the treatment room with a painful procedure, and the reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for coping in a child of this age. This child is not old enough to understand the need for a lumbar puncture. The childs fear is related not to the unfamiliar environment but to the anticipated pain associated with the treatment room. The Question Stem indicates that the child has been through painful procedures in the treatment room, so Knowledge Deficient is not the most appropriate diagnosis.

B) The Question Stem indicates that the child associates the treatment room with a painful procedure, and the reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for coping in a child of this age. This child is not old enough to understand the need for a lumbar puncture. The childs fear is related not to the unfamiliar environment but to the anticipated pain associated with the treatment room. The Question Stem indicates that the child has been through painful procedures in the treatment room, so Knowledge Deficient is not the most appropriate diagnosis.

C) The Question Stem indicates that the child associates the treatment room with a painful procedure, and the reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for coping in a child of this age. This child is not old enough to understand the need for a lumbar puncture. The childs fear is related not to the unfamiliar environment but to the anticipated pain associated with the treatment room. The Question Stem indicates that the child has been through painful procedures in the treatment room, so Knowledge Deficient is not the most appropriate diagnosis.

D) The Question Stem indicates that the child associates the treatment room with a painful procedure, and the reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for coping in a child of this age. This child is not old enough to understand the need for a lumbar puncture. The childs fear is related not to the unfamiliar environment but to the anticipated pain associated with the treatment room. The Question Stem indicates that the child has been through painful procedures in the treatment room, so Knowledge Deficient is not the most appropriate diagnosis.

Page Ref: 170

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Nursing Process: Diagnosis

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for individuals with acute and chronic pain.

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5) The nurse is creating a pain management plan using the three-step approach for a client with intractable pain. Which interventions should the nurse include in this plan?

Select all that apply.

A) Administer a nonopioid analgesic first.

B) Administer an opioid analgesic first.

C) Administer a nonopioid with an opioid second.

D) Administer an opioid analgesic last.

E) Administer analgesics upon client request.

Answer: A, C, D

Explanation: A) The first step in the three-step approach to pain management involves administering a nonopioid drug first. If pain is not adequately controlled with this mild intervention, clients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drugs. If the client is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. Pain-relieving drugs should be given by the clock (every 3-6 hours) rather than on demand to maintain freedom from pain.

B) The first step in the three-step approach to pain management involves administering a nonopioid drug first. If pain is not adequately controlled with this mild intervention, clients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drugs. If the client is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. Pain-relieving drugs should be given by the clock (every 3-6 hours) rather than on demand to maintain freedom from pain.

C) The first step in the three-step approach to pain management involves administering a nonopioid drug first. If pain is not adequately controlled with this mild intervention, clients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drugs. If the client is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. Pain-relieving drugs should be given by the clock (every 3-6 hours) rather than on demand to maintain freedom from pain.

D) The first step in the three-step approach to pain management involves administering a nonopioid drug first. If pain is not adequately controlled with this mild intervention, clients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drugs. If the client is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. Pain-relieving drugs should be given by the clock (every 3-6 hours) rather than on demand to maintain freedom from pain.

E) The first step in the three-step approach to pain management involves administering a nonopioid drug first. If pain is not adequately controlled with this mild intervention, clients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drugs. If the client is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. Pain-relieving drugs should be given by the clock (every 3-6 hours) rather than on demand to maintain freedom from pain.

Page Ref: 163

Cognitive Level: Creating

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 6. Plan evidence-based care for an individual with acute or chronic pain and his or

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her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

6) A female client has returned to the unit following a hysterectomy. The nurse knows that which intervention will provide the most pain relief for the client?

A) Offer pain relief before the client complains of pain.

B) Assess the pain level every 4 hours around the clock.

C) Wait until the client can describe the pain specifically.

D) Allow the client to sleep off the anesthesia, and then offer pain medication.

Answer: A

Explanation: A) Anticipating a clients pain will ensure a more manageable pain experience than waiting until the client complains of pain. Pain management needs to be implemented prior to the clients describing specific postoperative pain, or sleeping off anesthesia. If the client is asleep, she should not be awakened simply to assess the pain every 4 hours unless there are other significant nonverbal signs during sleep that indicate that the client is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site.

B) Anticipating a clients pain will ensure a more manageable pain experience than waiting until the client complains of pain. Pain management needs to be implemented prior to the clients describing specific postoperative pain, or sleeping off anesthesia. If the client is asleep, she should not be awakened simply to assess the pain every 4 hours unless there are other significant nonverbal signs during sleep that indicate that the client is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site.

C) Anticipating a clients pain will ensure a more manageable pain experience than waiting until the client complains of pain. Pain management needs to be implemented prior to the clients describing specific postoperative pain, or sleeping off anesthesia. If the client is asleep, she should not be awakened simply to assess the pain every 4 hours unless there are other significant nonverbal signs during sleep that indicate that the client is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site.

D) Anticipating a clients pain will ensure a more manageable pain experience than waiting until the client complains of pain. Pain management needs to be implemented prior to the clients describing specific postoperative pain, or sleeping off anesthesia. If the client is asleep, she should not be awakened simply to assess the pain every 4 hours unless there are other significant nonverbal signs during sleep that indicate that the client is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site.

Page Ref: 171

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 7. Evaluate expected outcomes for an individual with acute or chronic pain.

Copyright 2015 Pearson Education, Inc.

7) The nurse is reviewing the admission orders for an 86-year-old client who is being admitted for a hysterectomy. The client, who has been diagnosed as having uterine cancer, has chronic pain caused by arthritis. The physician has ordered long-acting oral narcotic medication to be administered every 4 hours. What should the nurse do when providing the medication to the client?

A) Administer the medication when the client requests.

B) Administer the medication around the clock.

C) Consult the physician to order intravenous pain medication.

D) Administer the medication sparingly to avoid narcotic addiction.

Answer: B

Explanation: A) Pain medication is best when it is administered around the clock. Needless suffering occurs when the medication is used sparingly or when waiting for the client to request something for pain. The elderly are less likely to become addicted to narcotics. Oral medications are the least invasive and may provide sufficient relief; therefore, they should be tried first.

B) Pain medication is best when it is administered around the clock. Needless suffering occurs when the medication is used sparingly or when waiting for the client to request something for pain. The elderly are less likely to become addicted to narcotics. Oral medications are the least invasive and may provide sufficient relief; therefore, they should be tried first.

C) Pain medication is best when it is administered around the clock. Needless suffering occurs when the medication is used sparingly or when waiting for the client to request something for pain. The elderly are less likely to become addicted to narcotics. Oral medications are the least invasive and may provide sufficient relief; therefore, they should be tried first.

D) Pain medication is best when it is administered around the clock. Needless suffering occurs when the medication is used sparingly or when waiting for the client to request something for pain. The elderly are less likely to become addicted to narcotics. Oral medications are the least invasive and may provide sufficient relief; therefore, they should be tried first.

Page Ref: 171

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with acute or chronic pain.

Copyright 2015 Pearson Education, Inc.

8) A 6-year-old clients IV has infiltrated and must be restarted immediately for medication administration. There is no time for placing local anesthetic cream on the skin to decrease the pain associated with the procedure. What complementary therapies would be most helpful when placing the IV for this pediatric client?

A) Moderate sedation

B) Restraint using a Mummy Wrap

C) Anesthesia

D) Distraction using bubbles

Answer: D

Explanation: A) Complementary therapiesespecially guided imagery, relaxation techniques, and distractioncan reduce the anxiety associated with the anticipation of the procedure. Bubbles would provide distraction for this pediatric client. All the other choices are not considered complementary therapies and are inappropriate for the situation.

B) Complementary therapiesespecially guided imagery, relaxation techniques, and distractioncan reduce the anxiety associated with the anticipation of the procedure. Bubbles would provide distraction for this pediatric client. All the other choices are not considered complementary therapies and are inappropriate for the situation.

C) Complementary therapiesespecially guided imagery, relaxation techniques, and distractioncan reduce the anxiety associated with the anticipation of the procedure. Bubbles would provide distraction for this pediatric client. All the other choices are not considered complementary therapies and are inappropriate for the situation.

D) Complementary therapiesespecially guided imagery, relaxation techniques, and distractioncan reduce the anxiety associated with the anticipation of the procedure. Bubbles would provide distraction for this pediatric client. All the other choices are not considered complementary therapies and are inappropriate for the situation.

Page Ref: 158

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with acute or chronic pain and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

Exemplar 3.2 End-of-Life Care

1) The nurse is taking care of a client with terminal lung cancer who is showing signs of imminent death. What changes should the nurse expect the client to exhibit?

Select all that apply.

A) Decreased blood pressure

B) Initial increased heart rate followed by bradycardia

C) An increase in the volume of Korotkoffs sounds

D) Diaphoresis

E) An increase in cardiac output

Answer: A, B, D

Explanation: A) The heart rate might initially increase as hypoxia develops; then the heart rate and blood pressure decrease, resulting in decreased cardiac output. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin; and changes in skin coloring. A change in pulse pressure and a decrease in the volume of Korotkoffs sounds indicate imminent death. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

B) The heart rate might initially increase as hypoxia develops; then the heart rate and blood pressure decrease, resulting in decreased cardiac output. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin; and changes in skin coloring. A change in pulse pressure and a decrease in the volume of Korotkoffs sounds indicate imminent death. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

C) The heart rate might initially increase as hypoxia develops; then the heart rate and blood pressure decrease, resulting in decreased cardiac output. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin; and changes in skin coloring. A change in pulse pressure and a decrease in the volume of Korotkoffs sounds indicate imminent death. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

D) The heart rate might initially increase as hypoxia develops; then the heart rate and blood pressure decrease, resulting in decreased cardiac output. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin; and changes in skin coloring. A change in pulse pressure and a decrease in the volume of Korotkoffs sounds indicate imminent death. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

E) The heart rate might initially increase as hypoxia develops; then the heart rate and blood pressure decrease, resulting in decreased cardiac output. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin; and changes in skin coloring. A change in pulse pressure and a decrease in the volume of Korotkoffs sounds indicate imminent death. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

Page Ref: 175

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of symptoms seen in clients at the end of life.

2) A competent elderly client has a living will that expresses the clients desire to avoid resuscitation and

Copyright 2015 Pearson Education, Inc.

heroic life support measures. The family members are not supportive of this directive and plan to contest the living will. Which nursing action is the most appropriate?

A) Place the document on the chart.

B) Contact the Social Services department.

C) Explain to the client that the conflict could invalidate the document.

D) Notify the hospital attorney.

Answer: A

Explanation: A) The client is competent. The wishes of the client must take priority. The document should first be placed on the chart and the physician notified. If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted. There is no need to notify the hospital attorney at this time. A lack of support by the family, or a plan to contest, does not invalidate the document legally.

B) The client is competent. The wishes of the client must take priority. The document should first be placed on the chart and the physician notified. If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted. There is no need to notify the hospital attorney at this time. A lack of support by the family, or a plan to contest, does not invalidate the document legally.

C) The client is competent. The wishes of the client must take priority. The document should first be placed on the chart and the physician notified. If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted. There is no need to notify the hospital attorney at this time. A lack of support by the family, or a plan to contest, does not invalidate the document legally.

D) The client is competent. The wishes of the client must take priority. The document should first be placed on the chart and the physician notified. If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted. There is no need to notify the hospital attorney at this time. A lack of support by the family, or a plan to contest, does not invalidate the document legally.

Page Ref: 176

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors and prevention methods associated with symptoms seen at the end of life.

3) The nurse is caring for a Catholic client who has suffered a massive cerebral hemorrhage and is not expected to survive. Which intervention is most appropriate?

A) Discuss the need to cremate the client, as burial is not accepted in this faith.

B) Make plans for the family to wash the body after death.

C) Contact a rabbi so that the client can participate in prayer.

D) Contact a priest to deliver the Sacrament of the Sick.

Answer: D

Explanation: A) In the Catholic faith, it is common to receive the Sacrament of the Sick from a priest in order to receive spiritual strength and prepare for death. Contacting a rabbi would be appropriate for a Jewish client, and making plans for the family to wash the body is appropriate for the Muslim faith. Cremation is not preferred over burial in the Catholic faith.

B) In the Catholic faith, it is common to receive the Sacrament of the Sick from a priest in order to receive spiritual strength and prepare for death. Contacting a rabbi would be appropriate for a Jewish client, and making plans for the family to wash the body is appropriate for the Muslim faith. Cremation is not preferred over burial in the Catholic faith.

C) In the Catholic faith, it is common to receive the Sacrament of the Sick from a priest in order to receive spiritual strength and prepare for death. Contacting a rabbi would be appropriate for a Jewish client, and making plans for the family to wash the body is appropriate for the Muslim faith. Cremation is not preferred over burial in the Catholic faith.

D) In the Catholic faith, it is common to receive the Sacrament of the Sick from a priest in order to receive spiritual strength and prepare for death. Contacting a rabbi would be appropriate for a Jewish client, and making plans for the family to wash the body is appropriate for the Muslim faith. Cremation is not preferred over burial in the Catholic faith.

Page Ref: 180

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care for individuals at the end of life.

4) The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis for this family?

A) Anticipatory Grieving

B) Hopelessness

C) Complicated Grieving

D) Caregiver Role Strain

Answer: A

Explanation: A) Grieving prior to the actual loss is termed anticipatory grieving. There are no assessment findings in the question that indicate complicated grieving or hopelessness. This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain.

B) Grieving prior to the actual loss is termed anticipatory grieving. There are no assessment findings in the question that indicate complicated grieving or hopelessness. This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain.

C) Grieving prior to the actual loss is termed anticipatory grieving. There are no assessment findings in the question that indicate complicated grieving or hopelessness. This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain.

D) Grieving prior to the actual loss is termed anticipatory grieving. There are no assessment findings in the question that indicate complicated grieving or hopelessness. This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain.

Page Ref: 183

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Diagnosis

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual at the end of life.

5) An older client with terminal lung cancer is not breathing well and has cold and mottled skin. The client has a living will and requests comfort measures only. What should the nurse do to help this client?

A) Ask the family what they want to be done for the client.

B) Withhold all care until the client dies.

C) Contact the physician for orders to control the clients breathing.

D) Provide the client with pain medication as ordered.

Answer: D

Explanation: A) Comfort measures only indicates that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide client comfort is intensified and maintained through the end stages of the clients life. Nursing care will include the administration of pain medication and providing personal hygiene and nutrition. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the physician to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the clients written wishes when a living will is present and in force.

B) Comfort measures only indicates that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide client comfort is intensified and maintained through the end stages of the clients life. Nursing care will include the administration of pain medication and providing personal hygiene and nutrition. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the physician to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the clients written wishes when a living will is present and in force.

C) Comfort measures only indicates that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide client comfort is intensified and maintained through the end stages of the clients life. Nursing care will include the administration of pain medication and providing personal hygiene and nutrition. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the physician to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the clients written wishes when a living will is present and in force.

D) Comfort measures only indicates that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide client comfort is intensified and maintained through the end stages of the clients life. Nursing care will include the administration of pain medication and providing personal hygiene and nutrition. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the physician to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the clients written wishes when a living will is present and in force.

Page Ref: 177

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual at the end of life and his or her family in collaboration with other members of the healthcare team.

6) The nurse is caring for a dying child. Which nursing action supports the primary goal for a dying child?

A) Keep the child entertained so she does not think about dying.

B) Ensure that a good relationship is maintained with the family.

C) Administer pain medication as ordered.

D) Maintain a busy schedule for child and family members.

Answer: C

Explanation: A) The major goal for the dying child is to promote comfort and keep the child pain-free by providing analgesia to promote optimal pain relief. Maintaining a good relationship is important but not a major goal for the childs care. Keeping the child entertained is good, but the client needs to voice her feelings about death and dying. A dying child does not have the energy to maintain a busy schedule.

B) The major goal for the dying child is to promote comfort and keep the child pain-free by providing analgesia to promote optimal pain relief. Maintaining a good relationship is important but not a major goal for the childs care. Keeping the child entertained is good, but the client needs to voice her feelings about death and dying. A dying child does not have the energy to maintain a busy schedule.

C) The major goal for the dying child is to promote comfort and keep the child pain-free by providing analgesia to promote optimal pain relief. Maintaining a good relationship is important but not a major goal for the childs care. Keeping the child entertained is good, but the client needs to voice her feelings about death and dying. A dying child does not have the energy to maintain a busy schedule.

D) The major goal for the dying child is to promote comfort and keep the child pain-free by providing analgesia to promote optimal pain relief. Maintaining a good relationship is important but not a major goal for the childs care. Keeping the child entertained is good, but the client needs to voice her feelings about death and dying. A dying child does not have the energy to maintain a busy schedule.

Page Ref: 179

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Nursing Process: Evaluation

Learning Outcome: 7. Evaluate expected outcomes for an individual at the end of life.

7) The parents of a child with terminal cancer ask the nurse that the child not be told that he will not recover. The child asks the nurse if he is dying. What should the nurse do at this time?

A) Suggest a meeting with the healthcare team and the parents.

B) Offer to bring in the child life therapist to help explain the situation.

C) Tell the child he is dying and offer to stay with him.

D) Ignore the childs question and change the subject.

Answer: A

Explanation: A) Offering to set up a meeting with the healthcare team to discuss the parents fears and concerns about telling their child the truth is the best action by the nurse. Telling the child he is dying would be going against the parents wishes. Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate. The nurse should explain that the parents will talk to the child about this. The child has asked the nurse, but because the child is a minor, the nurse must consult with the parents first. Legally they cannot talk to the child.

B) Offering to set up a meeting with the healthcare team to discuss the parents fears and concerns about telling their child the truth is the best action by the nurse. Telling the child he is dying would be going against the parents wishes. Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate. The nurse should explain that the parents will talk to the child about this. The child has asked the nurse, but because the child is a minor, the nurse must consult with the parents first. Legally they cannot talk to the child.

C) Offering to set up a meeting with the healthcare team to discuss the parents fears and concerns about telling their child the truth is the best action by the nurse. Telling the child he is dying would be going against the parents wishes. Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate. The nurse should explain that the parents will talk to the child about this. The child has asked the nurse, but because the child is a minor, the nurse must consult with the parents first. Legally they cannot talk to the child.

D) Offering to set up a meeting with the healthcare team to discuss the parents fears and concerns about telling their child the truth is the best action by the nurse. Telling the child he is dying would be going against the parents wishes. Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate. The nurse should explain that the parents will talk to the child about this. The child has asked the nurse, but because the child is a minor, the nurse must consult with the parents first. Legally they cannot talk to the child.

Page Ref: 178

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual at the end of life.

8) A 12-year-old child has been brought to the Emergency Department after a car accident. The parents witness and stare at the resuscitation scene unfolding before them. The child is not responding to the resuscitative efforts after 30 minutes. Which is the best communication strategy for the nurse to use in this situation?

A) Ask the parents whether they would like resuscitative efforts to be continued at this point.

B) Ask the parents to stand at the foot of the cart to watch.

C) Inform the parents that resuscitative efforts have not been effective and are not beneficial to the child.

D) Ask the parents to leave until the child has stabilized.

Answer: C

Explanation: A) Care must be used in how the parents are asked to withdraw therapies. An effective communication strategy is to inform the parents that an intervention was initiated to give the child the best chance of recovery, but it has not been effective and is not beneficial to the child. When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to indicate that the therapy is not effective in reversing overwhelming illness or brain damage. All other interventions mentioned are not effective communication strategies in this situation.

B) Care must be used in how the parents are asked to withdraw therapies. An effective communication strategy is to inform the parents that an intervention was initiated to give the child the best chance of recovery, but it has not been effective and is not beneficial to the child. When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to indicate that the therapy is not effective in reversing overwhelming illness or brain damage. All other interventions mentioned are not effective communication strategies in this situation.

C) Care must be used in how the parents are asked to withdraw therapies. An effective communication strategy is to inform the parents that an intervention was initiated to give the child the best chance of recovery, but it has not been effective and is not beneficial to the child. When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to indicate that the therapy is not effective in reversing overwhelming illness or brain damage. All other interventions mentioned are not effective communication strategies in this situation.

D) Care must be used in how the parents are asked to withdraw therapies. An effective communication strategy is to inform the parents that an intervention was initiated to give the child the best chance of recovery, but it has not been effective and is not beneficial to the child. When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to indicate that the therapy is not effective in reversing overwhelming illness or brain damage. All other interventions mentioned are not effective communication strategies in this situation.

Page Ref: 179-180

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual at the end of life and his or her family in collaboration with other members of the healthcare team.

9) The wife of a patient with end-stage COPD tells the nurse that she wishes her husband were eligible for hospice care but she thinks that hospice is only available for cancer patients. She is also concerned that, even if he were eligible for hospice care, they couldnt afford it, theyd have medical personnel constantly underfoot, and her husband would have to switch physicians. How should the nurse respond?

Select all that apply.

A) Inform her that a diagnosis of cancer is not required for hospice care.

B) Inform her that hospice care is very expensive.

C) Tell her that, even if her husband receives hospice care, he can remain under the care of his current physician.

D) Tell her that, even though her husband has end-stage COPD, he is not eligible for hospice care.

E) Inform her that all hospice programs provide 24/7 care.

Answer: A, C

Explanation: A) In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care. Hospice reinforces the client-primary physician relationship by advocating office or home visits. Hospice care is often less expensive than conventional care in the last 6 months of life. Hospice teams visit clients intermittently, although they are available 24/7 for support and care.

B) In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care. Hospice reinforces the client-primary physician relationship by advocating office or home visits. Hospice care is often less expensive than conventional care in the last 6 months of life. Hospice teams visit clients intermittently, although they are available 24/7 for support and care.

C) In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care. Hospice reinforces the client-primary physician relationship by advocating office or home visits. Hospice care is often less expensive than conventional care in the last 6 months of life. Hospice teams visit clients intermittently, although they are available 24/7 for support and care.

D) In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care. Hospice reinforces the client-primary physician relationship by advocating office or home visits. Hospice care is often less expensive than conventional care in the last 6 months of life. Hospice teams visit clients intermittently, although they are available 24/7 for support and care.

E) In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care. Hospice reinforces the client-primary physician relationship by advocating office or home visits. Hospice care is often less expensive than conventional care in the last 6 months of life. Hospice teams visit clients intermittently, although they are available 24/7 for support and care.

Page Ref: 178

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing Process: Planning

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual at the end of life.

10) A 16-year-old client with terminal cancer tells the nurse that she does not want any more treatment, even though her parents are planning for her to participate in a study trial that involves aggressive chemotherapy. How should the nurse handle this situation?

A) Tell the client that the decision is her parents and she has to participate in the study.

B) Tell her that, at 16, she can make her own decisions no matter what her parents want.

C) Request that the parents and daughter meet together with the healthcare team to discuss options and the implications of various choices.

D) Tell her not to worry, that she knows her parents want the best for her.

Answer: C

Explanation: A) Adolescents with a serious medical condition are more capable of making treatment decisions than most teenagers. However, the Patient Self- Determination Act of 1990 limits the legal rights of individuals younger than 18 to make their own healthcare decisions. If the adolescent states a desire to withdraw from or refuse treatment, her parents and healthcare team should discuss the reasons for her decision and help her understand the implications of her decision and any treatment alternatives that may influence her choice. Telling her not to worry does not address the problem.

B) Adolescents with a serious medical condition are more capable of making treatment decisions than most teenagers. However, the Patient Self- Determination Act of 1990 limits the legal rights of individuals younger than 18 to make their own healthcare decisions. If the adolescent states a desire to withdraw from or refuse treatment, her parents and healthcare team should discuss the reasons for her decision and help her understand the implications of her decision and any treatment alternatives that may influence her choice. Telling her not to worry does not address the problem.

C) Adolescents with a serious medical condition are more capable of making treatment decisions than most teenagers. However, the Patient Self- Determination Act of 1990 limits the legal rights of individuals younger than 18 to make their own healthcare decisions. If the adolescent states a desire to withdraw from or refuse treatment, her parents and healthcare team should discuss the reasons for her decision and help her understand the implications of her decision and any treatment alternatives that may influence her choice. Telling her not to worry does not address the problem.

D) Adolescents with a serious medical condition are more capable of making treatment decisions than most teenagers. However, the Patient Self- Determination Act of 1990 limits the legal rights of individuals younger than 18 to make their own healthcare decisions. If the adolescent states a desire to withdraw from or refuse treatment, her parents and healthcare team should discuss the reasons for her decision and help her understand the implications of her decision and any treatment alternatives that may influence her choice. Telling her not to worry does not address the problem.

Page Ref: 179

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Nursing Process: Planning

Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care for individuals at the end of life.

Exemplar 3.3 Fatigue

1) A client reports feeling tired and not refreshed after sleeping even when everyone at home laughs about her loud snoring at night. What should the nurse suspect as being the cause of this clients fatigue?

A) Insomnia

B) Depression

C) Thyroid disorder

D) Sleep apnea

Answer: D

Explanation: A) The client is snoring at home, which could indicate obstructive sleep apnea. Insomnia is the absence of sleep. There is not enough information to determine if the client is depressed or has a thyroid disorder.

B) The client is snoring at home, which could indicate obstructive sleep apnea. Insomnia is the absence of sleep. There is not enough information to determine if the client is depressed or has a thyroid disorder.

C) The client is snoring at home, which could indicate obstructive sleep apnea. Insomnia is the absence of sleep. There is not enough information to determine if the client is depressed or has a thyroid disorder.

D) The client is snoring at home, which could indicate obstructive sleep apnea. Insomnia is the absence of sleep. There is not enough information to determine if the client is depressed or has a thyroid disorder.

Page Ref: 185

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of fatigue.

2) A participant in a seminar given by the nurse asks for information about lifestyle situations that might contribute to chronic fatigue. What should the nurse identify in response to this request?

Select all that apply.

A) Synthroid use

B) Chronic back pain

C) Marijuana use

D) Vigorous exercise three times a week

E) Swimming after a meal

Answer: A, B, C

Explanation: A) Fatigue is a symptom that needs investigating. Some risk factors for fatigue are hypothyroidism, use of drugs such as marijuana, and chronic pain. Synthroid use indicates hypothyroidism. Swimming and vigorous exercise will energize, not produce fatigue.

B) Fatigue is a symptom that needs investigating. Some risk factors for fatigue are hypothyroidism, use of drugs such as marijuana, and chronic pain. Synthroid use indicates hypothyroidism. Swimming and vigorous exercise will energize, not produce fatigue.

C) Fatigue is a symptom that needs investigating. Some risk factors for fatigue are hypothyroidism, use of drugs such as marijuana, and chronic pain. Synthroid use indicates hypothyroidism. Swimming and vigorous exercise will energize, not produce fatigue.

D) Fatigue is a symptom that needs investigating. Some risk factors for fatigue are hypothyroidism, use of drugs such as marijuana, and chronic pain. Synthroid use indicates hypothyroidism. Swimming and vigorous exercise will energize, not produce fatigue.

E) Fatigue is a symptom that needs investigating. Some risk factors for fatigue are hypothyroidism, use of drugs such as marijuana, and chronic pain. Synthroid use indicates hypothyroidism. Swimming and vigorous exercise will energize, not produce fatigue.

Page Ref: 185

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors and prevention methods associated with fatigue.

3) During an assessment, an adolescent reports: I get up at 6 a.m., I attend early-morning band classes three times each week, I play sports for 2 hours each day after school, and homework takes me 3 hours each night. I always feel tired. Which history question would be the priority for the nurse to ask at this time?

A) Do you think you are involved in too many activities?

B) Do you consume foods high in iron such as red meat and green, leafy vegetables?

C) How many hours of sleep do you get each night?

D) Have you considered talking with your teachers about decreasing your homework, since you have so many extracurricular activities?

Answer: C

Explanation: A) The data in this scenario reveal very little time for sleep; therefore, the history should focus on sleep patterns, not diet. Asking if the client thinks the number of activities or homework should be reduced does not directly address the number of hours of sleep the client is getting.

B) The data in this scenario reveal very little time for sleep; therefore, the history should focus on sleep patterns, not diet. Asking if the client thinks the number of activities or homework should be reduced does not directly address the number of hours of sleep the client is getting.

C) The data in this scenario reveal very little time for sleep; therefore, the history should focus on sleep patterns, not diet. Asking if the client thinks the number of activities or homework should be reduced does not directly address the number of hours of sleep the client is getting.

D) The data in this scenario reveal very little time for sleep; therefore, the history should focus on sleep patterns, not diet. Asking if the client thinks the number of activities or homework should be reduced does not directly address the number of hours of sleep the client is getting.

Page Ref: 187

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 3. Illustrate the nursing process in providing culturally sensitive care across the life span for individuals with fatigue.

4) A 21-year-old male client has come to the clinic with complaints of not being able to study effectively. The nurse plans the care based on a nursing diagnosis of Fatigue. Which client statement validates this nursing diagnosis?

A) I sleep for 9 hours a night.

B) I have hay fever.

C) I drink one beer when I go out with friends.

D) I work out in the gym two days a week.

Answer: B

Explanation: A) Allergies and their reactions, such as hay fever, can cause a person to experience fatigue and to lose focus. Sleeping for 9 hours a night is sufficient. Working out in the gym will help counteract fatigue. Drinking a beer occasionally will not cause fatigue.

B) Allergies and their reactions, such as hay fever, can cause a person to experience fatigue and to lose focus. Sleeping for 9 hours a night is sufficient. Working out in the gym will help counteract fatigue. Drinking a beer occasionally will not cause fatigue.

C) Allergies and their reactions, such as hay fever, can cause a person to experience fatigue and to lose focus. Sleeping for 9 hours a night is sufficient. Working out in the gym will help counteract fatigue. Drinking a beer occasionally will not cause fatigue.

D) Allergies and their reactions, such as hay fever, can cause a person to experience fatigue and to lose focus. Sleeping for 9 hours a night is sufficient. Working out in the gym will help counteract fatigue. Drinking a beer occasionally will not cause fatigue.

Page Ref: 185

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with fatigue.

5) During a home visit, the nurse learns that a new mother is fatigued because the baby is not sleeping well. Which suggestion should the nurse make to help decrease this clients fatigue?

A) Advise the client to alternate night feedings with the babys father to allow each parent to rest.

B) Suggest that the client ask the neighbors to babysit one night a week.

C) Ask the physician for medication to restore energy.

D) Increase exercise time each week to promote energy.

Answer: A

Explanation: A) Getting up with the newborn causes fatigue over time. If the parents take turns getting up, each parent will get a full night of rest every other day, which should help with fatigue. Medications to restore energy are not appropriate in this case. Asking someone to babysit once will not increase rest time. These parents need sleep, and increasing exercise is not a long-term solution for sleep deprivation.

B) Getting up with the newborn causes fatigue over time. If the parents take turns getting up, each parent will get a full night of rest every other day, which should help with fatigue. Medications to restore energy are not appropriate in this case. Asking someone to babysit once will not increase rest time. These parents need sleep, and increasing exercise is not a long-term solution for sleep deprivation.

C) Getting up with the newborn causes fatigue over time. If the parents take turns getting up, each parent will get a full night of rest every other day, which should help with fatigue. Medications to restore energy are not appropriate in this case. Asking someone to babysit once will not increase rest time. These parents need sleep, and increasing exercise is not a long-term solution for sleep deprivation.

D) Getting up with the newborn causes fatigue over time. If the parents take turns getting up, each parent will get a full night of rest every other day, which should help with fatigue. Medications to restore energy are not appropriate in this case. Asking someone to babysit once will not increase rest time. These parents need sleep, and increasing exercise is not a long-term solution for sleep deprivation.

Page Ref: 189

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with fatigue and his or her family in collaboration with other members of the healthcare team.

6) The nurse is teaching a female client with chronic fatigue due to clinical depression regarding ways to increase energy levels. Which client statement indicates that teaching has been effective?

A) I need to increase exercise time each week.

B) I will spend time with friends.

C) I will take Wellbutrin as prescribed.

D) I will go shopping once a week.

Answer: C

Explanation: A) Depression can cause chronic fatigue. Compliance with medications results in relief of depression and therefore increases energy levels. Shopping, spending time with friends, and increasing exercise levels will not help the client who is clinically depressed.

B) Depression can cause chronic fatigue. Compliance with medications results in relief of depression and therefore increases energy levels. Shopping, spending time with friends, and increasing exercise levels will not help the client who is clinically depressed.

C) Depression can cause chronic fatigue. Compliance with medications results in relief of depression and therefore increases energy levels. Shopping, spending time with friends, and increasing exercise levels will not help the client who is clinically depressed.

D) Depression can cause chronic fatigue. Compliance with medications results in relief of depression and therefore increases energy levels. Shopping, spending time with friends, and increasing exercise levels will not help the client who is clinically depressed.

Page Ref: 185

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Evaluation

Learning Outcome: 7. Evaluate expected outcomes for an individual with fatigue.

7) The nurse is caring for a client who is experiencing chronic fatigue related to medication being taken for seasonal allergies. What should the nurse anticipate being prescribed to help this client?

A) A medication change to treat seasonal allergies

B) Physical therapy to promote exercise

C) Strategies to keep the client awake during the day

D) Sleep medication to increase rest time

Answer: A

Explanation: A) The nurse might expect the doctor to try different dosages or different medications to try to relieve the symptoms. Since the fatigue is due to medication side effects, other strategies will not be effective while the client is on the medication.

B) The nurse might expect the doctor to try different dosages or different medications to try to relieve the symptoms. Since the fatigue is due to medication side effects, other strategies will not be effective while the client is on the medication.

C) The nurse might expect the doctor to try different dosages or different medications to try to relieve the symptoms. Since the fatigue is due to medication side effects, other strategies will not be effective while the client is on the medication.

D) The nurse might expect the doctor to try different dosages or different medications to try to relieve the symptoms. Since the fatigue is due to medication side effects, other strategies will not be effective while the client is on the medication.

Page Ref: 185

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with fatigue.

8) A client has been prescribed iron supplements to treat fatigue and a hemoglobin level of 9. What additional information should the nurse suggest to the client to help reduce feelings of fatigue associated with a low red blood cell count?

Select all that apply.

A) Increasing intake of ice cream

B) Drinking a glass of orange juice each day

C) Increasing intake of red meat

D) Increasing intake of wax beans

E) Increasing intake of green, leafy vegetables

Answer: B, C, E

Explanation: A) Iron is absorbed better when accompanied with vitamin C in foods such as orange juice. Green, leafy vegetables and red meat are good sources of iron that the client can consume in a healthy diet. Milk, ice cream, and wax beans are not sources of dietary iron, and do not enhance the absorption of iron.

B) Iron is absorbed better when accompanied with vitamin C in foods such as orange juice. Green, leafy vegetables and red meat are good sources of iron that the client can consume in a healthy diet. Milk, ice cream, and wax beans are not sources of dietary iron, and do not enhance the absorption of iron.

C) Iron is absorbed better when accompanied with vitamin C in foods such as orange juice. Green, leafy vegetables and red meat are good sources of iron that the client can consume in a healthy diet. Milk, ice cream, and wax beans are not sources of dietary iron, and do not enhance the absorption of iron.

D) Iron is absorbed better when accompanied with vitamin C in foods such as orange juice. Green, leafy vegetables and red meat are good sources of iron that the client can consume in a healthy diet. Milk, ice cream, and wax beans are not sources of dietary iron, and do not enhance the absorption of iron.

E) Iron is absorbed better when accompanied with vitamin C in foods such as orange juice. Green, leafy vegetables and red meat are good sources of iron that the client can consume in a healthy diet. Milk, ice cream, and wax beans are not sources of dietary iron, and do not enhance the absorption of iron.

Page Ref: 188

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with fatigue and his or her family in collaboration with other members of the healthcare team.

9) A client, who has multiple sclerosis, is complaining of fatigue. What should the nurse recommend?

A) Advise the client to begin a high-intensity exercise program.

B) Tell the client to begin a mild-to-moderate exercise program, with the approval of her physician.

C) Suggest that the client restrict her activity as much as possible.

D) Tell the client that she will have to adjust to fatigue and that, with MS, nothing will help.

Answer: B

Explanation: A) Higher-intensity exercise does not appear to produce a greater reduction in fatigue. Clients who report persistent fatigue from some chronic conditions should be encouraged to begin a physician-approved mild-to-moderate exercise regimen. A sedentary lifestyle can contribute to fatigue and other health complications. The client does have options to address the problem of fatigue.

B) Higher-intensity exercise does not appear to produce a greater reduction in fatigue. Clients who report persistent fatigue from some chronic conditions should be encouraged to begin a physician-approved mild-to-moderate exercise regimen. A sedentary lifestyle can contribute to fatigue and other health complications. The client does have options to address the problem of fatigue.

C) Higher-intensity exercise does not appear to produce a greater reduction in fatigue. Clients who report persistent fatigue from some chronic conditions should be encouraged to begin a physician-approved mild-to-moderate exercise regimen. A sedentary lifestyle can contribute to fatigue and other health complications. The client does have options to address the problem of fatigue.

D) Higher-intensity exercise does not appear to produce a greater reduction in fatigue. Clients who report persistent fatigue from some chronic conditions should be encouraged to begin a physician-approved mild-to-moderate exercise regimen. A sedentary lifestyle can contribute to fatigue and other health complications. The client does have options to address the problem of fatigue.

Page Ref: 188

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 6. Plan evidence-based care for an individual with fatigue and his or her family in collaboration with other members of the healthcare team.

10) A 46-year-old female client has been diagnosed with chronic fatigue syndrome. Which of the following symptoms would not be associated with this condition?

A) Feeling unrefreshed after adequate sleep

B) Joint pain with swelling

C) Mild fever

D) Confusion

Answer: B

Explanation: A) Chronic fatigue syndrome is diagnosed only if it is accompanied by at least four of the following symptoms: malaise lasting longer than 24 hours after exercise, feeling unrefreshed after adequate sleep, forgetfulness, confusion, inability to concentrate, joint pain with no swelling, headaches not previously experienced, irritability, mild fever, muscle aches, muscle weakness, sore throat, and sore lymph nodes.

B) Chronic fatigue syndrome is diagnosed only if it is accompanied by at least four of the following symptoms: malaise lasting longer than 24 hours after exercise, feeling unrefreshed after adequate sleep, forgetfulness, confusion, inability to concentrate, joint pain with no swelling, headaches not previously experienced, irritability, mild fever, muscle aches, muscle weakness, sore throat, and sore lymph nodes.

C) Chronic fatigue syndrome is diagnosed only if it is accompanied by at least four of the following symptoms: malaise lasting longer than 24 hours after exercise, feeling unrefreshed after adequate sleep, forgetfulness, confusion, inability to concentrate, joint pain with no swelling, headaches not previously experienced, irritability, mild fever, muscle aches, muscle weakness, sore throat, and sore lymph nodes.

D) Chronic fatigue syndrome is diagnosed only if it is accompanied by at least four of the following symptoms: malaise lasting longer than 24 hours after exercise, feeling unrefreshed after adequate sleep, forgetfulness, confusion, inability to concentrate, joint pain with no swelling, headaches not previously experienced, irritability, mild fever, muscle aches, muscle weakness, sore throat, and sore lymph nodes.

Page Ref: 187

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of fatigue.

Exemplar 3.4 Fibromyalgia

1) The nurse is caring for a client who has been diagnosed with fibromyalgia. What should the nurse expect to assess in this client?

Select all that apply.

A) Irritable bowel syndrome

B) Insomnia

C) Pain in the calves of the leg

D) Nausea and vomiting

E) Anxiety

Answer: A, B, E

Explanation: A) The client with fibromyalgia experiences weakness, irritable bowel syndrome, stiffness, anxiety, and sleep disturbances. There is no evidence that pain in the calves, nausea, vomiting, and headache are symptoms of fibromyalgia.

B) The client with fibromyalgia experiences weakness, irritable bowel syndrome, stiffness, anxiety, and sleep disturbances. There is no evidence that pain in the calves, nausea, vomiting, and headache are symptoms of fibromyalgia.

C) The client with fibromyalgia experiences weakness, irritable bowel syndrome, stiffness, anxiety, and sleep disturbances. There is no evidence that pain in the calves, nausea, vomiting, and headache are symptoms of fibromyalgia.

D) The client with fibromyalgia experiences weakness, irritable bowel syndrome, stiffness, anxiety, and sleep disturbances. There is no evidence that pain in the calves, nausea, vomiting, and headache are symptoms of fibromyalgia.

E) The client with fibromyalgia experiences weakness, irritable bowel syndrome, stiffness, anxiety, and sleep disturbances. There is no evidence that pain in the calves, nausea, vomiting, and headache are symptoms of fibromyalgia.

Page Ref: 191

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of fibromyalgia.

2) The son of a client with fibromyalgia asks the nurse if he will also experience the health problem. What should the nurse respond to this question?

Select all that apply.

A) If your diet is high in fatty foods, you have a greater chance of developing fibromyalgia.

B) Having a family member with fibromyalgia increases the risk of developing it.

C) Fibromyalgia is caused by depression. If you are depressed, you have a greater risk of developing it.

D) Only people age 20-50 develop fibromyalgia.

E) Fibromyalgia is more prominent in women.

Answer: B, E

Explanation: A) There are many theories about the causes and risk factors about fibromyalgia. It is generally conceded that it is a problem for women more than men. Having a family member with the disease also increases the risk of development. The disease has not been linked to overexercise. It is a theory that fibromyalgia causes some depression, not the other way around. Diets have been suggested as possible treatment but are not thought to cause the disease.

B) There are many theories about the causes and risk factors about fibromyalgia. It is generally conceded that it is a problem for women more than men. Having a family member with the disease also increases the risk of development. The disease has not been linked to overexercise. It is a theory that fibromyalgia causes some depression, not the other way around. Diets have been suggested as possible treatment but are not thought to cause the disease.

C) There are many theories about the causes and risk factors about fibromyalgia. It is generally conceded that it is a problem for women more than men. Having a family member with the disease also increases the risk of development. The disease has not been linked to overexercise. It is a theory that fibromyalgia causes some depression, not the other way around. Diets have been suggested as possible treatment but are not thought to cause the disease.

D) There are many theories about the causes and risk factors about fibromyalgia. It is generally conceded that it is a problem for women more than men. Having a family member with the disease also increases the risk of development. The disease has not been linked to overexercise. It is a theory that fibromyalgia causes some depression, not the other way around. Diets have been suggested as possible treatment but are not thought to cause the disease.

E) There are many theories about the causes and risk factors about fibromyalgia. It is generally conceded that it is a problem for women more than men. Having a family member with the disease also increases the risk of development. The disease has not been linked to overexercise. It is a theory that fibromyalgia causes some depression, not the other way around. Diets have been suggested as possible treatment but are not thought to cause the disease.

Page Ref: 190

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors and prevention methods associated with fibromyalgia.

3) An Asian husband brings his wife to the clinic and states, I want you to fix my wife and tell her that there is nothing wrong with her. The client has symptoms of pain, sleep disorders, and stiffness. What would be most appropriate for the nurse to include in a plan of care for this family?

A) Medications used to treat fibromyalgia

B) An exercise program to increase energy

C) Information and literature on fibromyalgia

D) Suggested dietary changes to help with the pain

Answer: C

Explanation: A) In many cultures, accepting a disease like fibromyalgia may be difficult due to the vagueness of the disease. Information and written literature may help the family understand that the disease is real. The physician orders medication and diets. There is no proof that exercise, or lack thereof, causes fibromyalgia.

B) In many cultures, accepting a disease like fibromyalgia may be difficult due to the vagueness of the disease. Information and written literature may help the family understand that the disease is real. The physician orders medication and diets. There is no proof that exercise, or lack thereof, causes fibromyalgia.

C) In many cultures, accepting a disease like fibromyalgia may be difficult due to the vagueness of the disease. Information and written literature may help the family understand that the disease is real. The physician orders medication and diets. There is no proof that exercise, or lack thereof, causes fibromyalgia.

D) In many cultures, accepting a disease like fibromyalgia may be difficult due to the vagueness of the disease. Information and written literature may help the family understand that the disease is real. The physician orders medication and diets. There is no proof that exercise, or lack thereof, causes fibromyalgia.

Page Ref: 194

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with fibromyalgia.

4) The nurse identifies the diagnosis of pain as being appropriate for a client with fibromyalgia. Which manifestation did the client most likely report that caused the nurse to select this diagnosis?

A) Pain from eyestrain

B) Pain from a severe skin rash

C) Acute chest pain

D) Tender points in the knees

Answer: D

Explanation: A) Clients with fibromyalgia typically complain of multiple tender points generally including the neck, spine, and knees. Acute chest pain, pain from a rash, and muscle strain of the eye are not reported symptoms.

B) Clients with fibromyalgia typically complain of multiple tender points generally including the neck, spine, and knees. Acute chest pain, pain from a rash, and muscle strain of the eye are not reported symptoms.

C) Clients with fibromyalgia typically complain of multiple tender points generally including the neck, spine, and knees. Acute chest pain, pain from a rash, and muscle strain of the eye are not reported symptoms.

D) Clients with fibromyalgia typically complain of multiple tender points generally including the neck, spine, and knees. Acute chest pain, pain from a rash, and muscle strain of the eye are not reported symptoms.

Page Ref: 193

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with fibromyalgia.

5) During a home visit, the family of a client with fibromyalgia asks the nurse what they can do to help the client with painful episodes. What should the nurse suggest to the client and family?

A) Protect the client from injury.

B) Plan a family reunion.

C) Divide household chores among each member of the family.

D) Keep the client in bed.

Answer: C

Explanation: A) Although the causes and treatments are not all known, there is general agreement that reducing stress may help lessen the effects of fibromyalgia. The nurse could help the family by suggesting ways to decrease stress on the client by having the family pitch in on responsibilities. A family vacation might cause more stress to the client, who would more than likely be planning and packing. Keeping the client in bed would not be therapeutic. There is no reason to believe that this client is at higher risk for injury than another member of the family.

B) Although the causes and treatments are not all known, there is general agreement that reducing stress may help lessen the effects of fibromyalgia. The nurse could help the family by suggesting ways to decrease stress on the client by having the family pitch in on responsibilities. A family vacation might cause more stress to the client, who would more than likely be planning and packing. Keeping the client in bed would not be therapeutic. There is no reason to believe that this client is at higher risk for injury than another member of the family.

C) Although the causes and treatments are not all known, there is general agreement that reducing stress may help lessen the effects of fibromyalgia. The nurse could help the family by suggesting ways to decrease stress on the client by having the family pitch in on responsibilities. A family vacation might cause more stress to the client, who would more than likely be planning and packing. Keeping the client in bed would not be therapeutic. There is no reason to believe that this client is at higher risk for injury than another member of the family.

D) Although the causes and treatments are not all known, there is general agreement that reducing stress may help lessen the effects of fibromyalgia. The nurse could help the family by suggesting ways to decrease stress on the client by having the family pitch in on responsibilities. A family vacation might cause more stress to the client, who would more than likely be planning and packing. Keeping the client in bed would not be therapeutic. There is no reason to believe that this client is at higher risk for injury than another member of the family.

Page Ref: 193

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with fibromyalgia and his or her family in collaboration with other members of the healthcare team.

6) The nurse is discussing goals to relieve pain and fatigue with a client newly diagnosed with fibromyalgia. Which goal statement would be realistic for this client to achieve within 30 days?

A) Cook dinner five nights a week.

B) Join an exercise group.

C) Walk her son to school daily.

D) Get a job outside the home.

Answer: A

Explanation: A) Fibromyalgia saps the clients energy. The client might set as an initial goal to be able to perform daily tasks for the family such as cooking and doing the laundry. Walking her son to school daily is a bit ambitious to start, as are joining an exercise group and getting a job outside the home.

B) Fibromyalgia saps the clients energy. The client might set as an initial goal to be able to perform daily tasks for the family such as cooking and doing the laundry. Walking her son to school daily is a bit ambitious to start, as are joining an exercise group and getting a job outside the home.

C) Fibromyalgia saps the clients energy. The client might set as an initial goal to be able to perform daily tasks for the family such as cooking and doing the laundry. Walking her son to school daily is a bit ambitious to start, as are joining an exercise group and getting a job outside the home.

D) Fibromyalgia saps the clients energy. The client might set as an initial goal to be able to perform daily tasks for the family such as cooking and doing the laundry. Walking her son to school daily is a bit ambitious to start, as are joining an exercise group and getting a job outside the home.

Page Ref: 193

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 7. Evaluate expected outcomes for an individual with fibromyalgia.

7) The nurse is caring for a client who has recently been diagnosed with fibromyalgia. What should the nurse expect the healthcare provider to prescribe to help the client manage the disease?

Select all that apply.

A) Tenormin (Atenolol)

B) Aerobic exercise

C) Ibuprofen

D) Zolpidem (Ambien)

E) Pregabalin (Lyrica)

Answer: B, C, E

Explanation: A) Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain, pregabalin (Lyrica), and aerobic exercise. Zolpidem (Ambien) is for producing sleep. Tenormin (Atenolol) is an antihypertensive drug.

B) Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain, pregabalin (Lyrica), and aerobic exercise. Zolpidem (Ambien) is for producing sleep. Tenormin (Atenolol) is an antihypertensive drug.

C) Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain, pregabalin (Lyrica), and aerobic exercise. Zolpidem (Ambien) is for producing sleep. Tenormin (Atenolol) is an antihypertensive drug.

D) Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain, pregabalin (Lyrica), and aerobic exercise. Zolpidem (Ambien) is for producing sleep. Tenormin (Atenolol) is an antihypertensive drug.

E) Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain, pregabalin (Lyrica), and aerobic exercise. Zolpidem (Ambien) is for producing sleep. Tenormin (Atenolol) is an antihypertensive drug.

Page Ref: 191-193

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with fibromyalgia.

8) The mother of three teenagers has been diagnosed with fibromyalgia and asks the nurse to how to keep up with all of the childrens activities. What should the nurse suggest to the mother at this time?

A) Attempt to attend the all the functions of the children.

B) Negotiate with the children to alternate attending their functions.

C) Avoid attending any afterschool functions for the children.

D) Ask the children to limit their activities.

Answer: B

Explanation: A) Since it is too difficult to attend all of the childrens functions, the nurse suggests alternating the childrens functions. In this manner, the client feels that she is partially meeting the needs of each child. Not attending any functions will only add to the clients stress and may worsen symptoms. It is not reasonable for a client with fibromyalgia to try to run the home and attend all of the functions of each child. The children should not have to limit their activities because of the clients illness.

B) Since it is too difficult to attend all of the childrens functions, the nurse suggests alternating the childrens functions. In this manner, the client feels that she is partially meeting the needs of each child. Not attending any functions will only add to the clients stress and may worsen symptoms. It is not reasonable for a client with fibromyalgia to try to run the home and attend all of the functions of each child. The children should not have to limit their activities because of the clients illness.

C) Since it is too difficult to attend all of the childrens functions, the nurse suggests alternating the childrens functions. In this manner, the client feels that she is partially meeting the needs of each child. Not attending any functions will only add to the clients stress and may worsen symptoms. It is not reasonable for a client with fibromyalgia to try to run the home and attend all of the functions of each child. The children should not have to limit their activities because of the clients illness.

D) Since it is too difficult to attend all of the childrens functions, the nurse suggests alternating the childrens functions. In this manner, the client feels that she is partially meeting the needs of each child. Not attending any functions will only add to the clients stress and may worsen symptoms. It is not reasonable for a client with fibromyalgia to try to run the home and attend all of the functions of each child. The children should not have to limit their activities because of the clients illness.

Page Ref: 193

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with fibromyalgia and his or her family in collaboration with other members of the healthcare team.

9) A 32-year-old female client has been diagnosed with fibromyalgia. She asks the nurse whether her recent of infection with the Coxsackie B virus could have caused fibromyalgia. What is an appropriate response by the nurse?

A) The Coxsackie B virus has nothing to do with fibromyalgia.

B) The Coxsackie B virus may have triggered the fibromyalgia.

C) The Coxsackie virus definitely caused the fibromyalgia.

D) Fibromyalgia is a psychiatric disorder.

Answer: B

Explanation: A) The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus (HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia. Having a psychiatric disorder such as attention deficit/hyperactivity disorder (ADHD) or depression may be a risk factor for fibromyalgia but the condition is not a psychiatric disorder.

B) The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus (HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia. Having a psychiatric disorder such as attention deficit/hyperactivity disorder (ADHD) or depression may be a risk factor for fibromyalgia but the condition is not a psychiatric disorder.

C) The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus (HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia. Having a psychiatric disorder such as attention deficit/hyperactivity disorder (ADHD) or depression may be a risk factor for fibromyalgia but the condition is not a psychiatric disorder.

D) The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus (HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia. Having a psychiatric disorder such as attention deficit/hyperactivity disorder (ADHD) or depression may be a risk factor for fibromyalgia but the condition is not a psychiatric disorder.

Page Ref: 190

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of fibromyalgia.

10) The nurse is counseling a 57-year-old client with fibromyalgia. What are some elements of counseling that can help this client develop effective coping skills?

Select all that apply.

A) Teach the client strategies including distractions, relaxation techniques, a warm bath, or writing in a journal.

B) Remind the client that the client has a progressive disease.

C) Encourage the client to develop a strong support network of family and friends and to ask for help when needed.

D) Inform the client that the client does not need to see a specialist.

E) Suggest to the client that some symptoms may be psychosomatic.

Answer: A, C

Explanation: A) It helps to identify stressors that make pain and fatigue worse, and then develop strategies to avoid those stressors or to minimize symptoms when those stressors occur. Fibromyalgia is not a progressive disease. Getting appropriate help is important in managing fibromyalgia. Clients should be encouraged to see a fibromyalgia specialist. It is important to validate the clients perceptions.

B) It helps to identify stressors that make pain and fatigue worse, and then develop strategies to avoid those stressors or to minimize symptoms when those stressors occur. Fibromyalgia is not a progressive disease. Getting appropriate help is important in managing fibromyalgia. Clients should be encouraged to see a fibromyalgia specialist. It is important to validate the clients perceptions.

C) It helps to identify stressors that make pain and fatigue worse, and then develop strategies to avoid those stressors or to minimize symptoms when those stressors occur. Fibromyalgia is not a progressive disease. Getting appropriate help is important in managing fibromyalgia. Clients should be encouraged to see a fibromyalgia specialist. It is important to validate the clients perceptions.

D) It helps to identify stressors that make pain and fatigue worse, and then develop strategies to avoid those stressors or to minimize symptoms when those stressors occur. Fibromyalgia is not a progressive disease. Getting appropriate help is important in managing fibromyalgia. Clients should be encouraged to see a fibromyalgia specialist. It is important to validate the clients perceptions.

E) It helps to identify stressors that make pain and fatigue worse, and then develop strategies to avoid those stressors or to minimize symptoms when those stressors occur. Fibromyalgia is not a progressive disease. Getting appropriate help is important in managing fibromyalgia. Clients should be encouraged to see a fibromyalgia specialist. It is important to validate the clients perceptions.

Page Ref: 194

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with fibromyalgia.

Exemplar 3.5 Sleep-Rest Disorders

1) A client having difficulty sleeping asks the nurse what the complications of sleep deprivation might be. What should the nurse explain is a result of sleep deprivation?

A) Fatigue occurring at night

B) Auditory hallucinations

C) Improved wound healing

D) Development of Alzheimers disease

Answer: B

Explanation: A) The client who is deprived of sleep may experience visual or auditory hallucinations. Sleep deprivation is not known to be a causative factor for Alzheimers disease but is known to exacerbate behavioral problems in persons with Alzheimers disease. Fatigue may occur but this is during the daytime. Delayed healing is associated with sleep deprivation.

B) The client who is deprived of sleep may experience visual or auditory hallucinations. Sleep deprivation is not known to be a causative factor for Alzheimers disease but is known to exacerbate behavioral problems in persons with Alzheimers disease. Fatigue may occur but this is during the daytime. Delayed healing is associated with sleep deprivation.

C) The client who is deprived of sleep may experience visual or auditory hallucinations. Sleep deprivation is not known to be a causative factor for Alzheimers disease but is known to exacerbate behavioral problems in persons with Alzheimers disease. Fatigue may occur but this is during the daytime. Delayed healing is associated with sleep deprivation.

D) The client who is deprived of sleep may experience visual or auditory hallucinations. Sleep deprivation is not known to be a causative factor for Alzheimers disease but is known to exacerbate behavioral problems in persons with Alzheimers disease. Fatigue may occur but this is during the daytime. Delayed healing is associated with sleep deprivation.

Page Ref: 195

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of sleep-rest disorders.

2) The nurse is caring for a client recently diagnosed with schizophrenia. For what sleep issues is this client at risk because of this diagnosis?

Select all that apply.

A) Circadian cycle disruption

B) Great difficulty getting to sleep

C) REM rebound

D) High nighttime levels of melatonin

E) Reduced REM sleep

Answer: A, B, E

Explanation: A) The client with schizophrenia may have circadian cycle disruption, reduced REM sleep, and difficulty getting to sleep. This client may also have low nighttime levels of melatonin. This client will not experience REM rebound.

B) The client with schizophrenia may have circadian cycle disruption, reduced REM sleep, and difficulty getting to sleep. This client may also have low nighttime levels of melatonin. This client will not experience REM rebound.

C) The client with schizophrenia may have circadian cycle disruption, reduced REM sleep, and difficulty getting to sleep. This client may also have low nighttime levels of melatonin. This client will not experience REM rebound.

D) The client with schizophrenia may have circadian cycle disruption, reduced REM sleep, and difficulty getting to sleep. This client may also have low nighttime levels of melatonin. This client will not experience REM rebound.

E) The client with schizophrenia may have circadian cycle disruption, reduced REM sleep, and difficulty getting to sleep. This client may also have low nighttime levels of melatonin. This client will not experience REM rebound.

Page Ref: 196

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 2. Identify risk factors and prevention methods associated with sleep-rest disorders.

3) An older client is talking with the nurse about sleep problems. What fact regarding sleep should the nurse teach this older client?

A) All elderly individuals experience disrupted sleep and depression.

B) The need for sleep decreases with age.

C) Normally, a person should not awaken more than once during the night.

D) The elderly do not experience as much deep sleep as a younger person.

Answer: D

Explanation: A) Starting at age 20, there is a reduction in slow wave sleep, which is the deepest sleep. This reduction in deep sleep progresses with aging. Waking up three or more times during the night is considered abnormal. Generally, the amount of sleep needed is about the same for the youth, middle-aged, and older adult. The elderly may have more difficulty obtaining quality and quantity of sleep. Not all elderly people experience depression and sleep disturbances.

B) Starting at age 20, there is a reduction in slow wave sleep, which is the deepest sleep. This reduction in deep sleep progresses with aging. Waking up three or more times during the night is considered abnormal. Generally, the amount of sleep needed is about the same for the youth, middle-aged, and older adult. The elderly may have more difficulty obtaining quality and quantity of sleep. Not all elderly people experience depression and sleep disturbances.

C) Starting at age 20, there is a reduction in slow wave sleep, which is the deepest sleep. This reduction in deep sleep progresses with aging. Waking up three or more times during the night is considered abnormal. Generally, the amount of sleep needed is about the same for the youth, middle-aged, and older adult. The elderly may have more difficulty obtaining quality and quantity of sleep. Not all elderly people experience depression and sleep disturbances.

D) Starting at age 20, there is a reduction in slow wave sleep, which is the deepest sleep. This reduction in deep sleep progresses with aging. Waking up three or more times during the night is considered abnormal. Generally, the amount of sleep needed is about the same for the youth, middle-aged, and older adult. The elderly may have more difficulty obtaining quality and quantity of sleep. Not all elderly people experience depression and sleep disturbances.

Page Ref: 196

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with sleep-rest disorders.

4) An older client recovering from prostate surgery is waking up frequently during the night. Which client statement supports the nursing diagnosis Disturbed Sleep Pattern for this client?

A) The pain in my hips is unbearable at times.

B) I walk for half an hour after I eat breakfast.

C) I take my Zoloft as soon as I get up in the morning.

D) I have one cup of regular coffee in the morning.

Answer: A

Explanation: A) Physical discomfort or pain, especially from osteoarthritis and focused in the hips, often disrupts the sleep of older persons. The client is taking his prescribed antidepressant medication Zoloft (sertraline hydrochloride) appropriately because it has a stimulant effect and should be taken in the morning. A short walk in the morning is an appropriate type and timed exercise. Caffeine intake of one morning cup of coffee should have little interference with sleeping during the night.

B) Physical discomfort or pain, especially from osteoarthritis and focused in the hips, often disrupts the sleep of older persons. The client is taking his prescribed antidepressant medication Zoloft (sertraline hydrochloride) appropriately because it has a stimulant effect and should be taken in the morning. A short walk in the morning is an appropriate type and timed exercise. Caffeine intake of one morning cup of coffee should have little interference with sleeping during the night.

C) Physical discomfort or pain, especially from osteoarthritis and focused in the hips, often disrupts the sleep of older persons. The client is taking his prescribed antidepressant medication Zoloft (sertraline hydrochloride) appropriately because it has a stimulant effect and should be taken in the morning. A short walk in the morning is an appropriate type and timed exercise. Caffeine intake of one morning cup of coffee should have little interference with sleeping during the night.

D) Physical discomfort or pain, especially from osteoarthritis and focused in the hips, often disrupts the sleep of older persons. The client is taking his prescribed antidepressant medication Zoloft (sertraline hydrochloride) appropriately because it has a stimulant effect and should be taken in the morning. A short walk in the morning is an appropriate type and timed exercise. Caffeine intake of one morning cup of coffee should have little interference with sleeping during the night.

Page Ref: 196

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Diagnosis

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with sleep-rest disorders.

5) A client with clinical depression asks the nurse for suggestions on how to improve the quality of sleep. After reviewing the clients history, which suggestion should the nurse make to this client?

Select all that apply.

A) Avoid the use of alcohol late in the evening.

B) Consume a cup of tea before bed to relax.

C) Adjust the temperature in the room to a comfortable level.

D) Change the time of aerobic exercise to 1 hour prior to sleep.

E) Avoid smoking before bedtime.

Answer: A, C, E

Explanation: A) A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep and should be consumed well before bedtime. Nicotine is a stimulant and may prevent the client from falling asleep. Exercise within a few hours of bedtime acts as a stimulant and can cause the client to be unable to sleep. Tea contains caffeine, which is a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake during the night to urinate.

B) A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep and should be consumed well before bedtime. Nicotine is a stimulant and may prevent the client from falling asleep. Exercise within a few hours of bedtime acts as a stimulant and can cause the client to be unable to sleep. Tea contains caffeine, which is a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake during the night to urinate.

C) A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep and should be consumed well before bedtime. Nicotine is a stimulant and may prevent the client from falling asleep. Exercise within a few hours of bedtime acts as a stimulant and can cause the client to be unable to sleep. Tea contains caffeine, which is a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake during the night to urinate.

D) A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep and should be consumed well before bedtime. Nicotine is a stimulant and may prevent the client from falling asleep. Exercise within a few hours of bedtime acts as a stimulant and can cause the client to be unable to sleep. Tea contains caffeine, which is a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake during the night to urinate.

E) A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep and should be consumed well before bedtime. Nicotine is a stimulant and may prevent the client from falling asleep. Exercise within a few hours of bedtime acts as a stimulant and can cause the client to be unable to sleep. Tea contains caffeine, which is a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake during the night to urinate.

Page Ref: 201

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with sleep-rest disorders and his or her family in collaboration with other members of the healthcare team.

6) A resident in an assisted-living facility is restless most nights and sits in the lounge area reading. When questioned, the resident reports suffering from insomnia. What should the nurse expect as an outcome if the resident continues with this pattern of sleep?

A) Safety issues with an unsupervised resident in the lounge area

B) Onset of cardiac dysfunction

C) Onset of new underdiagnosed health problems

D) The ability to function during the day may be hindered by these episodes.

Answer: D

Explanation: A) Insomnia is defined as an inability to fall asleep or stay asleep on most nights for over a month. The individual experiencing insomnia is at risk for daytime drowsiness and may experience problems with concentration and function. Insomnia is not a cause for liability; it is up to the nurse to make sure that hospitalized client are safe, but the client cannot be restricted from moving about. There is no evidence that insomnia leads to cardiac problems. There is no evidence that the resident client is demonstrating underlying problems.

B) Insomnia is defined as an inability to fall asleep or stay asleep on most nights for over a month. The individual experiencing insomnia is at risk for daytime drowsiness and may experience problems with concentration and function. Insomnia is not a cause for liability; it is up to the nurse to make sure that hospitalized client are safe, but the client cannot be restricted from moving about. There is no evidence that insomnia leads to cardiac problems. There is no evidence that the resident client is demonstrating underlying problems.

C) Insomnia is defined as an inability to fall asleep or stay asleep on most nights for over a month. The individual experiencing insomnia is at risk for daytime drowsiness and may experience problems with concentration and function. Insomnia is not a cause for liability; it is up to the nurse to make sure that hospitalized client are safe, but the client cannot be restricted from moving about. There is no evidence that insomnia leads to cardiac problems. There is no evidence that the resident client is demonstrating underlying problems.

D) Insomnia is defined as an inability to fall asleep or stay asleep on most nights for over a month. The individual experiencing insomnia is at risk for daytime drowsiness and may experience problems with concentration and function. Insomnia is not a cause for liability; it is up to the nurse to make sure that hospitalized client are safe, but the client cannot be restricted from moving about. There is no evidence that insomnia leads to cardiac problems. There is no evidence that the resident client is demonstrating underlying problems.

Page Ref: 200

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Evaluation

Learning Outcome: 7. Evaluate expected outcomes for an individual with sleep-rest disorders.

7) A client with a history of insomnia is scheduled for a polysomnogram that requires an overnight stay in a sleep laboratory. What additional information about this test should the nurse provide to the client?

A) The test occurs 2 hours after awakening from the overnight sleep study.

B) The test requires a 24-hour interval of sleep deprivation.

C) The test records the biophysical changes the client experiences during sleep.

D) The test consists of five 20-minute nap trials.

Answer: C

Explanation: A) The polysomnogram records biophysiologic parameters such as brain waves and eye movements during sleep. The multiple sleep latency test (MSLT) occurs 2 hours after awakening from the overnight sleep study. Nap trials are part of the MSLT. The polysomnogram does not require a 24-hour sleep deprivation.

B) The polysomnogram records biophysiologic parameters such as brain waves and eye movements during sleep. The multiple sleep latency test (MSLT) occurs 2 hours after awakening from the overnight sleep study. Nap trials are part of the MSLT. The polysomnogram does not require a 24-hour sleep deprivation.

C) The polysomnogram records biophysiologic parameters such as brain waves and eye movements during sleep. The multiple sleep latency test (MSLT) occurs 2 hours after awakening from the overnight sleep study. Nap trials are part of the MSLT. The polysomnogram does not require a 24-hour sleep deprivation.

D) The polysomnogram records biophysiologic parameters such as brain waves and eye movements during sleep. The multiple sleep latency test (MSLT) occurs 2 hours after awakening from the overnight sleep study. Nap trials are part of the MSLT. The polysomnogram does not require a 24-hour sleep deprivation.

Page Ref: 197

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with sleep-rest disorders.

8) The nurse is assessing a clients sleep patterns. Which behavior assessment should the nurse use to make this assessment?

A) Videotaping client movement during sleep

B) Observing client alertness during sedentary, repetitive activities

C) Noting the ability of the to fall asleep within 1 hour

D) Noting the clients final awakening at the habitual sleeping time

Answer: B

Explanation: A) Behavioral assessment includes observation of alertness during sedentary, repetitive activities. It notes the ability to fall asleep within 10-30 minutes, not 1 hour. It notes the final awakening at the habitual rising time, not sleeping time, and uses the photographic serializing of movement during sleep, not videotaping.

B) Behavioral assessment includes observation of alertness during sedentary, repetitive activities. It notes the ability to fall asleep within 10-30 minutes, not 1 hour. It notes the final awakening at the habitual rising time, not sleeping time, and uses the photographic serializing of movement during sleep, not videotaping.

C) Behavioral assessment includes observation of alertness during sedentary, repetitive activities. It notes the ability to fall asleep within 10-30 minutes, not 1 hour. It notes the final awakening at the habitual rising time, not sleeping time, and uses the photographic serializing of movement during sleep, not videotaping.

D) Behavioral assessment includes observation of alertness during sedentary, repetitive activities. It notes the ability to fall asleep within 10-30 minutes, not 1 hour. It notes the final awakening at the habitual rising time, not sleeping time, and uses the photographic serializing of movement during sleep, not videotaping.

Page Ref: 201

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 6. Plan evidence-based care for an individual with sleep-rest disorders and his or her family in collaboration with other members of the healthcare team.

9) A concerned parent brings in her son, who is 13 years old, to see you. They both report that he doesnt go to sleep until late at night and then wakes up late in the morning. She doesnt know what to do. How might you respond?

A) Inform her that adolescents experience changes in the bodys internal clock associated with puberty.

B) Recommend a polysomnography (PSG).

C) Tell her to avoid giving her son any herbal preparations such as melatonin.

D) Inform them that the sons sleep habits, such as bringing electronic devices to bed, have no effect on his sleep pattern.

Answer: A

Explanation: A) The result of hormonal changes can be delayed sleep phase syndrome. A sleep study would only be indicated if the adolescent were experiencing other sleep disturbance symptoms. Possible solutions for delayed sleep phase syndrome are practicing good sleep habits and taking medications such as melatonin at night.

B) The result of hormonal changes can be delayed sleep phase syndrome. A sleep study would only be indicated if the adolescent were experiencing other sleep disturbance symptoms. Possible solutions for delayed sleep phase syndrome are practicing good sleep habits and taking medications such as melatonin at night.

C) The result of hormonal changes can be delayed sleep phase syndrome. A sleep study would only be indicated if the adolescent were experiencing other sleep disturbance symptoms. Possible solutions for delayed sleep phase syndrome are practicing good sleep habits and taking medications such as melatonin at night.

D) The result of hormonal changes can be delayed sleep phase syndrome. A sleep study would only be indicated if the adolescent were experiencing other sleep disturbance symptoms. Possible solutions for delayed sleep phase syndrome are practicing good sleep habits and taking medications such as melatonin at night.

Page Ref: 196

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 2. Identify risk factors and prevention methods associated with sleep-rest disorders.

10) A 55-year-old client diagnosed with sleep apnea has been prescribed a CPAP machine as treatment. The nurse is instructing the client on how to use the machine. What instruction should the nurse include?

A) Any size mask will work.

B) Straps can be loose, if that feels more comfortable.

C) Use relaxation exercises to reduce uncomfortable feelings from the mask.

D) Do not use a humidifier at the same time.

Answer: C

Explanation: A) Proper fitting of the mask to the face, including wearing the right size mask and keeping the straps tight, is important. Relaxation exercises can reduce the claustrophobic feelings caused by wearing the mask. Using a humidifier can minimize dry mouth and nose.

B) Proper fitting of the mask to the face, including wearing the right size mask and keeping the straps tight, is important. Relaxation exercises can reduce the claustrophobic feelings caused by wearing the mask. Using a humidifier can minimize dry mouth and nose.

C) Proper fitting of the mask to the face, including wearing the right size mask and keeping the straps tight, is important. Relaxation exercises can reduce the claustrophobic feelings caused by wearing the mask. Using a humidifier can minimize dry mouth and nose.

D) Proper fitting of the mask to the face, including wearing the right size mask and keeping the straps tight, is important. Relaxation exercises can reduce the claustrophobic feelings caused by wearing the mask. Using a humidifier can minimize dry mouth and nose.

Page Ref: 199

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with sleep-rest disorders.

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