Hesi rn comprehensive predictor
exam 2023.Edited on March 2023
100% (score) Quaranteed.
1An oriented patient has recently had surgery. Which action
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is best for the nurseto take to assess this
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patient’s pain? xc
xc a. Assess the patient’s body language.
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b. Ask the patient to rate the level of pain. xc xc xc xc xc xc xc xc
xc c. Observe the cardiac monitor for increased heart rate.
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d. Have the patient describe the effect of pain on the ability to c
x c xc xc xc xc xc xc xc xc xc xc xc xc
ope.
ANS: B xc
One of the most subjective and therefore most useful chara
xc xc xc xc xc xc xc xc xc
cteristics for reporting pain is its severity. xc xc xc xc xc xc
Therefore, the best way to assess a patient’s painis to ask t xc xc xc xc xc xc xc xc xc xc xc
he patient to rate the pain. Nonverbal communication, suc
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h as body language, is not as effective in assessing pain, es
xc xc xc xc xc xc xc xc xc xc xc
pecially when the patient is oriented. Heart rate sometime xc xc xc xc xc xc xc xc
s increases when a patient is in pain, but this is not a sympt
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om that is specific to pain. Pain sometimes affects a patien
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t’s ability to cope, but assessing the effect of pain on coping
xc xc xc xc xc xc xc xc xc xc xc xc
assesses the patient’sability to cope; it does not assess th xc xc xc xc xc xc xc xc xc
e patient’s pain.
xc xc
2.A nurse is caring for a patient who recently had abdominal su
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rgery and is experiencing severe pain. The patient’s blood pres
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sure is 110/60 mm Hg, xc xc xc xc
and heart rate is 60 beats/min. Additionally, the patient
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does not appear tobe in any distress. Which
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, 2
response by the nurse is most therapeutic? xc xc xc xc xc xc
“Your vitals do not show that you are having pain; can you describe
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a. your pain?” xc
b. “OK, I will go get you some narcotic pain relievers
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immediately.”
c. “What would you like to try to alleviate your pain?”
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d. “You do not look like you are in pain.”
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xc ANS: C xc
Be sure the patient is a partner in making decisions
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about the best approaches for managing pain. A patient
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20
knows the most about his or her pain and is an important 5 par
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tner in selecting successful pain therapies. The nurse must be
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lieve that a patient is in pain whenever the
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patient reports that he or she is inxc xc xc xc xc xc xc
, 3
pain, even if the patient does not appear to be in pain.
The nurse must be careful to not judge the patient based
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xc xc xc xc xc xc xc xc xc xc
on vital signs or nonverbal communication and must not as
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sume that the patient is seeking narcotics. Thepatient is a
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partner in pain management, so going to get narcotics to tr
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eat the pain without consulting with the patient first is not
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appropriate.
3.A nurse teaches the patient about the gate control th
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eory. Which statement made by a patient reflects a corr
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ect understanding about the relationship
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between the gate control theory of pain and the use of meditxc xc xc xc xc xc xc xc xc xc xc
ation to relievepain? xc xc
“Meditation controls pain byblocking pain impulses from coming xc xc xc x
c xc xc xc xc
a. through the gate.” xc xc
“Meditationaltersthe chemical composition of pain neuro x
c x
c xc xc xc x
c xc
regulators,
b. which closes the gate.” xc xc xc
“Meditation will help me sleep through the pain because it opens t xc xc xc xc xc xc xc xc xc xc xc
he
c. gate.”
d. “Meditation stops the occurrence of pain stimuli.” xc xc xc xc xc xc
ANS: A x
c
According to this theory, gating mechanisms located alon xc xc xc xc xc xc xc
g the central nervoussystem regulate or block pain impulse
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s. Pain impulses pass through when a gate is open and are
xc xc xc xc xc xc xc xc xc xc xc xc
blocked when a gate is closed. xc xc xc xc xc
Nonpharmacologic pain- xc
relief measures, such as meditation, work byclosing the
xc xc xc xc xc xc xc xc
gates, which keeps pain impulses from coming through.
xc xc xc xc xc xc xc
Meditation does not open pain gates or stop pain from oc xc xc xc xc xc xc xc xc xc xc
curring. Meditationalso does not have an effect on pain
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neuroregulators.
4.Anurse is planning care for an older-adult patient who is
x
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, 4
experiencing pain.Which statement made by the nurse indi xc x
c xc xc xc xc xc xc
cates the supervising nurse needs to
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follow up? xc
a. “As adults age, their ability to perceive pain decreases.” “O
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lder patients may have low serum albumin in their blood, c
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ausing
b. toxic effects of analgesic drugs.”
xc xc xc xc
“Patients who have dementia probably experience pain, andxc xc x
c xc xc xc xc xc
their pain xc
c. s not always well controlled.”
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20
“It is safe to administer
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5
opioids to older adults as long xc xc xc xc xc xc
as you start with
xc xc xc