N400 Exam 3 with correct answers |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
assessment finding would cause the nurse to question the order? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ rates pain an 8 on a 0 to 10 scale |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
confused to time and place |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
B/P 178/92 and pulse 118 |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
right shoulder immobilizer in place - correct answer✔✔confused to time and place
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
Clients must be cognitively and physically capable of using the PCA equipment safely. Confusion
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
in a client would lead the nurse to question the client's ability to correctly use the PCA.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pain scale. Which opioid neuromodulator does the nurse know is released with skin
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
stimulation and is more than likely responsible for this increased level of comfort? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Serotonin Dopamine Endorphins Melatonin - correct answer✔✔endorphins |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
certain measures, such as skin stimulation and relaxation techniques, release endorphins.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Serotonin is an important chemical and neurotransmitter in the human body. It is believed that |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
serotonin helps regulate mood and social behavior, appetite and digestion, sleep, memory, and |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sexual desire and function. Melatonin is a hormone that is produced by the pineal gland in
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,humans and animals and regulates sleep and wakefulness. Dopamine is a neurotransmitter that
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
helps control the brain's reward and pleasure centers.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The nurse that ascribes to the gate control theory of pain would be most likely to prescribe
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
which of the following for the relief of pain? (Select all that apply.)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Percocet |||\\\
Heat |||\\\
Massage |||\\\
Cold |||\\\
Acetaminophen - correct answer✔✔Heat |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Massage
|||\\\ Cold
|||\\\ Explanation:
The *gate theory supports that the signals at the gate in the spinal cord determine which
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
impulses eventually reach the brain*. A limited amount of sensory information can be
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
processed by the nervous system at any given moment. When there is too much information |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sent through, certain cells in the spinal column interrupt the signal as if closing a gate*. The
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
theory appears to explain why mechanical and electrical interventions such as *heat, cold,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pressure, and massage* provide effective pain relief. Percocet and acetaminophen are
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
medications that can be used for pain. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The triage nurse is assessing a 5-year-old client who has come to the emergency department
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
choose to use? |||\\\ |||\\\
visual analog scale Wong-Baker FACES® scale word scale numeric scale - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answer✔✔Wong-Baker FACES® scale |||\\\ |||\\\
,|||\\\ Explanation:
Children as young as 3 years of age can use the Wong-Baker FACES® scale. A word, numeric, or
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
visual analog scale is more appropriate for adults.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
2 years. Today, the client reports a headache that feels different than the normal headaches
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
she has experienced in the past. Which assessment question helps the nurse assess quality of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pain?
|||\\\ "When did your pain begin?" |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
"How long have you experienced this pain?" |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
"Could you please rate your pain on a 1-10 scale?" "Can you describe the type of pain you are
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
having?" - correct answer✔✔"Can you describe the type of pain you are having?" |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
Asking the client to describe the pain establishes quality. Asking the client to _rate pain on a 1-
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
10 scale reflects *intensity*_. Asking how long the pain has existed reflects duration. Asking
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
when the pain began reflects onset. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
system. Which statement is true of this medication delivery system? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ -Thorough client education is necessary to prevent overdoses. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-An antidote is automatically delivered if the client exceeds the recommended dose.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-The dose that is delivered when the client activates the machine is preset. - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answer✔✔The dose that is delivered when the client activates the machine is preset. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
, PCAs are designed to make it impossible for the client to exceed the client-specific dosing
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
parameters programmed into the machine. PCAs do not administer antidotes, and they are |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
almost always used to deliver opioid analgesics. The client does not need to be educated about
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
overdoses.
|||\\\
A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
off during conversation; however, he can be aroused. What would be the sedation score for
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
this client? |||\\\
|||\\\ 4 2 3 1 - correct answer✔✔3
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
The sedation score for this client is 3. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-1 is given to a client who is awake and alert,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-2 is given to a client who is slightly drowsy but easily aroused,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-3 is sedation - drowsy and drifting off during conversation; however, he can be aroused
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-4 describes a client who is *somnolent*, with minimal or no response to physical stimulation.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The nurse is administering medications to a client with neuropathic pain. The client asks why
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
he is getting an antidepressant medication since he is not depressed. What is the best response
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
by the nurse?
|||\\\ |||\\\ |||\\\
-"The doctor thinks it will help with your pain." |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-"Treating your depression, even if you don't think you have it, will help control your pain." |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-"All clients with pain have at least some depression."
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-"Antidepressants have been shown to have pain-relieving qualities in clients with neuropathic |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pain." - correct answer✔✔"Antidepressants have been shown to have pain-relieving qualities
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
in clients with neuropathic pain."
|||\\\ |||\\\ |||\\\ |||\\\
The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
assessment finding would cause the nurse to question the order? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ rates pain an 8 on a 0 to 10 scale |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
confused to time and place |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
B/P 178/92 and pulse 118 |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
right shoulder immobilizer in place - correct answer✔✔confused to time and place
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
Clients must be cognitively and physically capable of using the PCA equipment safely. Confusion
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
in a client would lead the nurse to question the client's ability to correctly use the PCA.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pain scale. Which opioid neuromodulator does the nurse know is released with skin
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
stimulation and is more than likely responsible for this increased level of comfort? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Serotonin Dopamine Endorphins Melatonin - correct answer✔✔endorphins |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
certain measures, such as skin stimulation and relaxation techniques, release endorphins.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Serotonin is an important chemical and neurotransmitter in the human body. It is believed that |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
serotonin helps regulate mood and social behavior, appetite and digestion, sleep, memory, and |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sexual desire and function. Melatonin is a hormone that is produced by the pineal gland in
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,humans and animals and regulates sleep and wakefulness. Dopamine is a neurotransmitter that
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
helps control the brain's reward and pleasure centers.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The nurse that ascribes to the gate control theory of pain would be most likely to prescribe
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
which of the following for the relief of pain? (Select all that apply.)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Percocet |||\\\
Heat |||\\\
Massage |||\\\
Cold |||\\\
Acetaminophen - correct answer✔✔Heat |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Massage
|||\\\ Cold
|||\\\ Explanation:
The *gate theory supports that the signals at the gate in the spinal cord determine which
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
impulses eventually reach the brain*. A limited amount of sensory information can be
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
processed by the nervous system at any given moment. When there is too much information |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sent through, certain cells in the spinal column interrupt the signal as if closing a gate*. The
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
theory appears to explain why mechanical and electrical interventions such as *heat, cold,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pressure, and massage* provide effective pain relief. Percocet and acetaminophen are
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
medications that can be used for pain. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The triage nurse is assessing a 5-year-old client who has come to the emergency department
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
choose to use? |||\\\ |||\\\
visual analog scale Wong-Baker FACES® scale word scale numeric scale - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answer✔✔Wong-Baker FACES® scale |||\\\ |||\\\
,|||\\\ Explanation:
Children as young as 3 years of age can use the Wong-Baker FACES® scale. A word, numeric, or
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
visual analog scale is more appropriate for adults.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
2 years. Today, the client reports a headache that feels different than the normal headaches
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
she has experienced in the past. Which assessment question helps the nurse assess quality of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pain?
|||\\\ "When did your pain begin?" |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
"How long have you experienced this pain?" |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
"Could you please rate your pain on a 1-10 scale?" "Can you describe the type of pain you are
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
having?" - correct answer✔✔"Can you describe the type of pain you are having?" |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
Asking the client to describe the pain establishes quality. Asking the client to _rate pain on a 1-
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
10 scale reflects *intensity*_. Asking how long the pain has existed reflects duration. Asking
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
when the pain began reflects onset. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
system. Which statement is true of this medication delivery system? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ -Thorough client education is necessary to prevent overdoses. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-An antidote is automatically delivered if the client exceeds the recommended dose.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-The dose that is delivered when the client activates the machine is preset. - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answer✔✔The dose that is delivered when the client activates the machine is preset. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
, PCAs are designed to make it impossible for the client to exceed the client-specific dosing
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
parameters programmed into the machine. PCAs do not administer antidotes, and they are |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
almost always used to deliver opioid analgesics. The client does not need to be educated about
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
overdoses.
|||\\\
A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
off during conversation; however, he can be aroused. What would be the sedation score for
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
this client? |||\\\
|||\\\ 4 2 3 1 - correct answer✔✔3
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ Explanation:
The sedation score for this client is 3. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-1 is given to a client who is awake and alert,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-2 is given to a client who is slightly drowsy but easily aroused,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-3 is sedation - drowsy and drifting off during conversation; however, he can be aroused
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-4 describes a client who is *somnolent*, with minimal or no response to physical stimulation.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The nurse is administering medications to a client with neuropathic pain. The client asks why
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
he is getting an antidepressant medication since he is not depressed. What is the best response
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
by the nurse?
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-"The doctor thinks it will help with your pain." |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-"Treating your depression, even if you don't think you have it, will help control your pain." |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
-"All clients with pain have at least some depression."
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-"Antidepressants have been shown to have pain-relieving qualities in clients with neuropathic |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pain." - correct answer✔✔"Antidepressants have been shown to have pain-relieving qualities
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in clients with neuropathic pain."
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