4 processes of nociception: - Answer-(1) transduction - noxious stimuli causes cell
damage & releases sensitizing chemicals
(2) transmission - action potential travels up spinal cord from injury to brain, into the
thalamus & cortex for processing
(3) perception - conscious experience of pain
(4) modulation - neurons in brainstem descend to spinal cord & modify incoming
impulses
/.A 10-year-old girl was playing on a slide at a playground during a summer camp. She
fell and broke her arm. The camp notified the parents and took the child to the
emergency department according to the camp protocol for injuries. The parents arrive at
the emergency department and are stressed and frantic. The 10-year-old is happy in the
treatment room, eating a Popsicle and picking out the color of her cast. List in order of
priority what the nurse should say to the parents?
1. "Can I contact someone to help you?"
2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the
color of her cast."
3. "I'll have the doctor come out and talk to you as soon as possible."
4. "Let me help you two calm down a bit so I can take you to your daughter." - Answer-
2, 4, 3, 1
(My rationales: 2 directly lets the parents know that their daughter is fine, which would
help to calm them down and leave them with no wonder of "is my daughter okay?" 4 is
second best because the parents will still get to see their daughter soon and it
addresses that they are freaking out and probably shouldn't be, at least for the sake of
their daughter. 3 would probably make them even more anxious as it does not tell them
anything about the status of their child, but still would send someone out to them soon.
1 is just bad because you aren't doing anything to help them and you aren't even telling
them who will help them.)
/.A 34-year-old single father who is anxious, tearful, and tired from caring for his three
young children tells the nurse that he feels depressed and doesn't see how he can go
on much longer. Which of the following would be the nurse's best response?
,1. "Are you thinking of suicide?"
2. "You've been doing a good job raising your children. You can do it!"
3. "Is there someone who can help you during the evenings and weekends?"
4. "What do you mean when you say you can't go on any longer?" - Answer-4
(Though you should be direct in asking about suicide, the father did not explicitly give a
hint that he was contemplating suicide. Putting the idea into his head might bring harm
to the patient)
/.A community health nurse is providing teaching to the family of a client who has
primary dementia. Which of the following manifestations should the nurse tell the family
to expect?
A. Decreased auditory and visual acuity.
B. Decreased display of emotion.
C. Personality traits that are opposite of original traits.
D. Forgetfulness gradually progressing to disorientation. - Answer-D.
(Dementia usually appears first as forgetfulness. Other manifestations may be apparent
only upon neurologic examination or cognitive testing. Loss of functioning progresses
slowly from impaired language skills and difficulty with ordinary daily activities to severe
memory loss and complete disorientation with withdrawal from social interaction.)
/.A crisis intervention nurse is working with a mother whose Down syndrome child has
been hospitalized with pneumonia and who has lost her child's disability payment while
the child is hospitalized. The mother worries that her daughter will fall behind in special-
school classes during hospitalization. Which strategies are effective in helping this
mother cope with these stressors? (Select all that apply.)
1. Referral to social service process reestablishing the child's disability payment
2. Sending the child home in 72 hours and having the child return to school
3. Coordinating hospital-based and home-based schooling with the child's teacher
4. Teaching the mother signs and symptoms of a respiratory tract infection
5. Telling the mother that the stress will decrease in 6 weeks when everything is back to
normal - Answer-1, 3, 4
/.A grandfather living in Japan worries about his two young grandsons who disappeared
after a tsunami. This is an example of:
, 1. A situational crisis.
2. A maturational crisis.
3. An adventitious crisis.
4. A developmental crisis. - Answer-3.
(The tsunami is a naturally occurring disaster, which is a key characteristic of an
adventitious crisis)
/.A nurse in a long-term care facility is caring for a client who has late stage Alzheimer's
disease. Which of the following actions should the nurse include in the plan of care?
A. post a written schedule of daily activities.
B. use an overhead loudspeaker to announce events.
C. provide a consistent daily routine.
D. allow the client to choose free time activities. - Answer-C
(A consistent daily routine is appropriate for the care of a client who has Alzheimer's
disease.)
/.A nurse is applying a cold compress for a client who has pain and minor swelling in a
suture laceration on the forearm. Which of the following assessments should the nurse
use to determine whether the treatment is effective?
A. inspecting the site for reduced swelling
B. monitoring the clients pulse rate
C. asking the client to rate the pain
D. having the client perform range of motion of the affected arm - Answer-C
(Pain is a subjective experience. The nurse should encourage the client to quantify the
pain on a pain scale before, during, and after cold application to determine its
effectiveness.)
/.A nurse is caring for a client who has dementia due to Alzheimer's disease and was
admitted to a long-term care facility following the death of her partner of 40 years. The
client states, " I want to go home; my husband is waiting for me to cook dinner. "Which
of the following responses by the nurse is appropriate?
A. " this is where you live now."
B. " this is a safer place for you to live."
C. "Tell me what you like to cook for dinner."
D. "Your family said there is no one to care for you at home." - Answer-C.
damage & releases sensitizing chemicals
(2) transmission - action potential travels up spinal cord from injury to brain, into the
thalamus & cortex for processing
(3) perception - conscious experience of pain
(4) modulation - neurons in brainstem descend to spinal cord & modify incoming
impulses
/.A 10-year-old girl was playing on a slide at a playground during a summer camp. She
fell and broke her arm. The camp notified the parents and took the child to the
emergency department according to the camp protocol for injuries. The parents arrive at
the emergency department and are stressed and frantic. The 10-year-old is happy in the
treatment room, eating a Popsicle and picking out the color of her cast. List in order of
priority what the nurse should say to the parents?
1. "Can I contact someone to help you?"
2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the
color of her cast."
3. "I'll have the doctor come out and talk to you as soon as possible."
4. "Let me help you two calm down a bit so I can take you to your daughter." - Answer-
2, 4, 3, 1
(My rationales: 2 directly lets the parents know that their daughter is fine, which would
help to calm them down and leave them with no wonder of "is my daughter okay?" 4 is
second best because the parents will still get to see their daughter soon and it
addresses that they are freaking out and probably shouldn't be, at least for the sake of
their daughter. 3 would probably make them even more anxious as it does not tell them
anything about the status of their child, but still would send someone out to them soon.
1 is just bad because you aren't doing anything to help them and you aren't even telling
them who will help them.)
/.A 34-year-old single father who is anxious, tearful, and tired from caring for his three
young children tells the nurse that he feels depressed and doesn't see how he can go
on much longer. Which of the following would be the nurse's best response?
,1. "Are you thinking of suicide?"
2. "You've been doing a good job raising your children. You can do it!"
3. "Is there someone who can help you during the evenings and weekends?"
4. "What do you mean when you say you can't go on any longer?" - Answer-4
(Though you should be direct in asking about suicide, the father did not explicitly give a
hint that he was contemplating suicide. Putting the idea into his head might bring harm
to the patient)
/.A community health nurse is providing teaching to the family of a client who has
primary dementia. Which of the following manifestations should the nurse tell the family
to expect?
A. Decreased auditory and visual acuity.
B. Decreased display of emotion.
C. Personality traits that are opposite of original traits.
D. Forgetfulness gradually progressing to disorientation. - Answer-D.
(Dementia usually appears first as forgetfulness. Other manifestations may be apparent
only upon neurologic examination or cognitive testing. Loss of functioning progresses
slowly from impaired language skills and difficulty with ordinary daily activities to severe
memory loss and complete disorientation with withdrawal from social interaction.)
/.A crisis intervention nurse is working with a mother whose Down syndrome child has
been hospitalized with pneumonia and who has lost her child's disability payment while
the child is hospitalized. The mother worries that her daughter will fall behind in special-
school classes during hospitalization. Which strategies are effective in helping this
mother cope with these stressors? (Select all that apply.)
1. Referral to social service process reestablishing the child's disability payment
2. Sending the child home in 72 hours and having the child return to school
3. Coordinating hospital-based and home-based schooling with the child's teacher
4. Teaching the mother signs and symptoms of a respiratory tract infection
5. Telling the mother that the stress will decrease in 6 weeks when everything is back to
normal - Answer-1, 3, 4
/.A grandfather living in Japan worries about his two young grandsons who disappeared
after a tsunami. This is an example of:
, 1. A situational crisis.
2. A maturational crisis.
3. An adventitious crisis.
4. A developmental crisis. - Answer-3.
(The tsunami is a naturally occurring disaster, which is a key characteristic of an
adventitious crisis)
/.A nurse in a long-term care facility is caring for a client who has late stage Alzheimer's
disease. Which of the following actions should the nurse include in the plan of care?
A. post a written schedule of daily activities.
B. use an overhead loudspeaker to announce events.
C. provide a consistent daily routine.
D. allow the client to choose free time activities. - Answer-C
(A consistent daily routine is appropriate for the care of a client who has Alzheimer's
disease.)
/.A nurse is applying a cold compress for a client who has pain and minor swelling in a
suture laceration on the forearm. Which of the following assessments should the nurse
use to determine whether the treatment is effective?
A. inspecting the site for reduced swelling
B. monitoring the clients pulse rate
C. asking the client to rate the pain
D. having the client perform range of motion of the affected arm - Answer-C
(Pain is a subjective experience. The nurse should encourage the client to quantify the
pain on a pain scale before, during, and after cold application to determine its
effectiveness.)
/.A nurse is caring for a client who has dementia due to Alzheimer's disease and was
admitted to a long-term care facility following the death of her partner of 40 years. The
client states, " I want to go home; my husband is waiting for me to cook dinner. "Which
of the following responses by the nurse is appropriate?
A. " this is where you live now."
B. " this is a safer place for you to live."
C. "Tell me what you like to cook for dinner."
D. "Your family said there is no one to care for you at home." - Answer-C.
