TEST BANK OF MEDICAL SURGICAL NURSING IGNATAVICIUS 7TH EDITION

TEST BANK OF MEDICAL SURGICAL NURSING IGNATAVICIUS 7TH EDITION MULTIPLE CHOICE Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? a. Monitoring the client for changes in postoperative status such as wound infection b. Documenting all changes observed in the client and maintaining a postoperative flow sheet c. Notifying the physician of the client’s change in blood pressure from 140 to 88 mm Hg systolic d. Notifying the physician of the client’s increase in restlessness after medication change The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission’s main objective? a. Performing range-of-motion exercises on the client three times each day b. Ensuring that the client is eating 100% of the meals served to him or her c. Assessing the client’s respirations when administering opioids d. Delegating to the nursing assistant to give the client a complete bath daily Which action by the nurse shows an understanding of the principle of self-determination? a. Allowing a postoperative client to decide to take medication with fruit juice rather than water b. Allowing a teenager to decide not to go to a clinic when there is evidence that she is having profuse vaginal bleeding c. Allowing a parent to decide not to proceed with a lifesaving operation for a 12-yearold client d. Allowing an older client with dementia to decide not to take cardiac medication throughout the shift The nurse is initiating a series of teaching sessions with an older client. What is the nurse’s highest-priority, client-centered action before beginning the session? a. 1 | P a g e Ensure that the client’s family is present and will participate. b. Make certain that the client is wearing his glasses.c. Have printed handouts ready to use during the session. d. Schedule the session for early evening after the client’s meal. Which action best demonstrates the nurse using client-centered care when planning a menu for a Vietnamese client who is newly diagnosed with diabetes? a. Asking the client what food he or she would eat on a standard diabetic menu b. Asking family members to make selections for the client from a diabetic menu c. Ordering a typical diabetic meal for the client and planning diet teaching d. Researching the Vietnamese culture before discussing diabetic meal planning The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? a. Insert a central line to give intravenous fluid to a dehydrated client. b. Use sterile technique when changing dressings on a new surgical site. c. Intubate a client whose oxygen saturation is 92%. d. Prescribe aspirin for a client who presents with an acute myocardial infarction Which action by the nurse demonstrates the best practice for nursing documentation on a computerized record? a. Deleting all documentation errors on the computerized record b. Using red font to denote all significant events that have occurred c. Waiting until the end of the shift to record a summary of information d. Documenting assessment data at the point of care 2 | P a g eA client is scheduled for a mastectomy. As she is about to receive the preoperative medication, she tells the nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicates that the nurse is acting as a client advocate? a. Telling the client her surgeon is excellent and knows what is best for her condition b. Calling the surgeon to come and explain all treatment options to the client c. Holding the client’s hand and offering to pray with her for a good outcome d. Arranging for a postoperative visit from a cancer survivor What priority assessment data should be shared with the interdisciplinary team from a client admitted to the emergency department with a lacerated artery? a. Information regarding next of kin to notify in case the client dies b. History about what medications the client is currently taking c. Measurement of blood pressure and pulse d. Assessment of rate and depth of respirations Which intervention can the client expect to receive from a medical- surgical nurse in an ambulatory care setting? a. Drawing blood for routine or preoperative testing b. Teaching the client how to change a dressing on an incision c. Obtaining the client’s signature on a surgical consent form d. Performing a comprehensive physical examination An emergency department (ED) nurse gives report on a client who is being transferred to the medical- surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This statement represents which part of the SBAR hand-off? a. Situation 3 | P a g eb. Background c. Assessment d. Recommendation The nurse is present when the physician discusses the potential effects of a chemotherapy regimen for a client with cancer. Weighing the benefits of the chemotherapy against possible side effects is an example of which ethical principle? a. Paternalism b. Beneficence c. Justice d. Autonomy The physician prescribes warfarin (Coumadin) 15 mg daily. The nurse notes that this is three times the normal dose for this client based on the client’s medication profile and laboratory work. What does the nurse do first? a. Give the dose and document the concern. b. Call the pharmacy for a consultation. c. Call the physician to question the order. d. Hold the medication for that day. c. Which statement best describes the process of nursing case management? a. The coordination of care services to at-risk populations b. A collaborative process to promote quality and cost-effective care The implementation of care to acutely ill, underserved populations d. A cost-effective care delivery model meeting the needs of specially defined groups 4 | P a g eWhich client is best served by a case manager? a. An older woman with chronic cystitis c. b. A middle-aged man with moderate hypertension An older woman with chronic heart failure and diabetes mellitus d. A young adult with a fractured ankle from a sports injury The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel? a. Complete the nursing care plan. b. Assist the client with meals. c. Evaluate the pulse oximetry reading. d. Assess level of consciousness. MULTIPLE RESPONSE The nurse on a medical-surgical unit notices that there has been an increase in the number of client falls. Which methods would be effective in promoting quality improvement on this issue? (Select all that apply.) a. c. Identify causes of falls on the unit by looking at specific client cases. b. Look at the research and the literature on prevention of falls. Complain to the manager that team members are neglecting the clients. d. Use sit and stand alarms because they seem to be working on other units. e. Try more frequent rounding on clients as suggested by co-workers. 5 | P a g eWhich settings would require maximum implementation of the nurse supervisor role? (Select all that apply.) c. a. Acute care setting b. Home care setting Skilled nursing facility d. Assisted-living facility e. Rehabilitation facility Which activities are within the role of the case manager? (Select all that apply.) a. Gathering and organizing data about a client from client records and interviews c. b. Planning care for a client with emphasis on client satisfaction Coordinating care among a variety of health care professionals and settings d. Promoting the client’s interests while negotiating necessary health care e. Advocating for the client and the family throughout the continuum of care f. Using resources for appropriate client health care services A client has metastatic lung cancer and is hospitalized for chemotherapy. Which intervention does the nurse delegate to the unlicensed assistive personnel? (Select all that apply.) a. Assist the client with repositioning. b. Teach the client to use the incentive spirometer. c. Take vital signs every 4 hours. d. Record intake and output measurements. e. Promote the expression of grief and loss. Chapter 2: Introduction to Complementary and Alternative Therapies Test Bank 6 | P a g eMULTIPLE CHOICE The nurse wishes to learn more about the client’s use of natural products and their effectiveness. The nurse consults the National Center for Complementary and Alternative Medicine because it is known that this center serves which function? a. c. Educates health professionals about complementary therapies b. Educates new mothers on the benefits of massage Engages in fundraising to offset client expenses with medical care d. Provides a scholarship for a student to study naturopathy A client is anxious about having a dressing change. Which statement indicates that the nurse is promoting appropriate complementary therapy? a. “I’ll call the doctor and ask for a larger dose of pain medication before the dressing change.” b. “As we begin the next dressing change, I want you to think of a beautiful, calm place where you feel happy and peaceful.” c. “I’ll get another nurse to stay in the room with us during the dressing change so that you have a hand to hold during the procedure.” d. “Are you familiar with acupuncture? It’s a very effective technique.” The nurse has designed a treatment plan that includes the use of massage. Which intervention will the nurse implement first? c. a. Assess the client to determine the most effective type of massage technique to use. b. Inspect the skin over the tissue to be massaged to ensure that it is not infected or bruised. Determine whether a licensed therapist will be needed to carry out the massage technique 7 | P a g ed. Obtain permission from the client to implement this type of technique. A client who has been using which therapy requires the most immediate intervention by the nurse? a. Aromatherapy to treat depression b. Herbal preparations to treat hypertension c. Therapeutic touch to decrease level of pain d. Tai Chi to improve joint flexibility A client scheduled for surgery has been taking garlic supplements. Which action is most important for the nurse to take? a. No action is necessary because the herbal agent is harmless. b. Notify the charge nurse that the client has been taking garlic. c. Note the information on the client’s record and place in the chart. d. Notify the surgeon that the client has been taking garlic capsules. For which client does the nurse arrange animal-assisted therapy? a. Middle-aged adult in a psychiatric facility with a history of schizophrenia b. Older adult client with end-stage lung cancer in hospice care c. Older adult client in a nursing home who is unresponsive d. Adolescent in a drug treatment facility with a history of violent outbursts Which statement indicates that the nurse understands the risks associated with herbal preparations? a. Herbs are guaranteed to be safe and effective but are not necessarily natural. 8 | P a g eb. Herbs require a different type of prescription than is required for standard prescribed medications. c. Herbs are not classified as drugs and are regulated less strictly by the U.S. Food and Drug Administration (FDA). d. Herbs are guaranteed to be all natural and of high quality but are not necessarily effective. A client asks the nurse to pray with him. The nurse is an atheist. Which statement by the nurse is the correct response? a. “Yes, let’s pray together.” b. “No, I’m sorry, I can’t do that.” c. “No, I don’t believe in prayer.” d. “I’ll hold your hand while you pray.” The client has been diagnosed with cancer and is experiencing depression and insomnia as side effects of chemotherapy. The client tells the nurse that she has been supplementing her antidepressant medication with lavender oil and sandalwood but they aren’t working. Which statement by the nurse is the best response? a. c. “Tell me more about exactly what you are taking, how much you take, and when you take the antidepressants and use the oils.” b. “Perhaps you’re not using enough of the oil or are using it incorrectly.” I’ll speak with your doctor to get you some medication that you can take while continuing the aromatherapy.” d. “You don’t want your doctor to put you on sleeping pills and antidepressants. Keep using them.” 9 | P a g eThe client is undergoing treatment for cancer and is experiencing a high level of anxiety. The client expresses interest in complementary therapies that might decrease the level of anxiety. Which action is the best choice for the nurse to implement with this client? a. Direct the client to an imaginative peaceful setting using imagery. b. Provide assistance in finding an acupuncturist. Suggest Tai Chi during chemotherapy treatments. c. d. Encourage the use of acupressure over tumor sites. Which clients would benefit most from relaxation therapy? a. Middle-age client who is undergoing chemotherapy treatments b. Young client who is diagnosed with schizophrenia c. Older client who is comatose and unresponsive d. Young client who is diagnosed with major depression A nurse is assisting a client in preparing for surgery by using progressive muscle relaxation. Which rationale best supports the use of this therapy at this time? a. It rebalances or repatterns a person’s energy field. c. b. It improves flexibility and assists with positioning during surgery. It applies pressure, releasing congestion and promoting energy flow. d. It uses intentional tensing and releasing of successive muscle groups. 10 | P a g eA client tells the nurse that he or she is considering using herbal supplements. What is the nurse’s best response? a. c. “Herbs are not classified as drugs in the United States, so there is no contraindication to using them.” b. “Herbs have pharmacologic effects on the body and can interact with some prescription medications.” “It is never permissible to use herbal supplements with prescription medications.” d. “I will refer you to an herbalist, who can help you decide which medications you can take.” A client who is status post aortic valve replacement takes sodium warfarin (Coumadin) daily and has started taking Ginkgo biloba. What is the priority action for the nurse to take? a. c. Encourage the use of Ginkgo biloba to enhance the client’s systemic circulation. b. Assess the client for any bruising or petechiae. Explain that replacing Ginkgo biloba with garlic would be much safer. d. Assess for any forgetfulness or inappropriate speech. Which statement indicates that the client needs further teaching about complementary therapy? a. “I’ve decided to use herb therapy for cancer treatment, so I can cancel my radiation treatments.” b. “I’m hoping that massage therapy will help reduce the amount of pain medication I use for my myalgia.” c. “I think it helps me get better faster when I picture the drugs punching out the germs in my body.” d. “I intend to pray about my cancer treatment several times a day. It makes me feel so much better.” Which teaching strategy is appropriate for a client who wishes to use mind-body complementary therapy to supplement traditional treatment for cancer? 11 | P a g ea. Instruct the client to make a follow-up appointment with the health care provider after using mind- body treatments to assess the client’s response to treatment. b. Instruct the client never to use alternative or complementary treatments for serious illnesses. c. Explain to the client that physicians and nurses are not prepared to recommend and monitor alternative treatments. d. Explain to the client that physicians and nurses do not incorporate such treatments into their practice. Which complementary or alternative therapy would the nurse recommend to a client with “stiff joints” to improve mobility? a. Imagery b. Animal-assisted therapy c. Tai Chi d. Aromatherapy A client is experiencing nausea and vomiting from chemotherapy. Which alternative or complementary therapy would be best for the nurse to explore with the client? a. Meditation b. Imagery c. Yoga d. Music therapy 12 | P a g eThe nurse is working in the community and completes home visits with older adult clients. Which statement by a client demonstrates a need for further instruction about the use of complementary and alternative therapies? a. c. “My doctor monitors my kidney function since I started taking calcium.” b. “I always talk to my doctor first before starting an herbal preparation.” “I heard that St. John’s wort is good for any type of depression.” d. “I may start a Tai Chi program to help with my mobility and lift my spirits.” MULTIPLE RESPONSE During an initial health assessment interview, the nurse learns that the client is taking warfarin (Coumadin) for a history of deep vein thrombosis. Later, the client admits to taking several herbal preparations as well. Which herbal preparations would the nurse caution the client to avoid? (Select all that apply.) a. e. Ginkgo biloba b. Garlic c. Ginseng d. Zinc St. John’s wort The nurse wishes to start music therapy with an older adult client who has high anxiety and hypertension. What essential elements should be considered when music is used with this client? (Select all that apply.) a. Assess the client’s preferences in choice of music. b. Use fast tempo music to energize and motivate the client. c. Consider rap music to provide diversion. d. Consider live or recorded music such as music performed on a harp. e. Consider generation-specific music. 13 | P a g eChapter 3: Common Health Problems of Older Adults Test Bank MULTIPLE CHOICE An older client is agitated and develops new-onset confusion on admission to the long-term care unit. What is the best action for the nurse to take to minimize relocation stress syndrome for this client? a. Provide reorientation during hourly rounding. c. b. Obtain a certified sitter to remain with the client. Speak to the client as little as possible to avoid overstimulation. d. Provide adequate sedation to lessen fear-provoking situations. Which intervention would best support a client who relates a feeling of “loss of control” after having a mild stroke? a. Explain that such feelings are normal, but that expectations for rehabilitation must be realistic. b. Encourage the client to perform as many tasks as possible and to participate in decision making. c. Further assess the client’s mental status for other signs of denial or psychopathology. d. Obtain an order for physical and occupational therapy evaluations. What will the nurse teach the older client with hypertension who complains that “food does not taste good without salt”? a. 14 | P a g e Salt can be used as long as blood pressure remains controlled.b. All salt should be removed from the diet to preserve kidney function. c. Table salt can be used in small amounts in conjunction with diuretics. d. Herbs and spices can be substituted to season food. What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases? a. Providing assistance to the client in getting out of the bed or chair b. Placing the client in restraints to prevent movement without assistance c. Keeping all four siderails up while the client is in bed d. Requesting that a family member remain with the client to assist in ambulation An older adult client is in physical restraints. Which intervention by the nurse is the priority? a. Assess the client hourly while keeping the restraints in place. b. Assess the client every 30 to 60 minutes, releasing restraints every 2 hours. c. Assess the client once each shift, releasing the restraints for feeding. d. Assess the client twice each shift while keeping the restraints in place. An older adult client has become agitated and combative toward health care personnel on the unit. What is the first action that the nurse will take? a. Obtain an order for a sedative-hypnotic medication to reduce combative behavior. b. Attempt to soothe the client’s fears and reorient the client to surroundings. 15 | P a g ec. Obtain an order to place the client’s arms in restraints to protect personnel. d. Arrange for the client to be transferred to a mental health facility. An older adult client presents with signs and symptoms related to digoxin toxicity. Which age-related change may have contributed to this problem? a. Increased total body water c. b. Decreased renal blood flow Increased gastrointestinal motility d. Decreased ratio of adipose tissue to lean body mass A nurse is assessing a client’s understanding of medication therapy. Which statement indicates that the client needs further instruction? a. “My husband is on the same medication, so we always take our medications together in the morning.” b. “I prepare all my medication for the week and place the pills in a container labeled for each day.” c. “When I don’t sleep well at night, I take two thyroid pills the next day instead of just one.” d. “I take my Coumadin every day when the noon news comes on the television.” An older adult client is being discharged from the hospital on several medications. Which intervention best reinforces medication teaching for this client? a. Have the client actively participate in drug administration during hospitalization. c. b. Include the client’s children in discussions regarding medication administration. Give the client a pamphlet with the actions, side effects, and doses of all drugs. d. Make a chart showing which drugs should be taken at specified times during the day. 16 | P a g eAn older adult client’s spouse has died, and the family expresses concern that the client has lost weight recently and now refuses to attend the annual family reunion. The nurse should assess this client further for what clinical condition? a. Psychosis b. Depression c. Dementia d. Delirium Which behavior exhibited by an older adult client alerts the nurse to the possibility that the client is experiencing delirium? a. Becoming confused within 24 hours after hospital admission b. Displaying a cheerful attitude despite a poor prognosis c. Becoming withdrawn and sleeping most of the day d. Beginning to use slurred speech and losing coordination A client with Alzheimer’s disease has been hospitalized for dehydration. In making an assessment, the nurse notes the presence of a cluster of bruises on the client’s buttocks. What is the nurse’s priority action? a. Call the local police to report a crime. c. b. Notify the client’s physician and social worker. Confront the client’s caregiver with the suspicions. d. Alert security to prevent visits by the client’s caregiver. An older adult client is suspected of being neglected by the caregiver. 17 | P a g eWhat assessment provides the nurse with the best information about this possibility? a. Inspect skin in the “bathing suit zone” for bruises. b. Assess the client for orientation to person, place, and time. c. Compare the client’s current weight with prior recorded weights. d. Perform orthostatic pulse and blood pressure readings. A nurse is caring for an older adult client who lives alone. Which economic situation presents the most serious problem for this client? a. Stock market fluctuations b. Increased provider benefits c. Social Security as the basis of income d. Costs of creating a living will An older adult client is in the hospital. To what government resource would the nurse refer the client to help meet the cost of health care? a. Preferred provider organizations b. Health maintenance organizations c. Medicare Part A d. Medicare Part B A nurse is assessing a client at risk for dehydration. Which statement by the client indicates that more education by the nurse is required? a. c. “I try to limit coffee to one cup in the morning and one cup in the early evening.” b. “During the day I drink at least six to seven glasses of water.” “Alcohol causes me to frequently urinate so I cut it out of my diet.” 18 | P a g ed. “I stop drinking fluids in the afternoon to avoid bathroom trips at night.” An older adult recently had a hysterectomy and has requested some medication for pain. The physician leaves an order for meperidine (Demerol). Which action by the nurse is most appropriate? a. Assess the client’s pain 1 hour after giving the medication. b. Call the physician and request a different pain medication. c. Assess the client’s respiratory rate often after administering the Demerol. d. Ensure that the client does not receive iron supplements at the same time. A nurse manager is planning a comprehensive care plan for older clients admitted to the medical-surgical unit. To decrease hospital stays and lessen the pain that older clients experience, which standard intervention should the manager include in the care bundle for this population? a. Assess all clients for depression. b. Obtain a dietary consult for nutrition assessment. c. Perform medication reconciliation on admission. d. Screen all clients for alcohol and drug use. MULTIPLE RESPONSE What conditions predispose an older adult client to acute confusion or delirium? (Select all that apply.) a. Alcoholism b. Chronic pain c. Acute infection d. Electrolyte imbalances e. 19 | P a g e Multi-infarct cerebrovascular diseasef. Change in drug regimen An older adult client has been admitted to a skilled nursing facility following surgery. What interventions should the nurse add to this client’s care plan to assist with adjusting to this situation? ((Select all that apply.) a. Make sure the client has hearing aids and glasses. b. Offer the anxiolytic that the physician has prescribed. c. Encourage the family to bring in favorite pictures. e. d. Ask where the client wants the room furnishings placed. Encourage the client to eat meals alone in his or her room. f. Set a daily schedule for the client that includes group activities. The nurse is assessing several clients. Which clients does the nurse identify as being at high risk for falls? (Select all that apply.) The client: a. With visual impairment such as presbyopia b. Who is reluctant to use a cane while walking c. Who performs Tai Chi exercise daily d. Who wears a hearing aid and glasses e. Who has difficulty arising from a sitting position f. Who is male and over 55 years of age What interventions can the nurse apply to help an older adult client who is having trouble sleeping while in the hospital? (Select all that apply.) a. Changing the client’s sheets each night before sleep b. Decreasing the level of light surrounding the client’s bed c. Attempting to keep the client awake during the daytime 20 | P a g ed. Keeping staff conversations as quiet as possible e. Administering sleeping pills at night f. Administering pain medication before bedtime g. Asking the client if he or she would like to pray An 89-year-old is admitted to the medical-surgical floor. The nurse is formulating the client’s plan of care. In assessing the client, which findings would be considered part of the clinical syndrome of frailty? (Select all that apply.) a. Increased appetite b. Weight loss c. Weakness d. Decreased sleep e. Slowed gait Chapter 4: Cultural Aspects of Health and Illness Test Bank MULTIPLE CHOICE The nurse is caring for a client from another culture. Which action would demonstrate the first step of developing cultural competence? a. Avoiding assuming that members of the same culture all share the same beliefs and values b. Developing an understanding of his or her own cultural heritage, feelings, and experiences c. Becoming bilingual to communicate effectively with the population of clients served d. Developing an understanding of the religious beliefs of clients served by the nurse 21 | P a g eThe nurse is developing a teaching plan on cultural sensitivity for colleagues who are caring for clients from other cultures. What action by the nurse might a client of another culture interpret as culturally insensitive? a. Making sure that an Arab female client is covered during assessment b. Avoiding making direct eye contact with a male American Indian client c. Not encouraging a Japanese-American client to express feelings openly d. Hugging an Egyptian-American female client who has received bad news A Mexican-American client is insistent that her family members stay with her in her hospital room while she is recovering from surgery. What will be the priority action of the nurse? a. Explain the policy of the hospital regarding visitors. b. Ask the Spanish-speaking chaplain to help explain why this is unacceptable. c. Arrange for additional beds to accommodate family members’ overnight stay. d. Notify the physician of the client’s anxiety and suggest a prescription. A nurse is caring for a lesbian client. What is a priority assessment question for this client? a. “When was your last complete physical examination?” b. “How much alcohol do you consume?” c. “Do you smoke?” d. “Do you use recreational drugs?” The nurse is providing discharge instructions on medications to an older adult client. The client has expressed concern about paying the hospital bills. What will the nurse emphasize on the basis of best 22 | P a g ecultural practice? a. The client should be prepared to demonstrate filling the daily pill planner at the next appointment. b. The client should keep a daily diary of side effects experienced from the medications. c. The client must adhere to the medication regimen, unless the cost becomes prohibitive. d. The client should ask the pharmacist for the generic version of medications to keep costs to a minimum. What can health care agencies do to assist in meeting the cultural goals of Healthy People 2020? a. Ensure accurate recording of a client’s race and/or ethnicity in the medical record. b. Hire physicians and nurses from culturally diverse backgrounds. c. Provide magazines written in more than one language in waiting areas of clinics. d. Improve access to health care by establishing clinics closer to low- income housing. The nurse is assessing a new home health client. What observation would be relevant for a cultural assessment? a. The client asks the nurse how to obtain assistance with his utility bills. b. The client’s wife reports that the children are having difficulty in school. c. The client tells the nurse that he would like to move into public housing. d. The client’s wife corrects the husband’s response to questions about his parents. 23 | P a g eThe client states, “I cannot receive blood transfusions, because it is against my beliefs. I am concerned about having this surgery.” What is the nurse’s best response? a. c. “You should allow your health care team to do whatever is needed.” b. “The blood supply in this country is the safest in the world.” “There really is nothing unacceptable about blood transfusion.” d. “There are good alternatives to transfusions that we can discuss.” A nurse is working with a new group of immigrants and wants to learn more about their culture. Which method of cultural assessment should the nurse perform to gain a long-term understanding of this culture? a. Interview a client. b. Observe a group. c. Participate in the community. d. Visit a group of clients. The client expresses distress over missing religious services while in the hospital. What is the nurse’s best action? a. Tell the client that he or she shouldn’t worry about it right now. b. Ask the client’s spouse or family member to pray with the client. c. Ask the hospital’s professional chaplain to talk to the client. d. Encourage the client to reschedule procedures for another day. The nurse is caring for a homeless client after surgery. Which statement by the nurse indicates the best understanding of this special population? a. “When you receive your prescription, fill the medication at the nearest pharmacy.” b. “To prevent the risk of infection, you need to bathe daily and keep the incision clean.” c. “Tell me about your home situation and access to food and medications.” d. “To help with healing, be sure to eat meals high in protein and low in fat and cholesterol.” 24 | P a g eMULTIPLE RESPONSE Which factors are included as part of Purcell’s domains for assessing cultural groups or persons? (Select all that apply.) a. Nutrition and communication b. Family roles and organization c. Elementary education d. Biofeedback e. f. Death rituals and spirituality Alternative and complementary therapies Which statement by the nurse would potentially offend a client in a predominantly Hispanic clinic? (Select all that apply.) a. “Did you know that your child has the most beautiful eyes that I have ever seen?” b. “So I can best treat you, could you share your beliefs on the hot/cold theory of healing?” c. “Whom do you consider your primary source of healing and treatment?” e. d. “How can you believe that eating ice cream will stop the bleeding after having a baby?” “Why do you say that arthritis in older age is caused by childbirth as a young woman?” Chapter 5: Pain: The Fifth Vital Sign Test Bank MULTIPLE CHOICE 25 | P a g eThe nurse is caring for a client who was medicated for pain 1 hour ago. The client states that the medication is not working and the pain is still present. What is the first action that the nurse will take? a. Assess the client to determine a pain score. b. Believe the client’s report of pain. c. Wait until it is time for the next pain medication dose. d. Teach the client how to use guided imagery. When is the nurse correct in decreasing the dose of pain medication in a client with end-stage cancer? a. The spouse is worried that the client may become addicted. b. The client wants to remain alert during the visit of a long-time friend. c. The client has lost considerable weight and does not want to eat. d. The client is becoming combative at night. A client with chronic pain is being discharged from the hospital. When planning the client’s pain relief regimen for home, it is most important for the nurse to communicate with which member of the health care team? a. Advanced practice nurse b. Home health care nurse c. Primary physician d. Psychologist A client with arthritic pain is considering taking an herbal supplement to relieve arthritic pain. What teaching is most important for the nurse to carry out with this client? a. Inform any health care providers about the use of this supplement. b. Practice imagery along with taking the herbal supplement. c. Take only herbal supplements that are prescribed. d. Take herbal supplement at the onset of pain. 26 | P a g eWhat instruction should the nurse include in the discharge teaching plan of a client who has a transcutaneous electrical nerve stimulation (TENS) unit? a. c. “Pain relief is sustained when stimulation is stopped.” b. “The current is adjusted by the physician.” “The electrodes are placed away from the painful site.” d. “You can perceive a pins and needles sensation.” a. Why does the nurse always ask the client his or her pain level after taking routine vital signs? To determine whether pain is influencing blood pressure and heart rate b. To determine the need for more frequent vital sign measurement c. To ensure that pain assessment occurs on a regular basis d. To follow McCaffery’s guidelines on pain management A client with cholecystitis has pain in the right shoulder area and asks, “What is happening to me? What did I do to my shoulder?” What is the nurse’s best response? a. “You are weak from staying in bed.” b. “Does your other arm hurt too?” c. “Sometimes pain from a certain organ is referred elsewhere in the body.” d. “I am going to hold your medication until we can determine what is happening.” The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem? 27 | P a g ea. c. Middle-aged woman with a fractured arm b. Client with expressive aphasia Younger adult with metastatic cancer d. Client who has undergone an appendectomy The physician orders a dose of medication that does not resolve the client’s chronic pain. When the nurse questions the order, the physician explains that he or she fears the client will develop an addiction with higher drug dosages. What is the nurse’s best response? a. Administer the medication as ordered. b. Assist the client to use guided imagery. c. Consult with the pain control specialist. d. Explain to the client that lower doses are better. A client who has been taking oxycodone (OxyContin) for an extended period of time comes to the clinic reporting that the drug is no longer relieving his pain. Which category would be given to the client’s complaint? a. Addiction b. Physical dependence c. Pseudoaddiction d. Tolerance A home care client who is taking morphine for pain management abruptly stops taking the medication. Which symptom would indicate physical dependence? a. Abdominal cramping b. Craving for morphine 28 | P a g ec. Decreased heart rate d. Elevated temperature A home care client who is currently on hydromorphone (Dilaudid) for pain management presents to the hospital reporting abdominal cramping, nausea, and sweating. When taking the client’s history, the nurse asks which question first? a. “Are you currently in severe pain?” b. “Did you take more Dilaudid than prescribed?” c. “When did you take your last dose of Dilaudid?” d. “When was your last bowel movement?” The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? a. Administer blood pressure medication. b. Administer a drug to lower the heart rate. c. Assess whether the client needs anti-arthritis medication. d. Continue to assess for possible causes of elevated vital signs. The nurse is caring for four clients who are reporting pain. Based on the following assessments and histories, which client’s pain is most likely chronic in nature? a. c. Foley catheter inserted 30 minutes ago with a heart rate of 100 beats/min b. History of heart disease with a heart rate of 120 beats/min History of fibromyalgia with a blood pressure of 110/70 mm Hg d. Hip replacement surgery with a blood pressure of 170/90 mm Hg 29 | P a g eWhen a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain? a. Anger and hostility b. Expressed hopelessness c. Inability to concentrate d. Psychosocial withdrawal The nurse anticipates that the client who rates pain as 10 on a scale of 1 to 10 has undergone which surgical procedure? a. Cranial surgery b. Leg surgery c. Neck surgery d. Upper abdominal surgery Which assessment finding is cause for concern in a client who has taken 4 grams of acetaminophen (Tylenol) to relieve back pain? a. Difficulty with urination b. Decreased respiratory rate c. Gastrointestinal bleeding d. Increased liver function tests During preoperative assessment, the client tells the nurse about taking NSAIDs for years. What question is most important for the nurse to ask? a. “Did you ever have a problem with bleeding?” b. “Do you bruise easily?” 30 | P a g ec. “How many tablets do you take every day?” d. “When was the last time you took your NSAID? The client is taking an oxycodone-acetaminophen combination (Tylox) at home daily for chronic pain management. What instruction does the nurse give this client? a. c. “Avoid taking aspirin while you are on this medication.” b. “Drink plenty of water and eat foods high in fiber.” “Stop this medication after 3 days if the pain persists.” d. “Weigh yourself daily to determine whether you are retaining sodium or water.” The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse’s first action? a. Administering naloxone (Narcan) IV push b. Administering oxygen by nasal cannula c. Arousing the client by calling his or her name d. Documenting the findings and continuing to monitor The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take? a. Administer naloxone (Narcan). b. Administer oxygen. c. Assist with intubation. 31 | P a g ed. Monitor pain level. A client is admitted to the hospital with a history of oxycodone (Percodan) abuse. For which clinical manifestations does the nurse observe the client? a. Anorexia and weight loss b. Decreased heart rate and respirations c. Muscle twitching and profuse perspiration d. Sedation and constipation Which client would the nurse suggest should try subcutaneous opioid analgesia for pain management? a. Client who has had a surgical procedure b. Client with back pain who likes to walk c. Client with cancer who is nauseous d. Client experiencing acute chest pain A client with colon cancer is discharged to home with morphine for pain management. He is having episodes of nausea and vomiting. Which route of morphine administration would be most advantageous to use? a. Oral c. b. Rectal Intravenous d. Intramuscular 32 | P a g eThe nurse is caring for four clients. Which client assessment is the most indicative of having pain? a. Blood pressure 150/70 mm Hg and sleeping b. Client stating that he is “anxious” c. Heart rate of 105 beats/min and restlessness d. Postoperative client with a neck incision A client has a history of alcohol abuse. Which pain relief regimen does the nurse anticipate if morphine (MS Contin) is given for pain? a. A higher dose of opioids will be needed to provide effective pain relief. b. A lower dose of opioids will be needed to provide effective pain relief. c. The appropriate drug selection is an opioid agonist-antagonist combination. d. The client will receive no pain relief from the morphine. Which instruction is the most accurate for the nurse to give a client who has a patient-controlled analgesia device (PCA) after abdominal surgery? a. “Instruct your visitors to press the button for you when you are sleeping.” b. “Push the button every 15 minutes whether you feel pain at that time or not.” c. “Push the button when you first feel pain instead of waiting until pain is severe.” d. “Try to go as long as you possibly can before you press the button.” The nurse assesses several postoperative clients receiving patient- controlled epidural analgesia (PCEA). Which client does the nurse prioritize to assess first? a. Client receiving bupivacaine (Marcaine) describing “inability to move legs” c. b. Client receiving fentanyl (Sublimaze) describing “itchy arms” Client receiving hydromorphone (Dilaudid) describing “full feeling” 33 | P a g ed. Client receiving morphine describing “difficulty staying awake” A client has epidural analgesia with bupivacaine (Marcaine) for pain relief. For which condition should the nurse assess this client? a. Extremity itching b. Inability to raise legs off the bed c. Nausea and vomiting d. Respiratory rate of 8 breaths/min When assessing a client who is taking long-term ibuprofen (Motrin) for pain, the nurse finds numerous areas of bruising. What is the nurse’s first action? a. Assess for gastric discomfort. b. Assess for the presence of pain. c. Continue to monitor bruising. d. Place client on falls precaution. Which statement made by a nurse represents the need for further education regarding pain management in older adult clients? a. “Older adults are at greatest risk for undertreated pain.” c. b. “Older adults tend to report pain less often than younger adults.” “Older clients usually have more experience with pain than younger clients.” d. “Older clients have a different pain mechanism and do not feel it as much.” Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting? 34 | P a g ea. Cutaneous skin stimulation b. Hypnosis c. Imagery d. Radiofrequency ablation A client who is at the end of life is being given morphine for pain management. The family expresses concern that the morphine may cause the client to stop breathing and die. What is the nurse’s best response? a. “He needs the morphine to prevent pain.” b. “His respirations are not affected by the morphine.” c. “We will decrease the dose if his breathing slows.” d. “We will give him oxygen to help with his breathing.” A client is stating that he has the sensation of burning, aching, and dullness. Which afferent nerve fibers should be transmitting the pain? a. A delta fibers b. C fibers c. A alpha fibers d. A beta fibers A client is postoperative day one and has a patient-controlled analgesia (PCA) pump with a continuous basal dose for pain control. Currently, the client is stating that the operative pain is escalating. What is the first action of the nurse? a. Try diversion to take the client’s mind off the pain. 35 | P a g eb. Ask the client to ambulate around the unit. c. Assess the client’s pain according to PQRST. d. Call the physician to request an order to increase the basal dose. a. Which client does the nurse assess first for pain control? Older client with