Chapter 19

Question 1

A nurse is inquiring about a patient’s pain during morning assessment and asks the patient to provide a rating based on a scale of 0 to 10, with 0 meaning pain free and 10 meaning the worst pain. The patient reports a 9 out of 10. The patient is resting comfortably in bed watching television and does not appear to be in distress. What is the best nursing response?

Answer 1

Check to see when the patient was last medicated for pain.

Question 2

The nurse provides care for a patient who is prescribed alternating heat and cold therapy to the knee. Which is the priority assessment by the nurse after each application of therapy?

Answer 2

The patients skin color and temperature

Question 3

An 18-year-old is in the clinic with an arm injury after banging into a doorframe. Upon entering the room, the
nurse observes the individual rubbing the area. Based on the gate control theory of pain, how would the nurse
interpret this finding?

Answer 3

Stimulation of small nerves to open the gate

Question 4

The nurse placed a cold pack on a patient’s knee for 30 min. When the cold pack is removed, the skin is bright pink in color. The nurse recognizes that the patient is having a rebound effect. Which cause does the nurse understand?

Answer 4

The area has vasodilation to prevent tissue damage

Question 5

A patient with terminal cancer asks how massage can decrease pain. Which should the nurse explain about massage in pain control?

Answer 5

Stimulates the release of endorphins, which are thought to block the transmission of pain

Question 6

The nurse is providing care to a patient diagnosed with bone cancer. The nurse is aware that the patient is experiencing which type of pain?

Answer 6

Nociceptive pain
(often referred to as all deep somatic or osteogenic pain)
-EX of this are bone, ligaments, and tendon pain

Question 7

A patient with diabetes has an open foot wound but reports no pain. How should the nurse document this finding?

Answer 7

Injury due to neuropathy

Question 8

The nurse is preparing to apply cold therapy to a patient’s sprained ankle. The nurse observes the available equipment for applying cold therapy. Which characteristics of the equipment will best suit this patient’s needs?

Answer 8

Flexible, with a way to secure
(Needs to be able to wrap and tie)

Question 9

A patient with chronic rheumatoid arthritis is in the clinic for a yearly checkup. The nurse is performing a
pain assessment. What type of pain designation would the nurse expect the patient to have?

Answer 9

Deep somatic

Question 10

The nurse is caring for a patient with a fever. The health-care provider orders tepid baths for a rapid decrease in temperature. Which nursing knowledge recognizes why the temperature of the bath should be tepid?

Answer 10

A tepid bath will prevent chilling and shivering
(reduces fever w/o gaining body mechanisms that increase temperature)

Question 11

A critically ill patient may have difficulty in getting the restorative sleep necessary for healing. Which action should the nurse take to help this patient?

Answer 11

Dim the lights and close the door.

Question 12

The nurse is caring for a patient ordered to begin pain management with a transcutaneous electrical nerve stimulation (TENS) unit. Using knowledge about gate control theory, the nurse knows that which nerve fibers are involved with TENS therapy?

Answer 12

Broad fibers
( broad fibers are thought to close the gate, disrupting pain)

Question 13

A patient reports waking up frequently during the night and not getting restful sleep. Which response should
the nurse make?

Answer 13

“Drinking alcohol can cause you to wake up during the night.”

Question 14

Fluid entering the interstitial space will cause which of the following?

Answer 14

Edema

Question 15

postoperative patient has been prescribed patient-controlled analgesia (PCA) for pain control. Which
information should the nurse include in the plan of care?

Answer 15

Dosage prescription is programmed into the pump.
(When using a PCA, the dosage prescription is programmed into the
device)

Question 16

The nurse is preparing a patient for cardiac surgery. The patient states, “The doctor said they would lower my body temperature, which sounds strange.” Which answer by the nurse is correct?

Answer 16

When your temperature is lower it reduces the hearts need for oxygen

Question 17

A nurse is reviewing a patient’s medication profile and finds that the patient is taking gabapentin following a
motor vehicle accident (MVA) in which injuries were sustained. Medical history is negative for disease. How should the nurse interpret this finding?

Answer 17

The medication is used to treat pain from MVA

Question 18

The nurse is caring for a patient who sustained an injury that is edematous and painful. The health-care provider orders alternating heat and cold therapy. The nurse is aware that the cold therapy will help with pain and swelling. Which therapeutic purpose does the nurse recognize for the heat therapy?

Answer 18

Vasodilates the area to have white blood cells, nutrients, and oxygen get delivered quickly.

Question 19

A patient reports feeling pain “only when I move.” Which type of pain is this patient experiencing?

Answer 19

Deep somatic

Question 20

The nurse works at an adult wellness clinic. Which patient will the nurse recognize as having the lowest risk for sleep-related problems?

Answer 20

The patient that runs every morning

Question 21

A patient who has pain rated as a 7 on a scale from 1 to 10 continues to have pain despite having medication 2 hours ago. Which response should the nurse make when the patient requests additional medication?

Answer 21

“Let me reposition you and rub your back to help relieve the pain.”

Question 22

__________________________ is essential because it is when the brain works to repair small injuries to the body, mind, and emotions that occur as part of the natural wear and tear of daily living.

Answer 22

Restorative sleep

Question 23

A nurse is preparing to administer a vaccine injection to a patient who is very nervous. What method should
the nurse implement to decrease the patient’s anxiety?

Answer 23

Ask the patient about what activities they like to do.

Question 24

The nurse is caring for a patient who is experiencing a pain level of 4 on a scale of 0-10 after the administration of pain medication. Before seeking an increase in the patient’s medication order, the nurse decides to try distraction. Which activities are considered to be distractions for pain management? Select all that apply.

Answer 24

-Turning on the television
-Receiving a back rub
-Working on word puzzles

Question 25

A nurse is reviewing a patient’s medication profile and notes that the patient is taking clopidogrel. Medical history reveals chronic pain syndrome and recent cardiac stenting. Which additional medication present on the medication profile should alert the nurse to contact the health-care provider (HCP)?

Answer 25

325 mg ASA

Question 26

The nurse is hired to work in a pain clinic. The nurse manager encourages the nurse to look at pain in a holistic manner. Which focus will help the nurse to achieve this outlook?

Answer 26

understand that pain touches every aspect in an individuals life

Question 27

A patient reports having a sore jaw and tooth pain in the mornings. Which sleep disorder should the nurse suspect this patient has?

Answer 27

Bruxism

Question 28

The nurse is assessing a patient’s pain. Which areas of information are important? Select all that apply.

Answer 28

-Specific location -Pain level suing 0-10 scale -A description of the pain -Actions that cause the pain

Question 29

After the patient rates pain as an 8 on a scale from 1 to 10, the nurse, when bringing pain medication, finds the patient sleeping. Which action should the nurse take next?

Answer 29

Wake the patient gently and provide the medication.

Question 30

A 58-year-old patient is admitted to the hospital with a ruptured appendix for surgical repair, has poor vascular access, and is mildly dehydrated. What type of pain management would the nurse suspect that the health-care provider will order?

Answer 30

Patient-controlled analgesia (PCA) (PCA allows for ease of access and delivery of pain medication with appropriate safety monitoring.)

Question 31

The nurse is caring for multiple patients. Which patients will the nurse identify as being contraindicated for heat therapy? Select all that apply.

Answer 31

-Patient admitted of contusions -Patient with abdominal swelling

Question 32

A patient complaining of persistent shoulder pain is in the clinic for evaluation. Upon examination, vital signs are stable, and the patient appears angry that no one can help. How would the nurse interpret these findings?

Answer 32

Chronic pain pattern

Question 33

The nurse is caring for a patient just admitted with a knee joint injury. The health-care provider orders alternating heat and cold therapy. For which reason will the nurse question the health-care provider's order?

Answer 33

Heat therapy will initially cause more edema and pain

Question 34

A patient with chronic pain reports that pretending to be lying on a beach with the sun warming the legs helps relieve the chronic hip and leg pain caused by arthritis. Which nonpharmacological method is this patient using to control pain?

Answer 34

Guided imagery (uses the mind to help control the body and guide the patient toward a more relaxed state.)

Question 35

The nurse applies heat to a wound as ordered by the health-care provider. The nurse is aware that which process of healing is promoted by heat therapy?

Answer 35

Metabolism is increased to build and maintain tissue

Question 36

A patient has been using a TENS unit for one hour to help relieve back pain. Which action should the nurse take after removing the unit from the patient?

Answer 36

Assess pain level.

Question 37

The nurse provides care for a patient in the intensive care unit who displays irritability and confusion mid-morning. The patient expresses always feeling fatigued. Which sleep-related condition does the nurse suspect based on the current data?

Answer 37

Sleep deprivation

Question 38

A nurse finds a sleeping patient difficult to arouse to provide routine prescribed medications. Which stage of sleep was this patient most likely in?

Answer 38

STAGE IV

Question 39

The nurse is applying heat to a patient's swollen ankle. The patient states that the cold therapy makes the ankle less painful. Which purpose does the nurse recognize as the purpose of the heat therapy?

Answer 39

The resulting vasodilation will help carry away excess fluid and reduce edema

Question 40

A chronic pain patient arrives at the emergency room and, once transferred from the stretcher to the bed, becomes nonresponsive. Which priority actions should the nurse implement? Select all that apply.

Answer 40

-Administer naloxone. -Obtain vital signs. -Administer oxygen. -Place on cardiac monitor.

Question 41

The nurse receives an order from the health-care provider to apply moist heat to a patient's injury. The nurse can provide the moist heat by applying a moist towel to the heat source. Which heat source is contraindicated for conversion to moist heat?

Answer 41

Warming blankets (dry heat usage only)

Question 42

The nurse is providing care to a patient diagnosed with bone cancer. The nurse is aware that the patient is experiencing which type of pain?

Answer 42

Nociceptive (Deep somatic or oste)

Question 43

A nurse is completing a pain assessment scale for a newly admitted patient on the medical unit. Which components should be included in this type of assessment? Select all that apply

Answer 43

-Determining the specific location of the pain -Asking what helps to alleviate the pain -Asking when the pain started

Question 44

The nurse works in an acute care setting with patients who have had surgery. Which factors does the nurse identify as affecting how patients respond to or express pain? Select all that apply.

Answer 44

-Previous pain experiences -Personal support systems -Ethnic and cultural beliefs -Current developmental stage -Emotional response

Question 45

A patient being treated for chronic pain wants to reduce their intake of opiates and narcotics. What options should the nurse suggest to help support the patient’s request? Select all that apply.

Question 46

A nurse is performing an initial assessment of a 48-year-old patient’s sleeping habits. Which findings warrant further attention? Select all that apply.

Answer 46

-Patient dozes off during the day at times. -Patient sleeps 2 hours a night.

Question 47

The nurse is caring for an older female patient who is experiencing chronic pain. The patient describes the pain as a "deep, stabbing" pain. The nurse concludes that the pain is most likely related to which condition?

Answer 47

Spinal column compression

Question 48

The nurse is working in a pain management clinic. Which type of pain will the nurse identify as nociceptive pain? Select all that apply.

Answer 48

-Cutaneous pain -Osteogenic pain -Soft tissue pain

Question 49

The nurse is caring for a patient who had surgery earlier in the day. When the nurse enters the patient's room, the patient is sleeping. Which is the correct action for the nurse to take?