Fundamentals Of Nursing NCLEX Quiz 42

2.

Albert who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Which intervention is the most appropriate for him?

Referring the client for counseling and occupational therapy
Staying with the client as much as possible and building trust
Providing cutaneous stimulation and pharmacologic therapy
Providing distraction and guided imagery techniques

Correct Answer

A. Referring the client for counseling and occupational therapy

Explanation

Because it has been 6 months. the client needs professional help to get on with life and handle the limitations imposed by the current problems. Staying with the client. building trust. and providing method of pain relief. such as cutaneous stimulation. medications. distraction. and guided imagery interventions. would have been more appropriate in earlier stages of postburn injury. when physical pain was most severe and fewer psychologic factors needed to be addressed.

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3.

Which term would the nurse use to document pain at one site that is perceived in other site?

Referred pain
Phantom pain
Intractable pain
Aftermath of pain

Correct Answer

A. Referred pain

Explanation

Referred pain is pain occurring at one site that is perceived in another site. Referred pain follows dermatome and nerve root patterns. Phantom pain refers to pain in a part of the body that is no longer there. such as in amputation. Intractable pain refers to moderate to severe pain that cannot be relieved by any known treatment. Aftermath of pain. a phase of the pain experience and the most neglected phase. addresses the client’s response to the pain experience.

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4.

A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?

Telling the client to strictly limit the amount of movement of his inflamed joints
Teaching the client’s family how to transfer the client into a wheelchair
Teaching the client the proper method for massaging inflamed. sore joints
Encouraging gentle range-of-motion exercises after administering aspirin and before rising

Correct Answer

A. Encouraging gentle range-of-motion exercises after administering aspirin and before rising

Explanation

Aspirin raises the pain threshold and. although range-of-motion exercises hurt. mild exercise can relieve pain on rising. Strict limitation of motion only increases the client’s pain. Having others transfer the client into a wheelchair does not increase his feelings of dependency. Massage increases inflammation and should be avoided with this client.

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5.

Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp. throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first?

Assessing the client to rule out possible complications secondary to surgery
Checking the client’s chart to determine when pain medication was last administered
Explaining to the client that the pain should not be this severe 3 days postoperatively
Obtaining an order for a stronger pain medication because the client’s pain has increased

Correct Answer

A. Assessing the client to rule out possible complications secondary to surgery

Explanation

The nurse immediate action should be assess the client in an attempt to exclude possible complications that may be causing the client’s complaints. The health care provider ordered the pain medication for routine postoperative pain that is expected after abdominal surgery. not for such complications as hemorrhage. infection. or dehiscence. The nurse should never administer pain medication without assessing the client first. Obtaining an order for a strong medication may be appropriate after the nurse assesses the client and checks the chart to see whether the current analgesic is infective. Checking the client’s chart is appropriate after the nurse determines that the client is not experiencing complications from surgery. Pain is subjective. and each person has his own level of pain tolerance. The nurse must always believe the client’s complaint of pain.

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6.

Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?

Referring the client for hypnosis
Administering pain medication as prescribed
Removing all glaring lights and excessive noise
Using transcutaneous electric nerve stimulation

Correct Answer

A. Using transcutaneous electric nerve stimulation

Explanation

Nonpharmacologic pain relief interventions include cutaneous stimulation. back rubs. biofeedback. acupuncture. transcutaneous electric nerve stimulation. and more. Hypnosis is considered an alternative therapy. Medications are pharmacologic measures. Although removing glaring lights and excessive noise help to reduce or remove noxious stimuli. it is not specific to pain relief.

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7.

Which term refers to the pain that has a slower onset. is diffuse. radiates. and is marked by somatic pain from organs in any body activity?

Acute pain
Chronic pain
Superficial pain
Deep pain

Correct Answer

A. Deep pain

Explanation

Deep pain has a slow onset. is diffuse. and radiates. and is marked by somatic pain from organs in any body activity. Acute pain is rapid in onset. usually temporary (less than 6 months). and subsides spontaneously. Chronic pain is marked by gradual onset and lengthy duration (more than 6 months). Superficial pain has abrupt onset with sharp. stinging quality.

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8.

In planning pain reduction interventions. which pain theory provides information most useful to nurses?

Specificity theory
Pattern theory
Gate-control theory
Central-control theory

Correct Answer

A. Central-control theory

Explanation

No one theory explains all the factors underlying the pain experience. but the central-control theory discusses brain opiates with analgesic properties and how their release can be affected by actions initiated by the client and caregivers. The gate-control. specificity. and patter theories do not address pain control to the depth included in the central-control theory.

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9.

A 12-year-old student fall off the stairs. grabs his wrist. and cries. “Oh. my wrist! Help! The pain is so sharp. I think I broke it.” Based on this data. the pain the student is experiencing is caused by impulses traveling from receptors to the spinal cord along which type of nerve fibers?

Type A-delta fibers
Autonomic nerve fibers
Type C fibers
Somatic efferent fibers

Correct Answer

A. Type A-delta fibers

Explanation

Type A-delta fibers conduct impulses at a very rapid rate and are responsible for transmitting acute sharp pain signals from the peripheral nerves to the spinal cord. Only type A-delta fibers transmit sharp. piercing pain. Somatic efferent fibers affect the voluntary movement of skeletal muscles and joints. Type C fibers transmit sensory input at a much slower rate and produce a slow. chronic type of pain. The autonomic system regulates involuntary vital functions and organ control such as breathing.

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10.

Chuck. who is in the hospital. complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement? (Select all that apply.)

Assessing the client’s bowel sounds
Taking the client’s blood pressure and apical pulse
Obtaining a pulse oximeter reading
Notifying the health care provider
Determining the last time the client received pain medication
Encouraging the client to turn, cough, and deep breathe

Correct Answer(s)

A. Assessing the client’s bowel sounds
A. Taking the client’s blood pressure and apical pulse
A. Determining the last time the client received pain medication

Explanation

The nurse must rule out complications prior to administering pain medication. so her interventions would include assessing to make sure the client has bowel sounds and determining if the client is hemorrhaging by checking the client’s blood pressure and pulse. The nurse must also make sure the pain medication is due according to the health care provider’s orders. Obtaining a pulse oximeter reading and turning. coughing. and deep breathing will not help the client’s pain. There is no need to notify the health care provider in this situation.

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Fundamentals Of Nursing NCLEX Quiz 42

Ryan underwent an open reduction and internal fixation of the left hip. One day after the operation. the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?

Quiz Preview

Albert who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Which intervention is the most appropriate for him?

Which term would the nurse use to document pain at one site that is perceived in other site?

A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?

Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp. throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first?

Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?

Which term refers to the pain that has a slower onset. is diffuse. radiates. and is marked by somatic pain from organs in any body activity?

In planning pain reduction interventions. which pain theory provides information most useful to nurses?

A 12-year-old student fall off the stairs. grabs his wrist. and cries. “Oh. my wrist! Help! The pain is so sharp. I think I broke it.” Based on this data. the pain the student is experiencing is caused by impulses traveling from receptors to the spinal cord along which type of nerve fibers?

Chuck. who is in the hospital. complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement? (Select all that apply.)