Prioritization Delegation and Assignment 4th Edition LaCharity Test Bank

Prioritization Delegation and Assignment 4th Edition LaCharity Test Bank

Chapter 1. Pain MULTIPLE CHOICE 1.A client tells the nurse that she rarely experiences pain, but when she does, she seeks medical attention. The nurse realizes this client understands that pain is important because it: 1. is a protective system. 2. includes the automatic withdrawal reflex. 3. creates sensitivity to pain. 4. helps with healing. ANS: 1 Pain is a protective system that includes protection from unsafe behaviors by use of reflexes, memory, and avoidance. Even though the automatic withdrawal reflex is a part of the pain response, it does not explain why pain is important. Pain does not create sensitivity to pain. Pain does not help with healing. PTS: 1 DIF: Analyze REF: Definitions and Implications of Pain 2.A client complains that the bed sheets touching his skin are extremely painful. The nurse realizes this client is experiencing: 1. allodynia. 2. modulation. 3. kinesthesia. 4. proprioception. ANS: 1 Allodynia or hyperalgesia is a state where a slight or nonpainful stimulus is interpreted as very painful. Kinesthesia is the awareness of movement. Proprioception is the awareness of body position. Modulation is an influencing factor in the perception of pain. PTS: 1 DIF: Analyze REF: Peripheral Nervous System 3.A client is complaining of severe abdomen pain. The nurse realizes this client is experiencing which type of pain? 1. Neuralgia 2. Pathological 3. Somatic 4. Visceral ANS: 4 Visceral pain is pain arising from the body organs or gastrointestinal tract. Somatic pain is pain that originates from the bone, joints, muscles, skin, or connective pain. Neuralgia and pathological pain are both types of pain that result from injury to a nerve or malfunction of the neuronal transmission process or due to impaired regulation. PTS:1DIF:AnalyzeREF:Types of Pain 4.A client, diagnosed with acute appendicitis, is experiencing abdominal pain. The best way for the nurse to describe this clients pain would be: 1. chronic. 2. neuropathic. 3. referred. 4. acute. ANS: 4 Acute pain onset is sudden and of short duration. Chronic pain is a sudden or slow onset of mild to severe pain that lasts longer than 6 months. Referred pain is the result of the transfer of visceral pain sensations to a body surface at a distance from the actual origin. Neuropathic pain is paroxysmal pain that occurs along the branches of a nerve. PTS:1DIF:ApplyREF:Types of Pain 5.A client is observed holding a pillow over the abdominal region with both knees flexed in a side-lying position. Vital signs assessment reveals an elevated blood pressure and heart rate. Which of the following should the nurse say to this client? 1. Can I get you anything? 2. Would you like something for pain? 3. You look comfortable. 4. Your blood pressure is up. ANS: 2 Sympathetic responses to pain include elevated blood pressure and heart rate. And since the client is hugging a pillow over the abdominal region with both knees flexed in a side-lying position, the best thing for the nurse to say to this client is Would you like something for pain? The other responses are incorrect because they do not acknowledge that the client is experiencing pain. PTS: 1 DIF: Apply REF: Assessing the Clinical Manifestations of Pain 6.A client experiencing chronic pain asks the nurse why she is not prescribed Demerol like she received when she had a total knee replacement. Which of the following should the nurse respond to this client? 1. You dont need something that strong. 2. That medication does not exist anymore. 3. That medication does not last very long. 4. It can cause you have high blood pressure. ANS: 3 Meperidine is no longer a major drug for acute or chronic pain due to its short analgesic duration of 2 to 3 hours and the potential for accumulative toxic effects of its metabolite, normeperidine. The best response for the nurse to make to the client would be that medication does not last very long. The other responses are inaccurate. PTS:1DIF:ApplyREF:Opioid Analgesic