Answers to Part 1
ANSWERS:
1. Correct Answer: 4
Rationale:
As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem.
Rationale:
As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem.
2. Correct Answer: 3
Rationale:
Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension.
Rationale:
Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension.
3. Correct Answer: 1
Rationale:
Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant medication.
Rationale:
Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant medication.
4. Correct Answer: 3
Rationale:
Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins.
Rationale:
Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins.
5. Correct Answer: 3
Rationale:
The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain by increasing venous capacitance. Other clients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent.
Rationale:
The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain by increasing venous capacitance. Other clients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent.
6. Correct Answer: 1
Rationale:
The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside. Adequate dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs.
Rationale:
The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside. Adequate dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs.
7. Correct Answer: 2
Rationale:
First assess the client. The UAP has correctly reported her findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on your assessment findings, the other options may also be appropriate.
Rationale:
First assess the client. The UAP has correctly reported her findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on your assessment findings, the other options may also be appropriate.
8. Correct Answer: 4
Rationale:
At greatest risk are elderly clients, opiate-naive clients, and those with underlying pulmonary disease. The child has two of the three risk factors.
Rationale:
At greatest risk are elderly clients, opiate-naive clients, and those with underlying pulmonary disease. The child has two of the three risk factors.
9. Correct Answer: 1
Rationale:
This client has strong beliefs and emotions related to the issue of the sibling's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, but it should be kept in mind that their beliefs about drug addiction may be similar to those of the client.
Rationale:
This client has strong beliefs and emotions related to the issue of the sibling's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, but it should be kept in mind that their beliefs about drug addiction may be similar to those of the client.
10. Correct Answer: 2
Rationale:
Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.
Rationale:
Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.
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