Chapter 42: Comfort Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1 Which one of the following nursing interventions for a client in pain is based on the gate-control theory?

a.

Giving the client a back massage

b.

Changing the clients position in bed

c.

Giving the client a pain medication

d.

Limiting the number of visitors

ANS: a

a. The gate-control theory suggests that cutaneous stimulation activates larger, faster-transmitting A-beta sensory nerve fibers. This decreases pain transmission through small-diameter A-delta and C fibers. A back massage is a nursing intervention based on the gate-control theory.

b. Changing the clients position in bed is not a form of cutaneous stimulation used to relieve pain.

c. Giving the client a pain medication is a pharmacological approach to relieving pain. It is not based on the gate-control theory.

d. Limiting the number of visitors may provide a quiet environment conducive to relaxation, but it is not based on the gate-control theory.

REF: Text Reference: p. 1253

2. The client is receiving an epidural opioid infusion for pain relief. A priority nursing intervention when caring for this client is to:

a.

Use aseptic technique

b.

Label the port as an epidural catheter

c.

Monitor vitals signs every 15 minutes

d.

Avoid supplemental doses of sedatives

ANS: c

c. When clients are receiving epidural analgesia, monitoring occurs as often as every 15 minutes, including assessment of respiratory rate, respiratory effort, and skin color. Complications of epidural opioid use include nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus. A common complication of epidural anesthesia is hypotension. Assessing vital signs is the priority nursing intervention.

a. Because of the catheter location, strict surgical asepsis is needed to prevent a serious and potentially fatal infection.

b. To reduce the risk of accidental epidural injection of drugs intended for IV use, the catheter should be clearly labeled epidural catheter. However, it is not the priority nursing intervention.

d. Supplemental doses of opioids or sedative/hypnotics are avoided because of possible additive central nervous system adverse effects. However, this is not the priority nursing intervention.

REF: Text Reference: p. 1261

3. The client tells the nurse about a burning sensation in the epigastric area. The nurse should describe this type of pain as:

a.

Referred

b.

Radiating

c.

Deep visceral

d.

Superficial or cutaneous

ANS: c

c. Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may be described as a burning sensation.

a. Referred pain is felt in a part of the body separate from the source of pain, such as with a myocardial infarction, in which pain may be referred to the jaw, left arm, and left shoulder.

b. Radiating pain feels as though it travels down or along a body part, such as low back pain that is accompanied by pain radiating down the leg from sciatic nerve irritation.

d. Superficial or cutaneous pain is of short duration and is localized, as in a small cut.

REF: Text Reference: p. 1243

4 The nurse must frequently assess a client experiencing pain. When assessing the intensity of the pain, the nurse should:

a.

Ask about what precipitates the pain

b.

Question the client about the location of the pain

c.

Offer the client a pain scale to objectify the information

d.

Use open-ended questions to find out about the sensation

ANS: c

c. Descriptive scales are a more objective means of measuring pain intensity.

a. Asking the client what precipitates the pain does not assess intensity, but rather is an assessment of the pain pattern.

b. Asking the client about the location of pain does not assess the intensity of the clients pain.

d. To determine the quality of the clients pain, the nurse may ask open-ended questions to find out about the sensation experienced.

REF: Text Reference: p. 1243

5. The nurse on a postoperative care unit is assessing the quality of the clients pain. To obtain this specific information about the pain experience from the client, the nurse should ask:

a.

What does your discomfort feel like?

b.

What activities make the pain worse?

c.

How much does it hurt on a scale of 1 to 10?

d.

How much discomfort are you able to tolerate?

ANS: a

a. To determine the quality of the clients pain the nurse might say, What does your discomfort feel like? It is more accurate to have clients describe the pain in their own words whenever possible.

b. Inquiring about what activities make the pain worse is a type of question directed at determining the pain pattern.

c. Having the client rate his or her pain on a pain scale is a method of measuring the intensity of pain.

d. To determine the clients expectations, the nurse may ask the client, How much discomfort are you able to tolerate?

REF: Text Reference: p. 1244

6. The client will be going home on medication administered through a PCA (patient-controlled analgesia) system. To assist the family members with an understanding of how this therapy works, the nurse explains that the client:

a.

Has control over the frequency of the IV analgesia

b.

Can choose the dosage of the drug received

c.

May request the type of medication received

d.

Controls the route for administering the medication

ANS: a

a. With a PCA system, the client controls medication delivery.

b. The PCA system is designed to deliver no more than a specified number of doses. The client does not choose the dosage.

c. The physician prescribes the type of medication to be used. The advantage for the client is that he or she may self-administer opioids with minimal risk of overdose.

d. The client does not control the route for administration. Systemic PCA typically involves IV drug administration, but can also be given subcutaneously.

REF: Text Reference: p. 1259

7. An older client with mild musculoskeletal pain is being seen by the primary care provider. The nurse anticipates that treatment of this clients level of discomfort will include:

a.

Fentanyl

b.

Diazepam

c.

Acetaminophen

d.

Meperidine hydrochloride

ANS: c

c. A nonopioid analgesic, such as acetaminophen, is used to treat mild musculoskeletal pain effectively.

a. Fentanyl is about 100 times more potent than morphine. It is typically used for cancer pain, not mild musculoskeletal pain.

b. Diazepam is given as an anti-anxiety agent.

d. Meperidine hydrochloride is an opioid analgesic used to treat moderate to severe acute pain, not mild pain.

REF: Text Reference: p. 1256

8. The nurse tells the client that the urinary catheter insertion may feel uncomfortable. This is most accurately an example of:

a.

Distraction

b.

Reducing pain perception

c.

Anticipatory response

d.

Self-care maintenance

ANS: c

c. Pain can be prevented by anticipating painful events. Before performing procedures, the nurse considers the clients condition, aspects of the procedure that may be uncomfortable, and techniques to avoid causing pain. The nurse who tells the client that the urinary catheter insertion may feel uncomfortable is an example of anticipatory response.

a. This is not an example of using distraction. Distraction directs a clients attention to something else and thus can reduce the awareness of pain and even increase tolerance.

b. Reducing pain perception means to remove stimuli that are uncomfortable or to prevent stimuli that are painful, such as changing wet linens, or preventing constipation with fluids, diet, and exercise.

d. This is not an example of self-care maintenance. Self-care maintenance implies that the client is able to carry out necessary activities to care for himself or herself. This may include pain management measures.

REF: Text Reference: p. 1254

9. The nurse is working on a postoperative care unit in the medical center. Of the following clients, the nurse determines that the individual who is best suited for PCA management is the client who:

a.

Has psychogenic discomfort

b.

Is recovering after a total hip replacement

c.

Experiences renal dysfunction

d.

Recently experienced a cerebrovascular accident (stroke)

ANS: b

b. PCA is a safe method for postoperative pain management, such as the client recovering from total hip replacement surgery.

a. PCA would not be the mode of choice for treating psychogenic pain.

c. PCA would not be recommended for the client with renal dysfunction. The client with renal impairment would be at increased risk for drug toxicity due to decreased drug excretion.

d. Clients must be able to understand the use of the equipment and be physically able to locate and press the button to deliver the dose. The client who recently experienced a cerebrovascular accident may have difficulty managing the PCA system.

REF: Text Reference: p. 1257

10. A client with chronic back pain has an order for a transcutaneous electrical nerve stimulation (TENS) unit for pain control. The nurse should instruct the client to:

a.

Keep the unit on high

b.

Use the unit when pain is perceived

c.

Remove the electrodes at bedtime

d.

Use the therapy without medications

ANS: b

b. When a client feels pain, the TENS unit is turned on, and a buzzing or tingling sensation is created. The tingling sensation can be applied until pain relief occurs.

a. The client may adjust the intensity of skin stimulation. It does not have to remain on high.

c. The electrodes do not have to be removed at bedtime.

d. Medication can be administered with a TENS unit.

REF: Text Reference: p. 1254

11. A terminally ill client with liver cancer is experiencing great discomfort. A realistic goal in caring for the client is to:

a.

Increasingly administer narcotics to oversedate the client and thereby decrease the pain.

b.

Continue to change the analgesics until the right narcotic is found that completely alleviates the pain.

c.

Adapt the analgesics as the nursing assessment reveals the need for specific medications.

d.

Withhold analgesics as they are not being effective in relieving discomfort.

ANS: c

c. The best choice of treatment often changes as the clients condition and the characteristics of pain change. It is realistic to expect that a terminally ill clients need for pain medication will change over time with disease progression.

a. The goal is not to oversedate the client, but to provide pain control without excessive sedation.

b. It would be unrealistic to expect that the pain of terminal cancer will be completely alleviated.

d. Analgesics should not be withheld, as this would only increase the clients level of pain. The medication regimen may require adaptation to meet the clients needs.

REF: Text Reference: p. 1261

12. A client is having severe, continuous discomfort from kidney stones. Based on the clients experience, the nurse anticipates which of the following findings in the clients assessment?

a.

Tachycardia

b.

Diaphoresis

c.

Pupil dilation

d.

Nausea and vomiting

ANS: d

d. Acute severe or deep pain, as with kidney stones, will cause a parasympathetic response. The client would likely exhibit nausea and vomiting.

a. Tachycardia is a response of sympathetic stimulation, commonly seen with pain of low to moderate intensity and superficial pain.

b. Diaphoresis is a response of sympathetic stimulation, commonly seen with pain of low to moderate intensity and superficial pain.

c. Pupil dilation is a response of sympathetic stimulation, commonly seen with pain of low to moderate intensity and superficial pain.

REF: Text Reference: p. 1233

13. Nurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regards to the pain experience, which of the following is correct?

a.

The client is the best authority on the pain experience.

b.

Chronic pain is mostly psychological in nature.

c.

Regular use of analgesics leads to drug addition.

d.

The amount of tissue damage is accurately reflected in the degree of pain perceived.

ANS: a

a. A clients self-report of pain is the single most reliable indicator of the existence and intensity of pain and any related discomfort. Pain is individualistic.

b. A misconception about pain is that chronic pain is psychological.

c. The belief that administering analgesics regularly will lead to drug addiction is a misconception.

d. A misconception about pain is that the amount of tissue damage is accurately reflected in the degree of pain perceived.

REF: Text Reference: p. 1241

14. A nonpharmacological approach that the nurse may implement for clients experiencing pain that focuses on promoting pleasurable and meaningful stimuli is:

a.

Acupressure.

b.

Distraction.

c.

Biofeedback.

d.

Hypnosis.

ANS: b

b. Pleasurable stimuli cause the release of endorphins. The nurse assesses activities enjoyed by the client that may act as distractions. Distraction directs a clients attention to something else and thus can reduce the awareness of pain and even increase tolerance.

a. Acupressure does not focus on promoting pleasurable and meaningful stimuli. Acupressure is finger pressure applied therapeutically at selected points of the body.

c. Biofeedback focuses on an individuals physiological responses (e.g., blood pressure or tension) and ways to exercise voluntary control over those responses.

d. Hypnosis does not focus on promoting pleasurable and meaningful stimuli. Hypnosis is a condition resembling sleep in which the mind is susceptible to suggestions.

REF: Text Reference: p. 1252

15. In caring for the client who is receiving epidural analgesia, an appropriate nursing intervention is to:

a.

Change the tubing every 48-72 hours.

b.

Change the dressing every shift.

c.

Secure the catheter to the outside skin.

d.

Use a bulky occlusive dressing over the site.

ANS: c

c. To prevent catheter displacement, the catheter should be secured carefully to the outside skin.

a. The infusion tubing should be changed every 24 hours to prevent infection.

b. To prevent infection, the dressing should not be routinely changed over the site.

d. A transparent dressing should be used over the site to secure the catheter and aid inspection.

REF: Text Reference: p. 1261

16. The client is experiencing breakthrough pain while on opioids. An order is written for the client to receive a transmucosal fentanyl unit. In teaching about this medication, the nurse should include all of the following except:

a.

Swab the unit over the cheeks

b.

Chew the unit after administration

c.

Take no more than 2 units per episode of discomfort

d.

Allow the unit to dissolve slowly in the mouth over 15 minutes or more

ANS: b

b. The unit should be left intact and not chewed.

a. The unit is placed in the clients mouth and swabbed over the inside of the cheeks and lower gums.

c. No more than two units should be used per breakthrough pain episode.

d. The unit needs to be allowed to dissolve and absorb over a 15-minute period.

REF: Text Reference: p. 1263

17. The nurse consults with the primary physician of a client who is experiencing continuous, severe pain. In planning for the clients treatment, the nurse is aware of the principles of pain management and that it is appropriate to expect treatment to include:

a.

Focusing on intramuscular administration of analgesics

b.

Waiting for pain to become more intense before administering opioids

c.

Administering opioid with nonopioid analgesics for severe pain experiences

d.

Administering large doses of opioids initially to clients who have not taken the medications before

ANS: c

c. To treat a client who is experiencing continuous severe pain, the nurse should expect the client to receive opioid and nonopioid analgesics for severe pain experiences.

a. Intramuscular administration of analgesics is not expected because the injection itself is painful, and inconsistent erratic absorption of the drug may occur.

b. The nurse should administer opioids before the clients pain becomes intense. It is easier to maintain pain control than it is to get intense pain under control.

d. Large doses of opioids are not given initially to clients who have not taken the medications before as it may cause respiratory depression. The expectation is to begin with lower doses and titrate upward.

REF: Text Reference: p. 1256

18. Upon entering the room, the nurse discovers that the client is experiencing acute pain. An expected assessment finding for this client is:

a.

Bradycardia

b.

Bradypnea

c.

Diaphoresis

d.

Decreased muscle tension

ANS: c

c. An expected assessment finding of a client experiencing acute pain would be diaphoresis due to sympathetic nerve stimulation.

a. An expected assessment finding of a client experiencing acute pain would be an increased heart rate, not bradycardia.

b. An expected assessment finding of a client experiencing acute pain would be an increased respiratory rate, not bradypnea.

d. The client experiencing acute pain will have increased muscle tension.

REF: Text Reference: p. 1233

19. The client is unable to rest even after medication. The nurse decides to give the client a backrub. Which of the following strokes should the nurse use when finishing the backrub?

a.

Long firm strokes down the back

b.

Light strokes while moving up the back in a circular motion

c.

Kneeding movements toward the sacrum

d.

Circular motion upward from buttocks to shoulders

ANS: a

a. The nurse should end the backrub with long firm strokes down the back.

b. The backrub is not finished with light strokes while moving up the back in a circular motion.

c. Kneading movements toward the sacrum are done before ending the backrub with long firm strokes down the back.

d. The nurse should begin a backrub by massaging in a circular motion upward from buttocks to shoulders.

REF: Text Reference: p. 1255

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