Fundamentals Of Nursing NCLEX Quiz 42

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  • 1/10 Questions

    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?

    • Left hip dressing dry and intact
    • Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
    • Left leg in functional anatomic position
    • Left foot cold to touch; no palpable pedal pulse
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Fundamentals Of Nursing NCLEX Quiz 42 - Quiz

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  • 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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  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Aug 31, 2017
    Quiz Created by
    Santepro
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