NUR 155 CH 46 test bank Fundamentals of nursing Kozler & Erbs 9th edition

Kozier & Erbs Fundamentals of Nursing, 9/E Chapter 46 Question 1 Type: MCSA The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this infant? 1. FLACC scale 2. Wong-Baker FACES 3. Visual analog scale 4. Numeric rating scale Correct Answer: 1 Rationale 1: The FLACC scale has been validated in children from 2 months to 7 years old. Rationale 2: This pain scale would not be appropriate for a client of this age. Rationale 3: This pain scale would not be appropriate for a client of this age. Rationale 4: This pain scale would not be appropriate for a client of this age. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1097 Question 2 Type: MCSA The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication? 1. Gastrointestinal (GI) distress 2. Shakiness 3. Tremors 4. Rash Correct Answer: 1 Rationale 1: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal distress, such as heartburn or indigestion. Rationale 2: Shakiness is not a common side effect of NSAIDs. Rationale 3: Tremors are not a common side effect of NSAIDs. Rationale 4: A rash is not a common side effect of NSAIDs. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1107 Question 3 Type: MCSA Which of the following objective assessment data will the nurse obtain before administering a prescribed opioid medication to a client? 1. Pain level as stated by client 2. Any nausea the client may be feeling 3. Respiratory rate 4. Color of skin Correct Answer: 3 Rationale 1: This is an example of subjective data. Rationale 2: This is an example of subjective data. Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Rationale 4: This is not applicable to assess prior to administering an opioid medication to a client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain