Which of the following pain scales would the nurse use to measure intensity of pain in
toddlers? ANSWER FACES scale
Which of the following nonpharmacological nursing interventions has proven helpful in
the relief of postoperative pain? ANSWER Repositioning.
Rationale: Acute postoperative pain always requires the use of analgesics, but
nonpharmacological interventions such as repositioning the client can help relieve pain.
Ambulation is not specifically used to decrease postoperative pain. Purse-lipped
breathing is primarily used to improve ventilation. Deep breathing and coughing are
used to clear the respiratory tract.
Which statement is an accurate description of dysmenorrhea? - ANSWER Pain with
menses.
Reason: Dysmenorrhea is painful menses. Endometrial hyperplasia follows anovulation
and unopposed estrogen stimulation. Bleeding between menses is metrorrhagia. Heavy
bleeding with menses is menorrhagia.
When teaching postoperatively, for what reason would the nurse explain administering
an opioid analgesic through an epidural catheter? - ANSWER Relieves abdominal pain
Rationale: Opioids reduce pain by attaching to the opioid receptors in the brain, which
changes the perception of and response to pain; PCA via an epidural catheter permits
the client some control over the medication administration and most often the client
requests less medication. Narcotics hinder the use of oxygen; that is, the rate of
respiration slows, less oxygen is utilized, and the client should be monitored. Although
decreased anxiety and restlessness may be responses to an opioid, they are not the
primary reasons opioids are administered postoperatively after abdominal surgery.
Opioids are administered for pain relief, not to dilate blood vessels; antianginal
medications and vasodilators are administered for this purpose
Which caring intervention provides comfort, dignity, respect, and peace to a client?
ANSWER Relieving pain and suffering
, A client presents to the health care facility with a chief complaint of abdominal pain. For
what concomitant symptoms would the nurse question the client? ANSWER "What other
discomfort do you experience?" RATIONALE: Symptoms that accompany the chief
symptom of the illness and that increase the severity of the health condition are referred
to as concomitant symptoms. An example is nausea that may accompany the chief
symptom of pain. The nurse assesses the quality of the pain by asking the client to
describe the pain. The nurse obtains information about the location of the illness
through asking the client to identify the exact location. The nurse attempts to
understand the precipitating factors with questions about the activities that aggravate
the pain.
A client is prescribed intrathecal morphine to manage severe postoperative pain. Which
action should the nurse plan for the client's first 24 hours postoperatively? ANSWER
Respiratory rate monitoring hourly
Rationale: Intrathecal morphine depresses respiration depending on its rise in the
spinal column; hourly assessments for the first 12 to 24 hours will enable early
intervention with an antidote if respiratory depression needs correction. Bradycardia,
not tachycardia, and hypotension occur. It is too infrequent to administer naloxone
every 3 to 4 hours for this client whose respirations are depressed. The usual adult
dosage is 0.4 to 2 mg every 2 to 3 minutes, if indicated. CNS depression occurs
secondary to hypoxia.
Which of the following herbal therapies can be prescribed for a client experiencing
breast pain? Choose all that apply. One, some, or all options may be correct. - ANSWER
Chaste tree fruit, Bugleweed, Chamomile
Herbal therapies: Chamomile, bugleweed, and chaste tree fruit may be used for breast
tenderness. Dong quai is used for menstrual cramping and dysmenorrhea. Black
cohosh root relievesthe premenstrual aching and tension.
Which of the following is a sign of ulcer perforation in a client with peptic ulcer disease
(PUD)? (Select all that apply.) One, some, or all responses may be correct. ANSWER
Back and shoulder pain, Nausea and vomiting, Rigid abdomen, Hypotension,
Tachycardia
Explanation: Tachycardia and hypotension from fluid volume shifts from the vascular
compartment to the abdominal cavity are symptoms that may result from perforation of
an ulcer. The client with a perforated ulcer has a hard, rigid abdomen because of tensed
muscles and also nausea and vomiting. Irritation of the phrenic nerve can cause back
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