A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Clients self-report - Answer-d. Many ways to measure pain are in use, including numeric pain scales, behavioral...
NUR 202 Exam 4 Questions with Correct
Answers
A student asks the nurse what is the best way to assess a clients pain. Which response
by the nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Clients self-report - Answer-d. Many ways to measure pain are in use, including
numeric pain scales, behavioral assessments, and other objective observations.
However, the most accurate way to assess pain is to get a self-report from the client.
A new nurse reports to the precepting nurse that a client requested pain medication,
and when the nurse brought it, the client was sound asleep. The nurse states the client
cannot possibly sleep with the severe pain the client described. What response by the
experienced nurse is best?
a. Being able to sleep doesnt mean pain doesnt exist.
b. Have you ever experienced any type of pain?
c. The client should be assessed for drug addiction.
d. Youre right; I would put the medication back. - Answer-A. clients description is the
most accurate assessment of pain. The nurse should believe the client and provide pain
relief. Physiologic changes due to pain vary from client to client, and assessments of
them should not supersede the clients descriptions, especially if the pain is chronic in
nature. Asking if the new nurse has had pain is judgmental and flippant, and does not
provide useful information. This amount of information does not warrant an assessment
for drug addiction. Putting the medication back and ignoring the clients report of pain
serves no useful purpose.
A faculty member explains to students the process by which pain is perceived by the
client. Which processes does the faculty member include in the discussion? (Select all
that apply.)
a. Induction
b. Modulation
c. Sensory perception
d. Transduction
e. Transmission - Answer-b, c, d, e The four processes involved in making pain a
conscious experience are modulation, sensory perception, transduction, and
transmission.
A nursing student is studying pain sources. Which statements accurately describe
different types of pain? (Select all that apply.)
a. Neuropathic pain sometimes accompanies amputation.
b. Nociceptive pain originates from abnormal pain processing
.c. Deep somatic pain is pain arising from bone and connective tissues.
,d. Somatic pain originates from skin and subcutaneous tissues.
e. Visceral pain is often diffuse and poorly localized. - Answer-a, c, d, e Neuropathic
pain results from abnormal pain processing and is seen in amputations and
neuropathies. Somatic pain can arise from superficial sources such as skin, or deep
sources such as bone and connective tissues. Visceral pain originates from organs or
their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain
processing and consists of somatic and visceral pain.
A nurse teaches a client about performing intermittent self-catheterization. The client
states, I am not sure if I will be able to afford these catheters. How should the nurse
respond?
a. I will try to find out whether you qualify for money to purchase these necessary
supplies.
b. Even though it is expensive, the cost of taking care of urinary tract infections would
be even higher.
c. Instead of purchasing new catheters, you can boil the catheters and reuse them up to
10 times each.
d. You can reuse the catheters at home. Clean technique, rather than sterile technique,
is acceptable. - Answer-d. At home, clean technique for intermittent self-catheterization
is sufficient to prevent cystitis and other urinary tract infections. The nurse would refer
the client to the social worker to explore financial concerns. The nurse should not
threaten the client, nor should the client be instructed to boil the catheters.
A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention
should the nurse implement to assist with bladder dysfunction?
a. Insert an indwelling urinary catheter.
b. Stroke the medial aspect of the thigh.
c. Use the Cred maneuver every 3 hours.
d. Apply a Texas catheter with a leg bag. - Answer-c. Two techniques are used to
facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Cred
maneuver. Indwelling urinary catheters generally are not used because of the increased
incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates
voiding in clients with upper motor neuron problems. If the spinal cord injury is above
T12, the client is unaware of a full bladder and does not void or is incontinent.
Therefore, the client would not benefit from a Texas catheter with a leg bag.
A nurse teaches a client who has a flaccid bladder. Which bladder training technique
should the nurse teach?
a. Stroking the medial aspect of the thigh
b. Valsalva maneuver
c. Self-catheterization
d. Frequent toileting - Answer-b With a flaccid bladder, the voiding reflex arc is not intact
and additional stimulation may be needed to initiate voiding, such as with the Valsalva
and Cred maneuvers. Intermittent catheterization may be used after the previous
maneuvers are attempted. In reflex bladder, the voiding arc is intact and voiding can be
, initiated by any stimulus, such as stroking the medial aspect of the thigh. A consistent
toileting routine is used to re-establish voiding continence with an uninhibited bladder.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for
pressure ulcer development?
a. A 44-year-old prescribed IV antibiotics for pneumonia
b. A 26-year-old who is bedridden with a fractured leg
c. A 65-year-old with hemi-paralysis and incontinence
d. A 78-year-old requiring assistance to ambulate with a walker - Answer-c Being
immobile and being incontinent are two significant risk factors for the development of
pressure ulcers. The client with pneumonia does not have specific risk factors. The
young client who has a fractured leg and the client who needs assistance with
ambulation might be at moderate risk if they do not move about much, but having two
risk factors makes the 65-year-old the person at highest risk.
A nurse cares for a client who has a deep wound that is being treated with a wet-to-
damp dressing. Which intervention should the nurse include in this clients plan of care?
a. Change the dressing every 6 hours.
b. Assess the wound bed once a day.
c. Change the dressing when it is saturated.
d. Contact the provider when the dressing leaks. - Answer-a Wet-to-damp dressings are
changed every 4 to 6 hours to provide maximum dbridement. The wound should be
assessed each time the dressing is changed. Dry gauze dressings should be changed
when the outer layer becomes saturated. Synthetic dressings can be left in place for
extended periods of time but need to be changed if the seal breaks and the exudate
leaks.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse
evaluate for a wound infection?
a. Client with blood cultures pending
b. Client who has thin, serous wound drainage
c. Client with a white blood cell count of 23,000/mm3
d. Client whose wound has decreased in size - Answer-c A client with an elevated white
blood cell count should be evaluated for sources of infection. Pending cultures, thin
drainage, and a decrease in wound size are not indications that the client may have an
infection.
A nurse assesses a client who has a chronic wound. The client states, I do not clean the
wound and change the dressing every day because it costs too much for supplies. How
should the nurse respond?
a. You can use tap water instead of sterile saline to clean your wound.
b. If you dont clean the wound properly, you could end up in the hospital.
c. Sterile procedure is necessary to keep this wound from getting infected.
d. Good hand hygiene is the only thing that really matters with wound care. - Answer-a
For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable
and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes
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