Online Practice Test 46

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 46 > NCLEX® Review Date/Time Submitted: August 1, 2012 at 12:47 AM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		Which of the following is most important when assessing a client's pain? Your Answer: The client's perception of the pain
		Objective: Identify subjective and objective data to collect and analyze when assessing pain. Rationale: Pain is whatever the client perceives it is. The physical location of the pain, the client's vital signs, and the client's appearing uncomfortable are objective rather than subjective findings. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		When asked about pain, a client complains of having severe discomfort from arthritis. Vital signs are unchanged, and the client is calmly watching television. Which of the following nursing diagnoses is most appropriate? Your Answer: Altered sensory perception Correct Answer: Chronic pain
		Objective: Identify examples of nursing diagnoses for clients with pain. Rationale: Clients with chronic pain often live with their pain and show no outward signs. Clients with acute pain are more likely to show outward signs of pain. Those with chronic pain may not exhibit any overt signs, even when they experience severe pain. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
3.		A client with an acute bowel obstruction is having ischemic abdominal pain. This type of pain is best described as: Your Answer: Somatic Correct Answer: Visceral
		Objective: Identify examples of nursing diagnoses for clients with pain.  Rationale: Visceral best describes the client with an acute bowel obstruction having ischemic abdominal pain. Somatic is generalized body pain. Intractable is pain that cannot be relieved. Cutaneous is superficial pain. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		A postoperative client is prescribed acetaminophen (Tylenol) with codeine at discharge. When performing discharge teaching, the nurse:  Your Answer: Warns of signs of addiction Correct Answer: Recommends that the client take milk of magnesia at bedtime
		Objective: Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain. Rationale: Short-term use of codeine is not addicting. The client is instructed to take the medication as often as prescribed for pain. As the patient recovers, this will gradually decrease. There is no validity to the statement in Answer 3. Milk of Magnesia will prevent stomach discomfort, a common side effect of acetaminophen. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
5.		While waiting to perform x-rays on an injured right hand according to nonpharmacological pain management practice, pain can be modulated or reduced if the nurse: Your Answer: Applies ice to the right elbow
		Objective: Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain. Rationale: Applying ice to the right elbow can help reduce pain. Frequent assessment is important, but does not reduce pain. Answers 2 and 4 are not considered nonpharmacological pain management practices. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
6.		An 8-year-old client is crying with pain after a tonsillectomy. Which nursing intervention is most appropriate for this client? Your Answer: Hold him and provide comfort.
		Objective: Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain. Rationale: Holding and comforting the client while in pain is most appropriate. Children often regress in behavior when ill or in pain. Punishing, rewarding, or humiliating the child is not appropriate. Crying is an appropriate response to pain. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Decide what is the best action for client and situation
7.		Patient-controlled analgesia (PCA) effectiveness is evaluated by: Your Answer: The client's indicating that pain is a 1 on a scale of 1 to 10
		Objective: Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies. Rationale: PCA is evaluated by the client indicates that pain is a 1 on a scale of 1 to 10. Answer 1 is a preset safety interval set by the physician to prevent overdose. Many factors determine the size of the loading dose, including size of the patient, amount of medication already received, and degree of sedation. Clients in pain may still sleep. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		Severe cancer pain is most effectively treated with analgesics given: Your Answer: Around the clock, with extra doses available as needed
		Objective: Give an example of rational polypharmacy described by the American Pain Society. Rationale: Analgesics can be given around the clock as needed. A bolus may occasionally be needed for a flare-up of pain. Pain is better controlled if analgesia is given before pain returns. Analgesics are not limited in severe cancer pain. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		Both clients and nurses have misconceptions about pain. Which statement reflects a misconception?  Your Answer: Regular administration of analgesics leads to addiction.
		Objective: Differentiate tolerance, dependence, and addiction. Rationale: All of the answers are true statements except for Answer 4. The common misbelief that analgesics lead to addiction often prevents clients from receiving the best control of pain as possible. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		Following surgery, a client has great difficulty getting out of bed, walking, and coughing and deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used, even when suggested by the nurse. This concerns the nurse. Which statement is the best way to address this concern with the client?  Your Answer: "I noticed you haven't used your pain medication as often as you could, even though it is painful for you to get out of bed and to walk. Many people are reluctant to take pain medication. Tell me what makes you reluctant."
		Objective: Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies. Rationale: Pain sensation is not a reflection of one's bravery and strength. The point of PCA is to allow clients greater control over their pain medication, not less control. Scaring the client into taking pain medication is not an effective way to accomplish the goal of decreased pain. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.