Solutions - Chapter 46 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. A client recovering from abdominal surgery refuses analgesia, saying that he is “fine, as long as he doesn’t move.” Which nursing diagnosis should be a priority?
1.  Deficient Knowledge (pain control measures)
2.  Ineffective Health Maintenance
3.  Risk for Ineffective Airway Clearance
4.  Impaired Physical Mobility
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1ACT. Is there any other assessment data you would want to gather to help plan Mr. C.'s pain management?
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1CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
What conclusions, if any, can be drawn about Mrs. Lundahl’s pain status?
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1TYK. During the transduction phase of nociception, which method of pain control is most effective?
1.  Tricyclic antidepressants
2.  Opioids
3.  Ibuprofen
4.  Distraction
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2ACT. Mr. C. does not have a PCA. What nursing interventions are important?
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2CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
Does Mrs. Lundahl’s rating her pain as 5 mean that she is not experiencing pain severe enough to warrant intervention?
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2TYK. When a client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments?
1.  Pain tolerance
2.  Pain intensity
3.  Location of pain
4.  Pain history
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3ACT. What kind of data would you gather prior to having a discussion with the primary care provider about options for improving pain control in this client?
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3CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
What type of pain is Mrs. Lundahl experiencing?
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3TYK. A client who describes his pain as 7 on a scale of 0 to 10 is classified as having which of the following?
1.  No pain
2.  Mild pain
3.  Moderate pain
4.  Severe pain
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4CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
What interventions, in addition to pain medication, may be useful in reducing Mrs. Lundahl’s pain?
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4TYK. A client who had abdominal surgery 4 hours ago is receiving a continuous epidural infusion of an analgesic. Which of the following observations indicates the nurse should monitor the client closely?
1.  Drowsy; drifts off to sleep before completing a sentence
2.  Respirations = 18/min
3.  Drowsy; easily aroused
4.  Pain rating 1-2/10
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5CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
How will you know if your interventions have been effective in reducing Mrs. Lundahl’s pain?
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5TYK. The client has an order of morphine 2.5 to 5.0 mg intravenous (IV) every 4 hours. He received 2.5 mg IV 4 hours ago for pain rated at 3 on a scale of 0 to 10. He is now watching television and visiting with family members. When asked about his pain, he rates it as a 5. His vital signs are stable. What nursing intervention is the most appropriate?
1. Give morphine 3.5 mg IV and inform him to continue watching TV because it is a distraction from the pain.
2.  Give 2.5 mg of morphine IV to avoid the client becoming addicted.
3.  Give nothing at this time because he is not exhibiting any signs of pain.
4.  Give morphine 5.0 mg IV and reassess in 20 minutes.
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6TYK. During an admission nursing assessment, a client with diabetes describes his leg pain as a “dull, burning sensation.” The nurse recognizes this description to be characteristic of which type of pain?
1.  Physiological
2.  Somatic
3.  Visceral
4.  Neuropathic
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7TYK. Which interventions, when implemented by the nurse, would apply the gate control theory of pain? Select all that apply.
1.  Oral analgesics around the clock
2.  Massage
3.  Patient-controlled analgesia
4.  Heat or cold application
5.  Acupressure
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8TYK. Which statement best reflects the nurse’s assessment of the fifth vital sign?
1.  “Do you have any complaints?”
2.  “Are you experiencing any discomfort right now?”
3.  “Is there anything I can do for you now?”
4.  “Do you have any complaints of pain?”
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9TYK. When planning care for pain control of older clients, which principles should the nurse apply? Select all that apply.
1.  Pain is a natural outcome of the aging process.
2.  Pain perception increases with age.
3.  The client may deny pain.
4.  The nurse should avoid use of opioids.
5.  The client may describe pain as an “ache” or “discomfort.”
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