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Test Bank Nursing Basics for Clinical Practice 1st Edition Berman Snyder McKinney

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Nursing Basics for Clinical Practice 1st Edition Berman Snyder McKinney Test Bank

ISBN-13: 978-0136035480

ISBN-10: 0136035485

 

Nursing Basics for Clinical Practice 1st Edition Berman Snyder McKinney Test Bank

ISBN-13: 978-0136035480

ISBN-10: 0136035485

 

 

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Berman Basics Chapter 18

 

 

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

 

1)

 

The nurse is caring for an 8-month-old infant. Which of the following is the best tool the nurse should use for evaluating pain in this infant?

 

  1. A)

 

FLACC scale

 

  1. B)

 

Wong-Baker FACES

 

  1. C)

 

Visual analog scale

 

  1. D)

 

Any of the above

 

Answer:

 

A

 

Explanation:

 

  1. A)

 

The FLACC scale has been validated in children from 2 months to 7 years old. Options B and C are not appropriate for this age child.

Assessment

Health Promotion and Maintenance

Analysis

 

  1. B)

 

The FLACC scale has been validated in children from 2 months to 7 years old. Options B and C are not appropriate for this age child.

Assessment

Health Promotion and Maintenance

Analysis

 

  1. C)

 

The FLACC scale has been validated in children from 2 months to 7 years old. Options B and C are not appropriate for this age child.

Assessment

Health Promotion and Maintenance

Analysis

 

  1. D)

 

The FLACC scale has been validated in children from 2 months to 7 years old. Options B and C are not appropriate for this age child.

Assessment

Health Promotion and Maintenance

Analysis

Learning Outcome 18-6

 

 

 

2)

 

The nurse is preparing to discharge a client home with a prescription for ibuprofen. Which of the following is a well-known side effect of this drug?

 

  1. A)

 

Tremors

 

  1. B)

 

Gastrointestinal (GI) bleeding

 

  1. C)

 

Rash

 

  1. D)

 

Shakiness

 

Answer:

 

B

 

Explanation:

 

  1. A)

 

Gastrointestinal bleeding is a well-known side effect of any NSAID, including ibuprofen.

Evaluation

Health Promotion and Maintenance

Knowledge

 

  1. B)

 

Gastrointestinal bleeding is a well-known side effect of any NSAID, including ibuprofen.

Evaluation

Health Promotion and Maintenance

 

Knowledge

 

  1. C)

 

Gastrointestinal bleeding is a well-known side effect of any NSAID, including ibuprofen.

Evaluation

Health Promotion and Maintenance

Knowledge

 

  1. D)

 

Gastrointestinal bleeding is a well-known side effect of any NSAID, including ibuprofen.

Evaluation

Health Promotion and Maintenance

Knowledge

Learning Outcome 18-9

 

 

 

3)

 

Which of the following objective assessment data does the nurse know to obtain before administering any opioid?

 

  1. A)

 

Pain level as stated by client

 

  1. B)

 

Any nausea the client might be feeling

 

  1. C)

 

Color of skin

 

  1. D)

 

Respiratory rate

 

Answer:

 

D

 

Explanation:

 

  1. A)

 

Opioids can depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Options A and B are both subjective data.

Assessment

Physiological Integrity

Analysis

 

  1. B)

 

Opioids can depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Options A and B are both subjective data.

Assessment

Physiological Integrity

Analysis

 

  1. C)

 

Opioids can depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Options A and B are both subjective data.

Assessment

Physiological Integrity

Analysis

 

  1. D)

 

Opioids can depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Options A and B are both subjective data.

Assessment

Physiological Integrity

Analysis

Learning Outcome 18-9

 

 

 

4)

 

The nurse is to administer acetaminophen (Tylenol) p.r.n. for a headache. The client has been vomiting all day. Which of the following routes should the nurse use to administer the medication?

 

  1. A)

 

Vaginal

 

  1. B)

 

Oral

 

  1. C)

 

Intravenous

 

  1. D)

 

Rectal

 

Answer:

 

D

 

Explanation:

 

  1. A)

 

The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Assessment

Physiological Integrity

Analysis

 

  1. B)

 

The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Assessment

Physiological Integrity

Analysis

 

  1. C)

 

The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Assessment

Physiological Integrity

Analysis

 

  1. D)

 

The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Assessment

Physiological Integrity

Analysis

Learning Outcome 18-9

 

 

 

5)

 

The nurse is caring for a client who underwent a left below-the-knee amputation. The client calls and asks the nurse for pain medication. The client informs the nurse he has left foot pain. What type of pain is the client describing?

 

  1. A)

 

Narcotic-induced pain

 

  1. B)

 

Acute pain

 

  1. C)

 

Phantom limb pain

 

  1. D)

 

Chronic pain

 

Answer:

 

C

 

Explanation:

 

  1. A)

 

When the amputation involves a limb, it is termed phantom limb pain.

Assessment

Physiological Integrity

Knowledge

 

  1. B)

 

When the amputation involves a limb, it is termed phantom limb pain.

Assessment

Physiological Integrity

Knowledge

 

  1. C)

 

When the amputation involves a limb, it is termed phantom limb pain.

Assessment

Physiological Integrity

Knowledge

 

  1. D)

 

When the amputation involves a limb, it is termed phantom limb pain.

Assessment

 

 

 

Physiological Integrity

Knowledge

Learning Outcome 18-9

 

 

 

6)

 

The nurse is providing discharge instructions to a client receiving an opioid. Which of the following measures can be used to decrease the risk of constipation?

 

  1. A)

 

Take an antihistamine three times per day.

 

  1. B)

 

Drink 6–8 glasses of water per day.

 

  1. C)

 

Assess respiratory rate before taking medication.

 

  1. D)

 

Assess heart rate before taking medication.

 

Answer:

 

B

 

Explanation:

 

  1. A)

 

Increasing fluid intake can help prevent constipation. Option A will not affect constipation. Options C and D are not interventions that will prevent constipation.

Evaluation

Physiological Integrity

Analysis

 

  1. B)

 

Increasing fluid intake can help prevent constipation. Option A will not affect constipation. Options C and D are not interventions that will prevent constipation.

Evaluation

Physiological Integrity

Analysis

 

  1. C)

 

Increasing fluid intake can help prevent constipation. Option A will not affect constipation. Options C and D are not interventions that will prevent constipation.

Evaluation

Physiological Integrity

Analysis

 

  1. D)

 

Increasing fluid intake can help prevent constipation. Option A will not affect constipation. Options C and D are not interventions that will prevent constipation.

Evaluation

Physiological Integrity

Analysis

Learning Outcome 18-10

 

 

 

7)

 

The nurse is caring for a client on a PCA pump with morphine. Which of the following medications should the nurse have readily available?

 

  1. A)

 

Normal saline

 

  1. B)

 

Naloxone hydrochloride (Narcan)

 

  1. C)

 

Acetaminophen (Tylenol)

 

  1. D)

 

Diphenhydramine hydrochloride (Benadryl)

 

Answer:

 

B

 

Explanation:

 

  1. A)

 

Narcan is an opioid antagonist, and should be readily available when a client is receiving an opioid.

Implementation

Physiological Integrity

Analysis

 

  1. B)

 

Narcan is an opioid antagonist, and should be readily available when a client is receiving an opioid.

 

 

 

Implementation

Physiological Integrity

Analysis

 

  1. C)

 

Narcan is an opioid antagonist, and should be readily available when a client is receiving an opioid.

Implementation

Physiological Integrity

Analysis

 

  1. D)

 

Narcan is an opioid antagonist, and should be readily available when a client is receiving an opioid.

Implementation

Physiological Integrity

Analysis

Learning Outcome 18-6

 

 

 

8)

 

The client is taking meperidine (Demerol) and experiencing pruritus. Which of the following medications would the nurse expect the physician to order?

 

  1. A)

 

Normal saline

 

  1. B)

 

Diphenhydramine hydrochloride (Benadryl)

 

  1. C)

 

Acetaminophen (Tylenol)

 

  1. D)

 

Naloxone hydrochloride (Narcan)

 

Answer:

 

B

 

Explanation:

 

  1. A)

 

When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

Implementation

Physiological Integrity

Analysis

 

  1. B)

 

When clients experience pruritus, an antihistamine, such as Benadryl, is ordered

Implementation

Physiological Integrity

Analysis

 

  1. C)

 

When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

Implementation

Physiological Integrity

Analysis

 

  1. D)

 

When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

Implementation

Physiological Integrity

Analysis

Learning Outcome 18-4

 

 

 

9)

 

The nurse is admitting a client to the Emergency Department with complaints of severe abdominal pain. What is the nurse’s first action?

 

  1. A)

 

Administer IV pain medication as ordered.

 

  1. B)

 

Place a Foley catheter to bedside drainage.

 

  1. C)

 

Assess pain using a scale of 1–10.

 

  1. D)

 

Start an IV line of lactated Ringer’s.

 

Answer:

 

C

 

Explanation:

 

  1. A)

 

Assessment should always occur before implementation.

Implementation

Physiological Integrity

Analysis

 

  1. B)

 

Assessment should always occur before implementation.

Implementation

Physiological Integrity

Analysis

 

  1. C)

 

Assessment should always occur before implementation.

Implementation

Physiological Integrity

Analysis

 

  1. D)

 

Assessment should always occur before implementation.

Implementation

Physiological Integrity

Analysis

Learning Outcome 18-5

 

 

 

10)

 

If a client is having cardiac pain, but relates that the pain is in the left shoulder and denies chest pain, this client is experiencing which of the following?

 

  1. A)

 

Referred pain

 

  1. B)

 

Visceral pain

 

  1. C)

 

Phantom pain

 

  1. D)

 

Chronic pain

 

Answer:

 

A

 

Explanation:

 

  1. A)

 

Referred pain appears to arise in different areas of the body, as can occur with cardiac pain.

Assessment

Physiological Integrity

Analysis

 

  1. B)

 

Referred pain appears to arise in different areas of the body, as can occur with cardiac pain.

Assessment

Physiological Integrity

Analysis

 

  1. C)

 

Referred pain appears to arise in different areas of the body, as can occur with cardiac pain.

Assessment

Physiological Integrity

Analysis

 

  1. D)

 

Referred pain appears to arise in different areas of the body, as can occur with cardiac pain.

Assessment

Physiological Integrity

Analysis

Learning Outcome 18-2

 

 

 

11)

 

If a client rates his pain a 7 on a scale of 0–10, the intensity of his pain would be documented as which of the following?

 

  1. A)

 

Severe pain

 

  1. B)

 

Physiological pain

 

  1. C)

 

Moderate pain

 

  1. D)

 

Mild pain

 

Answer:

 

A

 

Explanation:

 

  1. A)

 

Severe pain is rated a 7 of 10 on a scale of 0–10.

Assessment

Physiological Integrity

Knowledge

 

  1. B)

 

Severe pain is rated a 7 of 10 on a scale of 0–10.

Assessment

Physiological Integrity

Knowledge

 

  1. C)

 

Severe pain is rated a 7 of 10 on a scale of 0–10.

Assessment

Physiological Integrity

Knowledge

 

  1. D)

 

Severe pain is rated a 7 of 10 on a scale of 0–10.

Assessment

Physiological Integrity

Knowledge

Learning Outcome 18-10

 

 

 

12)

 

The nurse is caring for a client presenting to the Emergency Department with a possible sprained ankle. This client most likely is experiencing what type of pain?

 

  1. A)

 

Severe pain

 

  1. B)

 

Somatic pain

 

  1. C)

 

Visceral pain

 

  1. D)

 

Mild pain

 

Answer:

 

B

 

Explanation:

 

  1. A)

 

Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut and aching of a sprained ankle are common examples of somatic pain.

Assessment

Physiological Integrity

Analysis

 

  1. B)

 

Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut and aching of a sprained ankle are common examples of somatic pain.

Assessment

Physiological Integrity

Analysis

 

  1. C)

 

Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut and aching of a sprained ankle are common examples of somatic pain.

Assessment

Physiological Integrity

Analysis

 

  1. D)

 

Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut and aching of a sprained ankle are common examples of somatic pain.

 

 

 

 

Assessment

Physiological Integrity

Analysis

Learning Outcome 18-2

 

 

 

13)

 

The client scheduled to undergo a minor surgery states, “The physician will not give me pain medication after surgery because my surgery is only minor.” The best response by the nurse is:

 

  1. A)

 

“You can experience pain after minor surgery, so you can have pain medication.”

 

  1. B)

 

“You can only have about half the dose, since your surgery is minor.”

 

  1. C)

 

“You are correct. I will need to teach you nonpharmacologic pain-relief measures.”

 

  1. D)

 

“You are correct. The physician will not order any pain medication.”

 

Answer:

 

A

 

Explanation:

 

  1. A)

 

Clients can experience intense pain after minor surgery, so pain medication may be ordered.

Implementation

Physiological Integrity

Analysis

 

  1. B)

 

Clients can experience intense pain after minor surgery, so pain medication may be ordered.

Implementation

Physiological Integrity

Analysis

 

  1. C)

 

Clients can experience intense pain after minor surgery, so pain medication may be ordered.

Implementation

Physiological Integrity

Analysis

 

  1. D)

 

Clients can experience intense pain after minor surgery, so pain medication may be ordered.

Implementation

Physiological Integrity

Analysis

Learning Outcome 18-3

 

 

 

14)

 

The nurse is performing discharge teaching for a client taking an NSAID. The client states that he has heard taking an antacid with this medication will help decrease the incidence of upset stomach. The nurse’s best response is:

 

  1. A)

 

“Antacids reduce the absorption and therefore the effectiveness of the NSAID.”

 

  1. B)

 

“Antacids help to reduce the incidence of gastric bleeding that could occur with the use of NSAIDs.”

 

  1. C)

 

“Antacids help to reduce the incidence of pain.”

 

  1. D)

 

“Antacids should never be taken with an NSAID.”

 

Answer:

 

A

 

Explanation:

 

  1. A)

 

Option A is the best answer. It is documented that the use of antacids can reduce the risk of gastric distress,

 

 

 

 

 

 

 

 

 

 

but can also reduce the absorption and the effectiveness of the medication.

Evaluation

Physiological Integrity

Analysis

 

  1. B)

 

Option A is the best answer. It is documented that the use of antacids can reduce the risk of gastric distress, but can also reduce the absorption and the effectiveness of the medication.

Evaluation

Physiological Integrity

Analysis

 

  1. C)

 

Option A is the best answer. It is documented that the use of antacids can reduce the risk of gastric distress, but can also reduce the absorption and the effectiveness of the medication.

Evaluation

Physiological Integrity

Analysis

 

  1. D)

 

Option A is the best answer. It is documented that the use of antacids can reduce the risk of gastric distress, but can also reduce the absorption and the effectiveness of the medication.

Evaluation

Physiological Integrity

Analysis

Learning Outcome 18-10

 

 

 

15)

 

The nurse is admitting a client who gave birth 2 hours ago. The client has an epidural catheter in place. Which of the following should be immediately reported to the physician?

 

  1. A)

 

Pulse rate: 80

 

  1. B)

 

Respiratory rate: 8

 

  1. C)

 

Blood pressure: 120/80

 

  1. D)

 

Pain rating of 4 on scale of 1–10

 

Answer:

 

B

 

Explanation:

 

  1. A)

 

A respiratory rate below 8 should be reported immediately. Options A and C are normal. Option D does not require the nurse to notify the physician.

Evaluation

Physiological Integrity

Analysis

 

  1. B)

 

A respiratory rate below 8 should be reported immediately. Options A and C are normal. Option D does not require the nurse to notify the physician.

Evaluation

Physiological Integrity

Analysis

 

  1. C)

 

A respiratory rate below 8 should be reported immediately. Options A and C are normal. Option D does not require the nurse to notify the physician.

Evaluation

 

 

Physiological Integrity

Analysis

 

  1. D)

 

A respiratory rate below 8 should be reported immediately. Options A and C are normal. Option D does not require the nurse to notify the physician.

Evaluation

Physiological Integrity

Analysis

Learning Outcome 18-5

 

 

 

16)

 

The client is admitted to the Emergency Department with complaints of abdominal pain. The client denies any nausea or vomiting. When asked, the client states that the pain started 2 hours ago and describes the pain as “cramping.” The client most likely is experiencing what type of pain?

 

  1. A)

 

Acute pain

 

  1. B)

 

Phantom pain

 

  1. C)

 

Visceral pain

 

  1. D)

 

Chronic pain

 

Answer:

 

A

 

Explanation:

 

  1. A)

 

Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

Assessment

Physiological Integrity

Analysis

 

  1. B)

 

Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

Assessment

Physiological Integrity

Analysis

 

  1. C)

 

Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

Assessment

Physiological Integrity

Analysis

 

  1. D)

 

Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

Assessment

Physiological Integrity

Analysis

Learning Outcome 18-1

 

 

 

17)

 

While conducting a pain assessment, the nurse knows to assess which of the following? Select all that apply.

 

  1. Duration
  2. Location
  3. Intensity
  4. Etiology
  5. Neurology

 

Answer:

 

1; 2; 3; 4

 

Explanation:

 

Pain can be described in terms of location, duration, intensity, and etiology.

Assessment

Physiologic Integrity

 

 

Knowledge

Learning Outcome 18-6

 

 

 

18)

 

The nurse is obtaining a comprehensive pain history on a client admitted with complaints of continuous low back pain. Which of the following should be included in the history? Select all that apply.

 

  1. Pain location
  2. Intensity
  3. Quality
  4. Alleviating factors
  5. Past pain experiences
  6. Effect on ADLs

 

Answer:

 

1; 2; 3; 4; 5; 6

 

Explanation:

 

All options should be obtained in the comprehensive pain history.

Assessment

Physiologic Integrity

Knowledge

Learning Outcome 18-6

 

 

 

20)

 

The nurse is caring for a client with a continuous local anesthetic. Which of the following interventions will the nurse perform?

 

  1. Assess for pain every 2–4 hours while the client is awake.
  2. Change dressing every 2–4 hours.
  3. Check the dressing every shift.
  4. Assess for signs of toxicity.
  5. Check the site of the catheter.

 

Answer:

 

1; 3; 4; 5

 

Explanation:

 

The dressing is not usually changed, in order to avoid dislodging the catheter.

Implementation

Physiologic Integrity

Analysis

Learning Outcome 18-8

 

 

 

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