CH 31 Pain, Comfort and Sleep

The nurse assesses a patient's sleep for NREM (non-rapid eye movement) sleep because this sleep has the characteristics of:

1. daytime activity.

2. offering the most rest.

3. irregular respirations.

4. increased heart rate.

ANS: B

NREM sleep is the stage of sleep when the body receives the most rest.

DIF: Cognitive Level: Comprehension REF: p. 609

OBJ: Theory #5

TOP: NREM Sleep

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient experiencing discomfort because of severe arthritis would be described as having pain.

1. acute

2. chronic

3. phantom

4. episodic

ANS: B

arthritis.

Chronic pain is pain in which symptoms are controlled, but there is no cure, such as in

DIF:

Cognitive Level: Comprehension

OBJ: Clinical Practice #2

REF: p. 594

TOP: Types of Pain

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient is beginning treatment for pain with a transcutaneous electrical nerve stimulator

(TENS) unit. The nurse will initially:

1. apply conductive jelly to uncoated electrodes.

2. turn the unit on before attaching it to the patient.

3. place electrodes on all four extremities.

4. adjust the settings below the level at which a tingling sensation is felt.

ANS: A

Conductive jelly is applied to electrodes that are not precoated to assure conductivity.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #4

REF: p. 601

TOP: TENS

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by:

1. increasing warmth to the incision site.

2. keeping sutures and staples in place.

3. supporting surface and internal tissues.

4. adding back support to enhance early ambulation.

ANS: C

Binders are cloths wrapped around a limb or body part that have an incision and are effective in reducing pain associated with strains, sprains, and surgical incisions by providing support to the surface of the area as well as the internal tissues.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #4

REF: p. 601

TOP: Pain Control

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse evaluating the effectiveness of an Aquathermia K pad for the leg is aware that the patient who has the least risk for burn injury from this device would be the patient with:

1. impaired peripheral circulation.

2. severely sprained ankle.

3. decreased level of consciousness from a stroke.

4. neuritis secondary to diabetes.

ANS: B

Patients with poor circulation, impaired movement or feeling, or decreased level of consciousness are more at risk for injury from burns when applications of heat are used.

DIF: Cognitive Level: Analysis

OBJ: Clinical Practice #4

REF: p. 602

TOP: Heat Application

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

A nurse caring for a patient who suffered a severe sprain and has an order for a cold pack application to the injured area would prevent patient injury by:

1. using heavy pressure on the cold pack for greater effectiveness.

2. preparing to apply heat instead if cold is not effective.

3. leaving the pack in place for over 30 minutes at a time.

4. placing a towel between the pack and the skin.

ANS: D

A protective towel or pad should be placed between the pack and the skin to avoid cold injury.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #4

REF: p. 602

TOP: Cold Application

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

A nurse is instructing a patient about relaxation techniques for pain management. The patient should:

1. keep bright lights on in the room.

2. use this technique as a way to wake up in the morning.

3. tense and relax individual muscle groups, starting with the toes and feet.

4. try to tense and relax all of the muscles of the body at the same time.

ANS: C

Relaxation involves alternately tensing and relaxing the toes and feet, then working upward through the leg, the abdomen, the chest, the arms, and finally, the neck and head.

DIF: Cognitive Level: Comprehension

REF: p. 602

TOP: Relaxation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

OBJ: Theory #4

A patient is receiving an ice massage for relief of muscle spasms in the neck. The patient complains that the ice is making the pain worse. Most helpful response from the nurse would be:

1. "I know it is uncomfortable right now, but it will get better in a few minutes."

2. "I will go get an ice pack to pace on your neck."

3. "The alteration of hot and cold application is very helpful for your spasms."

4. "I will stop these cold applications. Not everyone is helped by them."

ANS: D

Cold applications make some patients experience an increase in discomfort.

DIF: Cognitive Level: Analysis

REF: p. 602

OBJ: Theory #4

TOP: Ice Application

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient experiencing pain states that guided imagery has made the pain more manageable in the past. To assist this patient, the nurse should:

1. find a focal point in the room.

2. bring a newspaper or deck of cards according to patient choice.

3. obtain skin lotion and a towel to give a back rub.

4. read from a script that helps the patient visualize a restful place.

ANS: D

Persons who have difficulty with imagery can be assisted by someone reading a script to help a patient mentally travel to a favorite spot that is relaxing, soothing, or peaceful.

DIF: Cognitive Level: Application

REF: p. 603

TOP: Imagery

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Basic Care and Comfort

OBJ: Theory #4

The nurse takes into consideration that when the patient has an order for a patient-controlled analgesia (PCA) the pump will be programmed by the:

1. registered nurse.

2. primary care provider.

3. LPN/LVN.

4. pharmaceutical company.

ANS: A

PCA pumps are programmed by the RN or the pharmacist. The primary care provider's order will specify the size of the dose and the minimum time between doses.

DIF: Cognitive Level: Knowledge

REF: p. 606

TOP: Chiropractic KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ:

Theory #4

The nurse is aware that the new order for indomethacin (Indocin) involves the administration of a(n):

1. COX-2 inhibitor.

2. adjuvant analgesic.

3. narcotic analgesic.

4. nonsteroidal anti-inflammatory medication.

ANS: D

Indomethacin is a nonsteroidal anti-inflammatory (NSAID) drug which requires a prescription.

DIF: Cognitive Level: Knowledge

OBJ:

Clinical Practice #4

REF: p. 604

TOP: Indomethacin

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

The nurse appreciates the principal advantage in using patient-controlled analgesia (PCA) is that it:

1. reduces patient anxiety about pain by giving the patient more control in its management.

2. reduces the workload of the nurse, because it does not have to be checked often.

3. eliminates the risk of adverse drug effects from the medication.

4. completely eliminates any pain the patient is experiencing.

ANS: A

A principal advantage of PCA is that it reduces anxiety about pain, because patients are in control of their pain medication within machine set limits.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #5

REF: p. 605

TOP: PCA

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words and is unsteady when ambulating. The nurse should:

1. put up the side rails on the bed.

2. elevate the head of the bed 45 degrees and offer coffee or cola drink.

3. remove the patch and wipe off the skin.

4. apply ice to skin around the patch.

ANS: C

When overdose signs occur with Fentanyl patches, the patch should be removed, the skin cleansed and the problem documented and reported to the charge nurse or primary care provider.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #6

REF: p. 605

TOP: Fentanyl Patch

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

A nurse is assisting in the care of a patient who is receiving pain medication by the epidural route. It is most important to monitor this patient for which adverse drug effects?

1. Constipation

2. Headache

3. Nausea

4. Hypoventilation

ANS: D

Respiratory depression is a potentially dangerous side effect of epidural analgesia, and a patient receiving this type of pain medication requires frequent monitoring of respiratory rate.

DIF: Cognitive Level: Comprehension REF: p. 607

OBJ: Clinical Practice #6

TOP: Epidural Pain Control

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

A patient with an epidural catheter needs to have the dressing at the insertion site changed.

When cleaning the insertion site with povidone iodine swabs, the nurse should:

1. use a circular motion working from the insertion site outward.

2. use a circular motion working from the outside to the insertion site.

3. start above the insertion site and swab in a downward motion.

4. start below the insertion site and swab in an upward motion.

ANS: A

Proper aseptic technique includes starting at the center (the insertion site) and working outward using a circular motion.

DIF: Cognitive Level: Application

REF: p. 608

OBJ: Clinical Practice #5

TOP: Epidural Catheter

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

A nurse is assessing the status of a patient who is sleeping. Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?

1. Rapid respirations, rapid heart rate

2. Rapid respirations, slow heart rate

3. Decreased respirations, slow heart rate

4. Decreased respirations, rapid heart rate

ANS: C

Stage 3 of NREM sleep, in which respirations and heart rate slow, is similar to a coma; it is also called delta sleep or slow wave sleep because of the high-voltage slow brain waves that

occur.

DIF: Cognitive Level: Comprehension REF: p. 609

TOP: Sleep

KEY: Nursing Process Step: Assessmen

ISC: NCLEX: Physiological Integrity: Basic Care and Comfor

OBJ: Theory #7

The nurse recommends that normal sleepatchesp patterns can best be acquired by suggesting to the patient that they:

1. smoke cigarettes.

2. drink wine.

3. take a nap during the day.

4. exercise in the mornings.

ANS: D

Maintaining a regular exercise schedule not too close to bedtime helps a person sleep.

DIF: Cognitive Level: Comprehension

REF: p. 610

TOP: Sleep

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #8

A sleeping patient has periodic pauses in breathing, then starts to breathe again. The nurse recognizes this sleep pattern is consistent with:

1. insomnia.

2. sleep apnea.

3. narcolepsy.

4. excessive NREM sleep.

ANS: B

Sleep apnea is a condition in which the person stops breathing for brief periods during sleep.

DIF: Cognitive Level: Analysis

TOP: Sleep

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #8

Ref: pp. 610

The suggestion by the nurse which is most helpful to a patient who complains of chronically not feeling rested after sleep would be:

1. avoid going to bed hungry or overly full.

2. try to exercise just before going to bed.

3. sleep late the next morning if possible if you are tired on awakening.

4. take a nap during the day to help relieve overall fatigue.

ANS: A

Going to bed hungry or with a full stomach can interfere with sleep.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #8

REF: p. 611

TOP: Sleep Disturbances

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The most helpful intervention by the nurse for a hospitalized child who is having difficulty falling asleep would be to:

1. keep a night light on in the room.

2. turn off all the lights in the room.

3. have the parents bring a favorite blanket or pillow from home.

4. give of juice and cookies before being put to bed.

ANS: C

Many patients sleep better when they can have a favorite blanket or pillow from home.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #8

REF: p. 611

TOP: Sleep

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient who has difficulty falling asleep at night because of anxiety over family problems asks if he should start taking sedative pills from the pharmacy to sleep better. The best advice to give this patient is that these pills can be used for:

1. long periods of time, but it is best to check with the primary care provider first.

2. short periods of time, but it is best to check with the primary care provider first.

3. long periods of time without primary care provider approval, because they are nonprescription medications.

4. short periods of time without physician approval, because they are nonprescription medications.

ANS: B

Sedative and hypnotic medications can be used to promote sleep, but they should be used for short-term relief and only after a primary care provider has been consulted.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #8

REF: p. 612

TOP: Sleep

KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

A natural supplement that can enhance sleep for many people is:

1. melatonin.

2. calcium

3. magnesium.

4. oil of lavender.

ANS: A

Melatonin, a natural supplement, can enhance sleep hours for many people. Calcium and magnesium are used to relieve leg cramps.

DIF:

Cognitive Level: Knowledge

OBJ:

Clinical Practice #8

KEY: Nursing Process Step: N/A

REF: p. 612

TOP: Natural Sleep Aid

MSC: NCLEX: N/A

The nurse takes into consideration the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) standards for pain assessment and treatment include:

1. pain treatment is based on objective data collected by the nurse.

2. pain treatment ends at discharge.

3. pain is assessed only for patients who complain of pain.

4. all patients have the right to appropriate assessment of pain.

ANS: D

The JCAHO standards related to pain state that all patients have a right to appropriate assessment and management of pain and should be educated in the process prior to discharge.

DIF: Cognitive Level: Knowledge

REF: p. 594

TOP: JCAHO

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #1

A relative complains that an older adult patient takes frequent naps late in the day and awakens frequently during the night, and wants to know if this is normal. The nurse explains that an older adult:

1. will awaken more often during the night, but may nap more often during the day.

2. needs at least 10 hours of sleep a day to prevent fatigue.

3. requires less napping during the day to sleep better at night.

4. should be given hypnotics to induce better sleep.

ANS: A

Sleep habits are very individualized, but normally, as an adult age, sleep may be less at night with more naps being taken late in the day.

DIF: Cognitive Level: Comprehension

REF: p. 609

TOP: Sleep Needs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #6

A nurse explains that endorphins are capable of reducing pain:

1. as a naturally occurring morphine like enzyme.

2. in conditions that are physiological only.

3. by attaching to opioid receptors.

4. when psychological stressors are the cause of pain.

ANS: C

Endorphins are naturally occurring opiate like peptides which attach to the opioid receptors of nerve endings and bock pain transmission. Endorphins are effective against both physiologically and psychologically causes of pain.

DIF: Cognitive Level: Comprehension REF: p. 595

TOP: Endorphins KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #4

A nurse is preparing a patient for home care following cancer treatment.

He is discussing the use of the fentanyl patch.

Which of the following would be the most important instruction regarding safety?

1. Apply as directed by the primary care provider.

2. Store fentanyl patches in a locked cabinet.

3. Prepare the skin by cleaning with an antiseptic scrub solution.

4. Use as needed for break through pain.

ANS: B

Several deaths have been reported from children either fentanyl swallowing the patches or applying them to their skin. Teach the patient to keep the patches away from children, locked up is possible.

DIF: Cognitive Level: Analysis

TOP: Medical Methods of Pain Control

MSC: NCLEX: QSEN: Safety

REF: p. 605

OBJ: Clinical #1 and #2

KEY: Nursing Process Step: Implementation

The nurse outlines the four phases of nociceptive pain as: (Select all that apply.)

1. translation.

2. transduction.

3. transmission.

4. modulation.

5. perception.

ANS: B, C, D, E

The four phases of nociceptive pain are transduction, transmission, perception, and modulation.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #1

REF: p. 597

TOP: Nociceptive Pain

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse attempts to help an 86-year-old patient describe his pain because the nurse is aware the older adult may not express pain because they: (Select all that apply.)

1. are unaware of their discomfort.

2. believe pain is a natural consequence to aging.

3. are reluctant to bother the nursing staff.

4. have been culturally trained not to complain.

5. tear taking pain medication.

ANS: B,C, D

Older adults often do not verbalize their pain out of the mistaken belief that pain is part of aging. They are reluctant to "bother" the staff and have been culturally trained not to complain.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #1

REF: p. 598

TOP: Pain in the Older Adult

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse performing a focused assessment on pain will assess: (Select all that apply.)

1. history of pain.

2. verbal indicators.

3. psychological factors.

4. culture.

5. contributing factors.

ANS: A, B, C, E

Factors to be assessed in a focused assessment of pain are the history, verbal and nonverbal indicators, psychological and other contributing factors, medication, and treatments used.

Although culture may limit a person's ability to express pain, it is not an important issue on a focused assessment.

DIF: Cognitive Level: Comprehension

REF: p. 598

OBJ: Clinical Practice #1

TOP: Focused Pain Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

__________is considered to be the fifth vital sign.

ANS:

Pain

Pain assessment is now performed along with each assessment of vital signs, and pain is now considered the fifth vital sign

DIF: Cognitive Level: Knowledge

REF: p. 594

TOP: Pain

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #2

A type of pain that is of short duration, lasting from a few hours to a few days, is known as__________pain.

ANS: acute

Acute pain is of short duration, lasting from a few hours to a few days.

DIF: Cognitive Level: Knowledge

REF: p. 594

OBJ: Clinical Practice #2

TOP: Pain

KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

The ___________ is based on the premise that by stimulating large diameter nerve fibers pain is diminished or totally controlled.

ANS:

Gate Control Theory

The Gate Control Theory is based on the premise that by stimulating large diameter nerve fibers by massage or vibration the "gate" to pain perception is closed against the pain impulses from the small diameter nerve fibers.

DIF: Cognitive Level: Knowledge

TOP: Gate Control Theory

MSC: NCLEX: N/A

REF: p. 595

OBJ: Theory #3

KEY: Nursing Process Step: N/A

A pain scale FLACC is used in assessing pain in_____________.

ANS:

preverbal children and noncommunicacive adults

FLACC stands for Face, Legs, Activity, Cry, and Consolability, which are assessed to estimate the pain in preverbal infants.

DIF: Cognitive Level: Knowledge

OBJ: Clinical Practice #1

REF: p. 599

TOP: Pain in Infants

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

Travelers can combat "jet lag" by exposure to_____________for several hours.

ANS: sunlight

Exposure to sunlight for several hours will help "reset" a traveler's internal clock and reduce the effects of jet lag.

DIF: Cognitive Level: Comprehension

REF: p. 610

OBJ: Clinical Practice #6

TOP: Jet Lag

KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

A nurse removed a pain medication patch that has a metal clip before the patient goes to have a(n)________________.

ANS:

MRI

All metal must be removed from persons who are going to have an MRI.

DIF: Cognitive Level: Application

REF: p. 605

OBJ: Theory #4

TOP: MRI Consideration

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control