The nurse has completed the initial assessment of a patient and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this patient's pulse pressure? • 44 mm Hg • 92 mm Hg • 114 mm Hg • 184 mm Hg • A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female patient. After meeting the patient and bringing her into the examination room, what instruction should the nurse provide? • ìI'll get you to lay down flat on the exam table, please.î • ìPlease have a seat on the edge of the exam table.î • ìI'll start the assessment with you standing up and then help you onto the table.î • ìWhere would you like me to conduct your health assessment?î • The nurse has assisted a 74-year-old woman from a chair to the examination table during an assessment, and the nurse observes that the patient moves particularly slowly and stiffly. The nurse should question the patient regarding a possible history of what health problem? • Rhabdomyolysis • Diabetes • Kyphosis Downloaded by: stephaniedimas | stephanie.dimas@gmail.com Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material • Arthritis • A community health nurse is conducting a home visit to a patient who requires wound care. The nurse observes that the patient is diaphoretic and wishes to measure the patient's temperature. The nurse asks if the patient has a thermometer in her home, and she states that she owns an ìear thermometer.î What principle should guide the nurse's use of a tympanic thermometer? • Tympanic temperature is slightly higher than oral temperature. • Tympanic temperature is only used if all other methods are unavailable. • Tympanic temperature varies more widely than oral, rectal, and axillary temperatures. • In adults, tympanic temperature is equal to axillary temperature. • The nurse palpates a patient's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding? • Call a code blue from the bedside and prepare for resuscitation. • Assess the patient's jugular venous pressure. • Assess the patient's pulse at the carotid site. • Palpate the patient's femoral pulse. • The nurse palpates a patient's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding? • Auscultate the patient's apical pulse. • Palpate the patient's ulnar pulse. • Administer a dose of nitroglycerin. • Reposition the patient in a side-lying position. A palliative care nurse is explaining the basis of pain to a group of nurses who provide care on a general medical unit. Which of the following factors would the nurse include? Select all that apply. • Physiologic • Psychosocial • Cutaneous • Somatic • Visceral • A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta primary afferent fibers transmit pain that is felt as which of the following? • Burning • Throbbing • Sharp • Aching • A nurse is assessing the pain of a patient who has had major surgery. The patient also has been experiencing depression. Which of the following principles should guide the nurse's assessment of a patient's pain? • The patient is likely experiencing less pain than he is reporting. • The patient's depression exists independently of the level of pain. Downloaded by: stephaniedimas | stephanie.dimas@gmail.com Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material • It is likely that the patient's pain rating will be influences by his emotional state. • The degree of surgery will be the key indicator for level of pain experienced. • A patient has received a diagnosis of chronic nonmalignant pain. The nurse who is planning this patient's nursing care should understand that this patient has experienced this pain for at least how many months? • 3 • 6 • 9 • 12 • A nurse educator is presenting an in-service program to a group of nurses who will be working on an oncology unit. Which of the following characteristics of cancer pain should the nurse describe? • Its basis is usually chronic neuropathy. • It is most often caused by a specific recent trauma. • It usually appears in the first month after cancer develops. • It is typically caused by compressed peripheral nerves. • A nurse is admitting a patient to the postsurgical unit following breast reconstruction surgery. Which of the following would the nurse use as the primary assessment for the patient's pain? • The patient's spiritual view of the pain • Current pain therapies used preoperatively • The patient's report of her pain • Psychosocial questions related to her perceptions of pain • The nurse is using the Verbal Descriptor Scale to assess a patient's pain. The nurse will prioritize which of the following data? • The patient's facial expressions • The patient's report on a 0 to 10 numeric scale • The patient's rating on a 0 to 10 visual analog scale • The patient's explanation of how her pain feels • The nurse collects vital signs on a hospital patient who has recently been experiencing pain. Which of the following would suggest most strongly to the nurse that the patient is experiencing pain? • Respiratory rate of 18 breaths per minute • Temperature of 99.1∞F Downloaded by: stephaniedimas | stephanie.dimas@gmail.com Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material • Heart rate of 110 beats per minute • Blood pressure of 120/70 mm Hg • Based on the analysis of assessment data from a patient with pain, the nurse writes a health promotion diagnosis. Which of the following diagnoses would be most appropriate? • Readiness for enhanced spiritual well-being related to coping with prolonged physical pain • Risk for activity intolerance related to chronic pain and immobility • Bathing self-care deficit related to severe pain • Chronic pain related to chronic inflammatory process of rheumatoid arthritis • A nurse is preparing to document a collaborative problem for a patient with pain. Which of the following would be most appropriate? • ìImpaired physical mobility related to chronic painî • ìRisk for powerlessness related to chronic painî • ìReadiness for enhanced comfort levelî • ìRC: peripheral nerve compressionî • The nurse is assessing a patient whose chronic pain is poorly controlled. Which assessment finding should the nurse expect under these circumstances? • Decreased heart rate • Hypoglycemia • Increased urinary output • Decreased gastric motility • A patient rates his pain as 9 on a scale of 1 to 10. The nurse would expect to assess which of the following? • Constricted pupils • Hypotension • Increased serum glucose • Flaccid muscles • The nurse is assessing a patient's pain. Which question would be most appropriate to ask the patient when the goal is to identify precipitating factors that might have exacerbated the pain? • ìWhat were you doing when the pain first stated?î • ìDo concurrent symptoms accompany the pain?î • ìWhen did the pain start?î • ìIs the pain continuous or intermittent?î Downloaded by: stephaniedimas | stephanie.dimas@gmail.com Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material • A patient has questioned why the nurse asked him how his family members usually treat their pain. Which of the following would be the most appropriate response by the nurse? • ìIt is just a way for me to more fully understand you and your upbringing.î • ìIt helps me to direct interventions toward your cultural history.î • ìIt helps me to determine how the family understands and perceives pain.î • ìIt will allow me to see if you are more likely to react to pain in a negative manner.î • When assessing pain in an older adult patient who is alert and oriented, which assessment tool would be most appropriate to use? • Numerical rating scale • Faces Pain Scale-Revised • FLACC Scale • Graphic rating scale • The nurse is observing a patient for evidence of pain. Which of the following would most likely lead the nurse to suspect that the patient may be experiencing pain? • Frequent questioning • Slumped posture • Eye contact • Periodic position changes • A nurse is creating a concept map of the pathophysiology of pain. The nurse should identify which of the following as being responsible for transmitting pain sensations to the central nervous system? • Transduction • Modulation • Nociceptors • Cytokines • A patient who has fractured her arm is describing her pain as ìexcruciating.î The nurse determines that the patient is most likely experiencing what type of pain? • Cutaneous • Visceral • Deep somatic • Radiating • The nurse is assessing the patient's perception of pain and the patient's description of its intensity and quality. Which dimension of pain is the nurse evaluating? • Physical Downloaded by: stephaniedimas | stephanie.dimas@gmail.com Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material • Sensory • Behavioral • Cognitive • When attempting to assess a patient's pain, which of the following actions should the nurse perform first? • Observe behaviors in the patient. • Obtain a patient self-report. • Search for possible causes of pain. • Ask family members about the patient's pain. • A hospital's protocols for assessment have been modified in light of standards established by the Joint Commission. What change would bring practice into alignment with these standards? • Teaching all new patients about the basic pathophysiology of pain • Assessing patients' pain objectively rather than subjectively • Identifying pain as the fifth vital sign and assessing patients accordingly • Triaging patients according to the type of pain that they are experiencing • An emergency department nurse is assessing a patient's complaint of upper abdominal pain. Using the COLDSPA mnemonic, with what assessment question would the nurse begin? • ìCan you describe to me how your pain feels?î • ìHow would you rate your pain on a 10-point scale?î • ìIs your pain affecting your ability to cope?î • ìWould you describe your pain as acute, or as chronic?î • A nurse is providing care for an 84-year-old patient who has diagnoses of middle-stage Alzheimer disease and a femoral head fracture. What assessment tool should the nurse use to assess the patient's pain? • Graphic Rating Scale • Numeric Rating Scale (NRS) • Verbal Descriptor Scale • Faces Pain Scale-Revised (FPS-R)