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Med Surg ATI F-41 and 36 final
Terms in this set (10)
A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine?
A. presence of associated manifestations
B. location of the pain
C. pain quality
D. aggravating and relieving factors
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the clients pain?
A. ask the client what precipitates the pain
B. question the client about the location of the pain
C. offer the client a pain scale to measure their pain
D. use open-ended questions to identify the client's pain sensations.
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the nurse identify as experiencing chronic pain?
A. a client who has a broken femur and reports hip pain
B. a client who has incisional pain 72hr after pacemaker insertion
C. a client who has food poisoning and reports abdominal cramping
D. a client who has episodic back pain following a fall 2 years ago
A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids?
A. urinary incontinence
D. orthostatic hypotension
C, D, E
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
A. "Ill wait to use the device until its absolutely necessary"
B. "Ill be careful about pushing the button too much so I don't overdose"
C. "I should tell the nurse if the pain doesn't stop while I am using this device"
D. "I will ask mu adult child to push the dose button while im sleeping"
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADL's. Which of the following rationales for self-care should the nurse communicate with the family?
A. allowing the client to function independently will strengthen muscles and promote healing
B. the client needs privacy at times for self-reflecting and organizing life
C. the clients sense of loss can be lessened through retaining control of some areas of life
D. performing ADLs is a requirement prior to discharge from an acute care facility
A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through the surgery and quit smoking, if I could just live long enough to attend my Childs wedding," which of the stages of Kubler-Ross model of grief?
A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? SATA
A. "would you like me to contact the chaplain to come and speak to you?"
B. "you will feel better soon. you have been expecting this for a while now"
C. "lets talk about your children and how they are going to react"
D. "you know, it is quite normal to feel anger toward your loved one at this time"
E. "tell me more about how you are feeling"
A, D, E
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse state?
A. regular breathing patterns
B. warm extremities
C. increased urine output
D. decreased muscle tone
A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? SATA
A. remove the dentures from the body
B. make sure the body is lying completely flat
C. apply fresh linens and place a clean gown on the body
D. remove all equipment from the bedside
E. dim the lights in the room
C, D, E
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