58 Questions
What is the primary concern with opioid analgesics?
Respiratory depression and hypotension
What would the nurse suspect based on the assessment findings?
Opioid overdose
What should the nurse do first upon suspecting an opioid overdose?
Reassess the vital signs
What could cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation aside from opioid overdose?
Sleep
What is the appropriate action for the nurse after arousing the client?
Document the findings
When should the nurse contact the PHCP after suspecting an opioid overdose?
Immediately upon suspecting the overdose
Which method of measuring temperature should be avoided if the client has nasal congestion?
Oral temperature
What is an appropriate method of measuring temperature for a client who has undergone nasal surgery?
Rectal temperature
If a client just consumed coffee, what method of measuring temperature is acceptable?
Oral temperature
What is the least reliable method of measuring temperature?
Axillary temperature
Which method of measuring temperature is acceptable for a diaphoretic client if electronic equipment is available?
Measuring temperature on the forehead
What should be used if other, less invasive measures for measuring temperature are available?
Axillary temperature
What is the main purpose of mind-body therapies?
Enhancing the mind's capacity to affect bodily function and symptoms
Which of the following is NOT classified as a mind-body therapy?
Stationary exercise bicycle
What is the classification of Chamomile tea and IcyHot gel based on the text?
Herbal and topical thermal treatments
What is the main difference between acupuncture and attending church services in terms of therapy classification?
Acupuncture is a complementary therapy, while church services are religious prayer mind-body therapies.
Which statement describes a potential pain management plan for the 30-year-old male with acute pancreatitis?
IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen
Which route of administration is commonly used to deliver analgesics according to the text?
Intravenously (IV)
Based on the parents' statements, which action would indicate a need for further instruction?
Applying a small amount of white shoe polish on a soiled white cast
What is the most appropriate response by the nurse regarding exercise during painful periods in juvenile idiopathic arthritis?
Avoid all exercise during painful periods
In a child with abdominal distention and vomiting after spinal fusion for scoliosis, what would be the initial action by the nurse?
Notify the primary healthcare provider
What should the nurse prioritize when instructing parents of a child with scoliosis about brace use?
Using extra padding inside the brace for comfort
What is the main cause of superior mesenteric artery syndrome after surgical treatment of scoliosis?
Mechanical changes in abdominal contents
Why is it important to pay attention to postoperative vomiting in children with body casts or spinal fusion?
Due to the risk of superior mesenteric artery syndrome
Which syndrome does superior mesenteric artery syndrome mimic in terms of symptoms?
Intestinal obstruction
In what position should a child with superior mesenteric artery syndrome be placed after surgery?
Left lateral position
Which healthcare professional should be notified if signs of superior mesenteric artery syndrome are present in a child post-surgery?
Primary healthcare provider
What should be the focus of the nurse when analyzing client needs in a child with superior mesenteric artery syndrome post-surgery?
Physiological integrity analysis
Which nonpharmacologic therapy involves the application of herbs and vitamins?
Aloe vera
What nondrug therapy can be classified as a mind-body method for pain management?
Pilates
Which therapy involves the use of reiki for pain management?
Massage
What multimodal therapy for pain management uses guided imagery?
Meditation
Among the listed mind-body therapies, what is often used in pain management for relaxation?
Distraction techniques
What body-based modality is most suitable for pain relief through physical means?
Free weights
What should the nurse not assume about a client's pain?
The client is exaggerating the pain
Which BUN level would reflect continued dehydration in a client?
25 mg/dL (8.9 mmol/L)
Which physiological state may result in a lower-than-normal BUN value?
Fluid volume overload
What concept should be considered when evaluating a client's BUN level?
Hydration status
Why is it essential for nurses to focus on adequate fluid replacement in clients?
To maintain electrolyte balance
What should be the primary concern when analyzing a client's BUN level?
Hydration status
Which therapy is designed to enhance the mind's capacity to affect bodily function and symptoms?
Acupuncture
Which of the following is not classified as a mind-body therapy?
Hydrocodone
What is the main purpose of mind-body therapies?
Alleviate psychological distress
Which is an appropriate pain management plan for a 30-year-old male with acute pancreatitis?
IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen
What is the classification of acupuncture and attending church services in terms of therapy?
Religious prayer mind-body therapy and Chinese complementary therapy
In what category do stationary exercise bicycle, free weights, and spinning fall under?
Exercise therapies
Why is nasal congestion a reason to avoid taking an oral temperature?
It may cause respiratory distress during temperature measurement.
What is the normal range for activated partial thromboplastin time (aPTT)?
30-40 seconds
What is the therapeutic range for aPTT when a client is receiving heparin therapy?
45-100 seconds
Which statement accurately describes the therapeutic dose of heparin for deep vein thrombosis?
Maintain aPTT between 75 and 100 seconds.
What does an aPTT value of 65 seconds indicate about heparin therapy dosing?
The dose is within the therapeutic range.
How should the nurse interpret an aPTT value of 110 seconds in a client receiving heparin therapy?
The dose is supratherapeutic.
Which method of measuring temperature is the least reliable, and other methods should be used if available?
Axillary temperature
What is an acceptable method of measuring temperature for a diaphoretic client if electronic equipment is available?
Temperature on the neck behind the ear
In a client who just consumed coffee, which method of measuring temperature is acceptable?
Axillary temperature
Which route should be avoided for measuring temperature if the client has nasal congestion?
Oral temperature
If a client has undergone nasal surgery, what method of measuring temperature is appropriate?
Rectal temperature
What should be done if other, less invasive measures are available for measuring temperature?
Use ear temperature measurement
Study Notes
Non-Pharmacologic Strategies for Pain Relief
- Non-pharmacologic strategies for pain relief include body-based modalities (e.g., massage, acupuncture, heat and cold application) and mind-body methods (e.g., guided imagery, relaxation breathing, meditation).
- Multimodal therapies for pain management include Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat.
Mind-Body Therapies
- Mind-body therapies are designed to enhance the mind's capacity to affect bodily function and symptoms.
- Examples of mind-body therapies include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy.
- Acupuncture is an ancient Chinese complementary therapy that enhances the mind's capacity to affect bodily function and symptoms.
Pain Management Plan
- An appropriate pain management plan of care may include various medications, such as IV Dilaudid, hydrocodone, and acetaminophen.
- A variety of routes of administration are used to deliver analgesics.
Temperature Measurement
- An oral temperature should be avoided if the client has nasal congestion.
- Alternative methods of temperature measurement include rectal, axillary, and electronic temperature measurement.
Superior Mesenteric Artery Syndrome
- Superior mesenteric artery syndrome is a complication after surgical treatment of scoliosis.
- It is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body.
- Symptoms include vomiting and abdominal distention, similar to intestinal obstruction or paralytic ileus.
Nursing Care
- The nurse should take action when a child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting.
- Notification of the primary health care provider (PHCP) is necessary in this situation.
Learn the difference between mind-body therapies like meditation and relaxation techniques, and exercise therapies like stationary bikes and free weights. Test your knowledge on various therapies used to enhance the mind's capacity to affect bodily function.
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