Concept 28 Pain Combo PDF

Concept 28: Pain combo Giddens: Concepts for Nursing Practice, 3rd Edition MULTIPLE CHOICE 1. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain? a. Neuropathic pain...

Concept 28: Pain combo Giddens: Concepts for Nursing Practice, 3rd Edition MULTIPLE CHOICE 1. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain? a. Neuropathic pain b. Nociceptive pain c. Chronic pain d. Mixed pain syndrome ANS: B Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A 19-year-old male has sustained a transection of C-7 in a motor vehicle crash rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing? a. Neuropathic pain b. Visceral pain c. Eudynic pain d. Nociceptive pain ANS: A Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with neuropathic pain use very distinctive words to describe their pain, such as “burning,” “sharp,” and “shooting.” Visceral pain arises from the body cavities and responds to stretching, swelling and decreased oxygen levels. Eudynic pain refers to the normal transmission of pain via nociceptive receptors. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping or throbbing. OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 3. Controlling pain is important to promoting wellness. Unrelieved pain has been associated with complication? a. Prolonged stress response and a cascade of harmful effects system-wide b. Large tidal volumes and decreased lung capacity c. Decreased tumor growth and longevity d. Decreased carbohydrate, protein, and fat destruction ANS: A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response. OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 4. An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis (OA) pain. You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include which actions or activities? a. Pilates, breathing exercises, and aloe vera b. Guided imagery, relaxation breathing, and meditation c. Herbs, vitamins, and tai chi d. Alternating ice and heat to relieve pain and inflammation ANS: C Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins. OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A 70-year-old retired patent is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should the nurse consider in the plan of care considering the patient’s expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services ANS: B Mind-body therapies are designed to enhance the mind’s capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mindbody therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind’s capacity to affect bodily function and symptoms. OBJ: NCLEX Client Needs Category: Psychosocial Integrity 6. A 30-year-old male is admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include which medication(s)? a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen b. Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours c. Phenergan 25 mg IM q 6 hours d. Tylenol 325 mg q 6 hours ANS: A A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations. For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal. Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10. OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioid doses q 4 hours. What is the nurse’s first action? a. Call the rapid response team to care for the patient immediately. b. Discontinue the opioids on the medication administration record. c. Assess the patient’s blood pressure and pain level. d. Start a second intravenous line with a large bore catheter. ANS: A After establishing unresponsiveness, the next action is to call a Rapid Response. The patient is not able to subjectively describe pain if unresponsive. Another IV line may be needed, but first the nurse should call for help. The opioids should be discontinued on the MAR; however the priority action is to call for help. OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation Saunders Pain 1. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin 2. A nurse is precepting a new graduate nurse, and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. “I will be sure to ask my client what their pain level is on a scale of 0 to 10.” 2. “I know that I should follow up after giving medication to make sure it is effective.” 3. “I will be sure to cue in to any indicators that the client may be exaggerating pain.” 4. “I know that pain in the older client might manifest as sleep disturbances or depression.” 3. A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 1. 3 mg/dL (1.08 mmol/L) 2. 15 mg/dL (5.4 mmol/L) 3. 29 mg/dL (10.44 mmol/L) 4. 35 mg/dL (12.6 mmol/L) 4. The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature for a client who has just consumed hot coffee 4. Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic 5. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is 6. A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client’s laboratory report, would the nurse report before administering the dose of furosemide? 1. 3.2 mEq/L (3.2 mmol/L) 2. 3.8 mEq/L (3.8 mmol/L) 3. 4.2 mEq/L (4.2 mmol/L) 4. 4.8 mEq/L (4.8 mmol/L) 7. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results would the nurse report? Select all that apply. 1. Platelets 35,000 mm3 (35 × 109/L) 2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 mcmol/L) 6. White blood cells, 3000 mm3 (3.0 × 109/L) 8. The nurse is assessing a client who takes ibuprofen for pain. The nurse is gathering information on the client’s medication history and determines it is necessary to notify the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Atorvastatin 9. A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia 10. The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would implement neutropenic precautions if the client’s white blood cell count was which value? 1. 2000 mm3 (2.0 × 109/L) 2. 5800 mm3 (5.8 × 109/L) 3. 8400 mm3 (8.4 × 109/L) 4. 11,500 mm3 (11.5 × 109/L) 11. A client with a history of atrial fibrillation brought to the emergency department has accidentally been taking two times the prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? 1. Prepare to administer an antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thromboplastin time (aPTT) level. 4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR). 12. The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client’s room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action would the nurse take first? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the primary health care provider (PHCP). 4. Check the medication administration history on the PCA pump. 13. A client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client’s history? 1. Dehydration 2. Heart failure 3. Iron-deficiency anemia 4. Chronic obstructive pulmonary disease 14. A client with peptic ulcer disease and a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would plan to take which action after seeing the laboratory results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client’s medical record. Answers 1. Answer: 2 Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high, the nurse would anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect. Test-Taking Strategy: Focus on the subject, a PT of 35 seconds. Recall the normal range for this value and remember that a PT greater than 25 seconds places the client at risk for bleeding; this will direct you to the correct option. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Clinical Judgment/Cognitive Skill: Generate Solutions Content Area: Foundations of Care: Laboratory Tests Health Problem: Adult Health: Cardiovascular: Dysrhythmias Priority Concepts: Clinical Judgment; Clotting Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. p. 599. 2. Answer: 3 Rationale: Pain is a highly individual experience, and the new graduate nurse would not assume that the client is exaggerating pain. Rather, the nurse would frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse would assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain. The nurse would follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently from pain experienced by clients in other age-groups. Older clients with pain may experience sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse needs to be aware of this attribute in this population. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement as the answer. Recall that pain is a highly individual experience, and the nurse would not assume that the client is exaggerating pain. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Skills: Vital Signs Clinical Judgment/Cognitive Skill: Evaluate Outcomes Health Problem: Adult Health: Neurological: Pain Priority Concepts: Clinical Judgment; Pain Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. pp. 107-108. 3. Answer: 2 Rationale: The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.08 mmol/L) reflects a lower-than-normal value, which may occur with fluid volume overload, among other conditions. Test-Taking Strategy: Focus on the subject, adequate fluid replacement and the normal BUN level. The correct option is the only option that identifies a normal value. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Foundations of Care: Laboratory Tests Clinical Judgment/Cognitive Skill: Evaluate Outcomes Health Problem: Adult Health: Gastrointestinal: Dehydration Priority Concepts: Fluids and Electrolytes; Leadership Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. p. 1632. 4. Answer: 2 Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used, according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If electronic equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect action as the answer. Recall that nasal congestion is a reason to avoid taking an oral temperature, as the nasal congestion will cause problems with breathing while the temperature is being taken. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Skills: Vital Signs Clinical Judgment/Cognitive Skill: Evaluate Outcomes Health Problem: N/A Priority Concepts: Teaching and Learning; Thermoregulation Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing. (10th ed.). St. Louis: Elsevier. p. 468. 5. Answer: 4 Rationale: The normal aPTT varies between 30 and 40 seconds (30 and 40 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 times (45 to 60) and 2.5 times (75 to 100) normal. This means that the client’s value should not be less than 45 seconds or greater than 100 seconds. Thus, the client’s aPTT is within the therapeutic range and the dose should remain unchanged. Test-Taking Strategy: Focus on the subject, the expected aPTT for a client receiving a heparin sodium infusion. Remember that the normal range is 30 to 40 seconds and that the aPTT should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy. Simple multiplication of 1.5 and 2.5 by 30 and 40 will yield a range of 45 to 100 seconds. This client’s value is 65 seconds. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Foundations of Care: Laboratory Tests Clinical Judgment/Cognitive Skill: Generate Solutions Health Problem: Adult Health: Cardiovascular: Vascular Disorders Priority Concepts: Clinical Judgment; Clotting Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. p. 599. 6. Answer: 1 Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range. Test-Taking Strategy: Note the subject of the question, the level that needs to be reported. This indicates that you are looking for an abnormal level. Remember, the normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). This will direct you to the correct option. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Foundations of Care: Laboratory Tests Clinical Judgment/Cognitive Skill: Take Action Health Problem: Adult Health: Cardiovascular: Heart Failure Priority Concepts: Clinical Judgment; Fluids and Electrolytes Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. pp. 279-280. 7. Answer: 1, 2, 4, 6 Rationale: The normal values include the following: platelets 150,000 to 400,000 mm3 (150 to 400 × 109/L); sodium 135 to 145 mEq/L (135 to 145 mmol/L); potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); segmented neutrophils 62% to 68% (0.62 to 0.68); serum creatinine male: 0.6 to 1.2 mg/dL (53 to 106 mcmol/L); female: 0.5 to 1.1 mg/dL (44 to 97 mcmol/L); and white blood cells 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low. Test-Taking Strategy: Focus on the subject, the abnormal laboratory values that need to be reported. Knowledge of the normal laboratory values for the blood studies identified in the options will assist in answering this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Clinical Judgment/Cognitive Skill: Take Action Content Area: Foundations of Care: Laboratory Tests Health Problem: N/A Priority Concepts: Clinical Judgment; Collaboration Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. pp. 599, 1631, 1633. 8. Answer: 1, 2, 3 Rationale: Nonsteroidal antiinflammatory drugs (NSAIDs) can amplify the effects of anticoagulants; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral antidiabetic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination should be avoided. There is no known interaction between ibuprofen and simvastatin or atorvastatin. Test-Taking Strategy: Note the subject of the question, data provided by the client necessitating contacting the PHCP. Determining that ibuprofen is classified as an NSAID will help you determine that it should not be combined with anticoagulants. Also recalling that hypoglycemia can occur as an adverse effect if taken with antidiabetic agents will help you recall that these medications should not be combined. From the remaining options, it is necessary to remember that toxicity can result if NSAIDs are combined with calcium channel blockers. Also note that options 4 and 5 are comparable or alike and are antilipemic medications. This will assist in eliminating these options. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Skills: Vital Signs Clinical Judgment/Cognitive Skill: Take Action Health Problem: Adult Health: Neurological: Pain Priority Concepts: Clinical Judgment; Safety Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. p. 111. 9. Answer: 4 Rationale: The normal reference range for the glycosylated hemoglobin A1c is less than 5.7%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for the past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 183 mg/dL (10.1 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. Test-Taking Strategy: Focus on the subject, a glycosylated hemoglobin A1c level of 8%. Recalling the normal value and that an elevated value indicates hyperglycemia will assist in directing you to the correct option. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Foundations of Care: Laboratory Tests Clinical Judgment/Cognitive Skill: Generate Solutions Health Problem: Adult Health: Endocrine: Diabetes Mellitus Priority Concepts: Client Education; Glucose Regulation Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. pp. 1112-1113. 10. Answer: 1 Rationale: The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client’s values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values. Test-Taking Strategy: Focus on the subject, the need to implement neutropenic precautions. Recalling what neutropenic precautions involve and that the normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L) will direct you to the correct option. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Foundations of Care: Laboratory Tests Clinical Judgment/Cognitive Skill: Take Action Health Problem: Adult Health: Cancer: Breast Priority Concepts: Clinical Judgment; Infection Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. p. 1633. 11. Answer: 4 Rationale: The nurse would plan to draw a sample for PT and INR level to determine the client’s anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy. Test-Taking Strategy: Focus on the subject, a client who has taken an excessive dose of warfarin. Eliminate the option with aPTT first because it is unrelated to warfarin therapy and relates to heparin therapy. Next, eliminate the options indicating to administer an antidote and to transfuse the client because these therapies would not be implemented unless the PT and INR levels were known. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Foundations of Care: Laboratory Tests Clinical Judgment/Cognitive Skill: Generate Solutions Health Problem: Adult Health: Cardiovascular: Dysrhythmias Priority Concepts: Clinical Judgment; Clotting Reference: Ignatavicius, D., Workman, M. Rebar, C., & Heimgartner, N. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. pp. 787-788. 12. Answer: 2 Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse would suspect opioid overdose. The nurse would first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused, because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse would also check to see how much medication has been taken via the PCA pump and would continue to monitor the client closely to determine whether further action is needed. The nurse would contact the PHCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client. Test-Taking Strategy: First, note the strategic word, first. Focus on the data in the question and determine if an abnormality exists. It is clear that an abnormality exists because the client is drowsy and the vital signs are outside of the normal range. Recall that attempting to arouse the client would come before further assessment of the pump. The client would always be assessed before the equipment, before contacting the PHCP, and before documentation. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Skills: Vital Signs Clinical Judgment/Cognitive Skill: Take Action Health Problem: Adult Health: Neurological: Pain Priority Concepts: Clinical Judgment; Pain Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. pp. 114 – 115. 13. Answer: 3 Rationale: The normal hemoglobin level for an adult ranges from 12 to 18 g/dL (120 to 180 g/L). Iron-deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body’s need for more oxygen-carrying capacity. Test-Taking Strategy: Note the strategic words, most likely. Evaluate each of the conditions in the options in terms of their pathophysiology and whether each is likely to raise or lower the hemoglobin level. Also, note the relationship between hemoglobin level in the question and the correct option. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Foundations of Care: Laboratory Tests Clinical Judgment/Cognitive Skill: Analyze Cues Health Problem: Adult Health: Hematological: Anemias Priority Concepts: Clinical Judgment; Gas Exchange Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Mosby. p. 599. 14. Answer: 4 Rationale: A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). The nurse should place the report containing the normal laboratory value in the client’s medical record. A platelet count of 300,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed. Test-Taking Strategy: Focus on the subject, a platelet count of 300,000 mm3 (300 × 109/L). Remember that options that are comparable or alike are unlikely to be correct. With this in mind, eliminate options 1 and 3 first, to report the abnormally low count and to place the client on bleeding precautions. From the remaining options, recalling the normal range for this laboratory test will direct you to the correct option. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Foundations of Care: Laboratory Tests Clinical Judgment/Cognitive Skill: Generate Solutions Health Problem: Adult Health: Gastrointestinal: Peptic Ulcer Disease Priority Concepts: Clinical Judgment; Clotting 1. A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action would the nurse take? 1. Administer an analgesic. 2. Release the skin traction. 3. Apply ice to the extremity. 4. Notify the primary health care provider (PHCP). 2. A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and would include which intervention? 1. Ensure that all ropes are outside the pulleys. 2. Ensure that the weights are resting lightly on the floor. 3. Restrict diversional and play activities until the child is out of traction. 4. Check the primary health care provider’s (PHCP’s) prescriptions for the amount of weight to be applied. 3. A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm, and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child’s cast. Which statement by the parents indicates a need for further instruction? 1. “The cast may feel warm as the cast dries.” 2. “I can use lotion or powder around the cast edges to relieve itching.” 3. “A small amount of white shoe polish can touch up a soiled white cast.” 4. “If the cast becomes wet, a blow-dryer set on the cool setting may be used to dry the cast.” 4. The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse would make which response? 1. “Avoid all exercise during painful periods.” 2. “Range-of-motion exercises must be performed every day.” 3. “Have the child perform simple isometric exercises during this time.” 4. “Administer additional pain medication before performing rangeof-motion exercises.” 5. A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse would take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a left lateral position. 4. Notify the primary health care provider (PHCP). 6. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? 1. “I will encourage my child to perform prescribed exercises.” 2. “I will have my child wear soft fabric clothing under the brace.” 3. “I need to apply lotion under the brace to prevent skin breakdown.” 4. “I need to avoid the use of powder because it will cake under the brace.” 7. The nurse is assisting a primary health care provider (PHCP) in the examination of a 3-week-old infant with developmental dysplasia of the hip. What test or sign would the nurse expect the PHCP to assess? 1. Babinski’s sign 2. The Moro reflex 3. Ortolani’s maneuver 4. The palmar-plantar grasp 8. A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding would be noted in this condition? 1. Limited range of motion in the affected hip 2. An apparent lengthened femur on the affected side 3. Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed 4. Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table 9. Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? 1. “Treatment needs to be started as soon as possible.” 2. “I realize my infant will require follow-up care until fully grown.” 3. “I need to bring my infant back to the clinic in 1 month for a new cast.” 4. “I need to come to the clinic every week with my infant for the casting.” 10. The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions would be included on the list? Select all that apply. 1.Use the fingertips to lift the cast while it is drying. 2.Keep small toys and sharp objects away from the cast. 3.Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4.Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5.Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6.Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity. Answers 1. Answer: 4 Rationale: An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the PHCP needs to be notified immediately. Administering analgesics would not improve circulation. The skin traction would not be released without a PHCP’s prescription. Applying ice to an extremity with absent perfusion will worsen the problem. Ice may be prescribed when perfusion is adequate to decrease swelling. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. Focus on the data in the question, which indicate that circulation is impaired. This will direct you to the correct option. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Clinical Judgment/Cognitive Skill: Take Action Content Area: Complex Care: Emergency Situations/Management Health Problem: Pediatric-Specific: Fractures Priority Concepts: Clinical Judgment; Perfusion Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. pp. 1264-1265. 2. Answer: 4 Rationale: When a child is in traction, the nurse would check the PHCP’s prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of complications of immobilization. The nurse would provide therapeutic and diversional play activities for the child. Test-Taking Strategy: Focus on the subject, care of the child in traction. Eliminate option 3 first because of the word restrict. Next recall the general principles related to traction, recalling that weights need to hang freely and that ropes would remain in the pulleys. Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Clinical Judgment/Cognitive Skill: Generate Solutions Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Fractures Priority Concepts: Mobility; Safety Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. p. 1254. 3. Answer: 2 Rationale: Teaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements and indicate that the parents understand cast care. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Remember that lotions or powders can become sticky or caked and cause skin irritation. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Evaluate Outcomes Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Fractures Priority Concepts: Patient Education; Skin Integrity Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. pp. 1252-1253. 4. Answer: 3 Rationale: Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement. Test-Taking Strategy: Focus on the subject, exercise during an acute exacerbation of the disease. Eliminate options 1 and 2 because of the closed-ended words “all” and “must,” and option 4 because of the word additional. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Take Action Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Juvenile Idiopathic Arthritis Priority Concepts: Mobility; Pain Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. p. 1289. 5. Answer: 4 Rationale: Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Focus on the data in the question and think about the complications that can occur after surgical treatment for scoliosis. Eliminate option 2 first because it would not be implemented unless prescribed by the PHCP. Eliminate option 3 next because this child requires logrolling, and the left lateral position may cause injury after surgery. From the remaining options, note the assessment signs and symptoms in the question. These would alert you that notification of the PHCP is necessary. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Clinical Judgment/Cognitive Skill: Take Action Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Scoliosis Priority Concepts: Clinical Judgment; Collaboration Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. pp. 689, 1278. 6. Answer: 3 Rationale: A brace may be prescribed to treat scoliosis. Braces are not curative but may slow the progression of the curvature to allow skeletal growth and maturity. The use of lotions or powders under a brace needs to be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Careful reading of the options and applying the principles associated with cast care will direct you to the correct option. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Evaluate Outcomes Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Scoliosis Priority Concepts: Patient Education; Mobility Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. p.1298. 7. Answer: 3 Rationale: In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani’s maneuver is a test to assess for hip instability and can be done only before 4 weeks of age. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A “clicking” sensation indicates a dislocated femoral head moving into the acetabulum. Babinski’s sign is abnormal in anyone older than 2 years of age and indicates central nervous system abnormality. The Moro reflex is normally present at birth but is absent by 6 months; if still present at 6 months, there is an indication of neurological abnormality. The palmar-plantar grasp is present at birth and lessens within 8 months. Test-Taking Strategy: Options 1 and 2 can be eliminated first because they are comparable or alike and are both tests of neurological function. To select the correct answer from the remaining options, remember that Ortolani’s maneuver is an assessment technique for hip dysplasia that can only be done before 4 weeks of age. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Developmental Dysplasia of Hip Priority Concepts: Clinical Judgment; Mobility Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. p.1280. 8. Answer: 1 Rationale: In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip when the child is placed supine with the knees and hips flexed would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity. Test-Taking Strategy: Note the subject, assessment findings in developmental dysplasia of the hip. Also, note the age of the infant and focus on the infant’s diagnosis. Visualizing each of the assessment findings described in the options will direct you to the correct option. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Developmental Dysplasia of Hip Priority Concepts: Development; Mobility Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. p. 1280. 9. Answer: 3 Rationale: Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. This will assist you in eliminating options 1 and 2. Recalling that serial manipulations and casting are required weekly will assist in directing you to the correct option. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Evaluate Outcomes Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Clubfoot Priority Concepts: Patient Education; Mobility Reference: Hockenberry, M., Wilson, D., & Rodgers, C. (2019). Wong’s nursing care of infants and children. (11th ed.). St. Louis: Elsevier. p. 1284. 10. Answer: 2, 5, 6 Rationale: While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the PHCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the PHCP would be notified. Test-Taking Strategy: Use of the ABCs—airway, breathing, and circulation—and safety principles related to care of a child with a cast will assist in answering this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Clinical Judgment/Cognitive Skill: Generate Solutions Content Area: Pediatrics: Musculoskeletal Health Problem: Pediatric-Specific: Fractures Priority Concepts: Patient Education; Safety