Nokea
A nurse is assessing a patient receiving a continuous opioid infusion. For which outcome of treatment would the nurse immediately notify the primary care provider?
- A. A respiratory rate of 11/min with normal depth
- B. A sedation level of 4
- C. Mild forgetfulness
- D. Reported constipation
Correct Answer: B
Rationale: A sedation level of 4 (somnolent, minimal/no response) indicates risk of respiratory depression, requiring immediate provider notification and possible naloxone (B). A respiratory rate of 11/min (A) is not alarming, and forgetfulness or constipation (C, D) are less urgent.
You may also like to solve these questions
A nurse in a rehabilitation facility is evaluating patients with chronic pain to develop an interprofessional plan of care. Which patients would the nurse identify who could benefit from a multimodal approach to pain management? Select all that apply.
- A. Patient receiving chemotherapy for bladder cancer
- B. Adolescent who had an appendectomy
- C. Patient who is experiencing a ruptured aneurysm
- D. Patient with fibromyalgia requesting pain medication
- E. Patient having back pain related to an accident that occurred last year
- F. Patient experiencing pain from second-degree burns
Correct Answer: A,D,E
Rationale: Chronic pain, lasting beyond the normal healing period, benefits from a multimodal approach. Patients with cancer pain (A), fibromyalgia (D), and chronic back pain (E) fit this criterion. Appendectomy (B) and burns (F) typically involve acute pain, and a ruptured aneurysm (C) is an emergency requiring immediate intervention.
A nurse plans to promote a patient's natural pain mediators by using a whirlpool following intensive physical therapy to the legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques?
- A. Prostaglandins
- B. Substance P
- C. Endorphins
- D. Serotonin
Correct Answer: C
Rationale: Endorphins are powerful pain-blocking neuromodulators released through relaxation techniques like whirlpool therapy (C). Prostaglandins and substance P (A, B) enhance pain transmission, and serotonin (D) primarily affects mood and smooth muscle function.
When assessing pain in a child, the nurse needs to be aware of what considerations?
- A. Immature neurologic development results in reduced pain sensation
- B. Inadequate or inconsistent relief of pain is widespread
- C. Reliable assessment tools are currently unavailable
- D. Narcotic analgesic use should be avoided
Correct Answer: B
Rationale: Inadequate or inconsistent pain relief in children is a widespread issue (B). Children feel pain, reliable assessment tools exist, and opioids can be used safely with careful monitoring, making A, C, and D incorrect.
A nurse is caring for patients who are nonverbal. What are examples of behavioral responses to pain? Select all that apply.
- A. Cradling a wrist that was injured in a car accident
- B. Moaning and crying from abdominal pain
- C. Increasing pulse following a myocardial infarction
- D. Striking out at a nurse who attempts to provide a bath
- E. Acting depressed and withdrawn while experiencing chronic cancer pain
- F. Pulling away from a nurse trying to give an injection
Correct Answer: A,B,D,F
Rationale: Behavioral responses include cradling an injured area (A), moaning and crying (B), striking out (D), and pulling away (F). Increased pulse (C) is a physiologic response, and depression/withdrawal (E) is an affective response.
Based on this information, the provider decides to add pharmacologic strategies to the plan of care. Which interventions are the priority for Carla? Select all that apply.
- A. Provide information about a multimodal pain regimen
- B. Focus on the side effects of high-dose immediate-release opioids
- C. Discuss the significant risk for addiction with Carla and her wife
- D. Teach adjuvant medications such as gabapentin for treatment of neuropathic pain
- E. Integrate elements from the biopsychosocial model when designing interventions
Correct Answer: A,D,E
Rationale: Priority interventions include educating about a multimodal pain regimen (A), teaching about adjuvant medications like gabapentin for neuropathic pain (D), and integrating biopsychosocial elements (E) to address Carla's chronic pain holistically. Focusing on high-dose opioid side effects (B) or addiction risks (C) is less relevant, as Carla prefers avoiding pain medications and no high-dose opioids are indicated.