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A pregnant woman has received an epidural analgesic prior to delivery. Assessment for which outcome to the medication will the nurse prioritize?
- A. Pruritus
- B. Urinary retention
- C. Vomiting
- D. Respiratory depression
Correct Answer: D
Rationale: Respiratory depression (D) is the priority outcome to monitor with epidural opioids, as it is life-threatening. Pruritus, urinary retention, and vomiting (A, B, C) are less critical side effects.
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The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient?
- A. CRIES
- B. COMFORT
- C. FLACC
- D. FACES
Correct Answer: A
Rationale: The CRIES Pain Scale is designed for neonates and infants from 0 to 6 months (A), making it ideal for a NICU neonate. COMFORT (B) is for critically ill pediatric patients, FLACC (C) for infants and children 2 months to 7 years, and FACES (D) for children who can compare pain to facial expressions.
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.
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.
Based on the objective and subjective assessment of this patient, where should the nurse focus the initial efforts of the interprofessional team?
- A. Collaborating with the endocrinologist to manage the patient's blood glucose and A1c
- B. Consulting psychiatry to set up a medication regimen to treat the patient's anxiety and depression
- C. Working with the provider, the patient, and the patient's wife to address functional pain goals
- D. Providing detailed information on the microvascular and macrovascular complications of type 2 diabetes
Correct Answer: C
Rationale: The priority is addressing Carla's functional pain goals (C) to improve her quality of life, as her pain impacts her daily functioning and stress affects her diabetes management. While glucose control (A) and psychiatric consultation (B) are relevant, pain management is the immediate focus. Education on complications (D) is secondary to addressing current pain.
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.