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Although denying pain a patient is irritable responds slowly and exhibits periods of tachycardia. What should the nurse assess for in this patient?
- A. Electrolyte imbalance
- B. Allergic response
- C. Sleep deprivation
- D. Constipation
Correct Answer: C
Rationale: With sleep deprivation, patients may experience a variety of physiologic and psychological symptoms.
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Which documentation sample is the most helpful to share assessment findings and pain relief interventions?
- A. 1600: Patient reports chest pain. Medicated with morphine sulfate.
- B. 1600: Patient reports sharp chest pain. Morphine sulfate given IM.
- C. 1600: Patient reports sharp pain in left chest radiating to neck. Morphine sulfate 5 mg administered IM in right deltoid.
- D. 1600: Patient requested medication for pain in left chest. Morphine sulfate 10 mg PO given.
Correct Answer: C
Rationale: The nurse should record subjective information relative to the pain, as well as the intervention and administration route.
A patient is receiving epidural analgesics. What should the nurse monitor closely in this patient?
- A. Temperature elevation from 98°F to 99.2°F (36.6°C to 37.3°C)
- B. Increase in pulse rate from 88 to 99
- C. Decrease in respirations from 16 to 14
- D. Decrease in blood pressure from 120/80 to 110/68
Correct Answer: C
Rationale: Administering epidural analgesics requires close monitoring for respiratory depression. None of the other options is indicative of opiate toxicity.
A nurse is caring for a patient who requires long-term management for severe pain. What should be the drug of choice for this patient?
- A. Aspirin
- B. Morphine
- C. Oxycodone
- D. Acetaminophen
Correct Answer: B
Rationale: Morphine and hydromorphone are the opioids of choice for long-term management of severe pain.
The nurse is giving a backrub to a patient to relieve pain. What pain theory is the nurse using?
- A. Synergism
- B. Gate control
- C. Distraction
- D. Guided imagery
Correct Answer: B
Rationale: The pressure of a backrub will close the gate, according to the gate control theory of pain.
A male patient reports to the home health nurse that he does not feel rested although he has slept 8 hours. For what should the nurse assess?
- A. Having vivid dreams
- B. Eating a heavy meal before going to bed
- C. Consuming an excessive amount of alcohol
- D. Taking an anxiolytic medication
Correct Answer: D
Rationale: Anxiolytic (antianxiety) medications interfere with REM sleep, which is when people achieve full rest.