Nokea
List and briefly describe the five dimensions of pain.
- A. Biological dimension: Physiological aspects of pain
- B. Behavioral dimension: Observable responses to pain
- C. Cognitive dimension: Thought processes related to pain
- D. Emotional dimension: Psychological reactions to pain
Correct Answer: A
Rationale: The correct answer includes all five dimensions: biological, behavioral, cognitive, emotional, and sociocultural.
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The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
- A. Cough and deep breathe every 2 hours.
- B. Place the client in contact isolation.
- C. Provide a diet high in protein.
- D. Institute seizure precautions.
Correct Answer: A
Rationale: Encouraging coughing and deep breathing helps prevent pulmonary complications.
Derek has recently converted his outdoor garage to a gym. He has been exercising frequently in his new gym due to the convenience, even in the extreme heat. He has started taking salt tablets. The physician thinks his current symptoms may be owing to hypernatremia. His physician recognizes these as:
- A. Cardiac arrhythmias,palpitations and sinus arrest.
- B. Weakness,dizziness,abdominal distention, nausea ,vomiting, and diarrhea.
- C. Weight gain,irritability,muscle twitching and decreased myocardial contractility.
- D. Muscle cramps,malaise,constipation,rhabdomyolysis and pupillary constriction.
Correct Answer: B
Rationale: The correct answer is Weakness, dizziness, abdominal distention, nausea, vomiting, and diarrhea (B). Hypernatremia occurs when there is an excess of sodium in the body, often due to dehydration or excessive salt intake. Symptoms include gastrointestinal disturbances, neurological symptoms like confusion and dizziness, and muscle weakness.
A healthcare provider is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the provider place at the client's bedside?
- A. Bag valve mask device
- B. Defibrillator machine
- C. Chest tube equipment
- D. Central venous catheter tray
Correct Answer: A
Rationale: The correct answer is A: Bag valve mask device. In the PACU, a client who received a competitive neuromuscular blocking agent may have impaired respiratory function. Placing a bag valve mask device at the bedside is crucial for providing immediate respiratory support if needed. This device allows manual ventilation in case of respiratory distress.
Summary:
- Choice B: Defibrillator machine is not necessary for a client receiving a competitive neuromuscular blocking agent.
- Choice C: Chest tube equipment is not typically needed for this situation.
- Choice D: Central venous catheter tray is not directly related to the respiratory support required for a client with impaired respiratory function.
Which task should be delegated to the LPN/LVN?
- A. Gently cleanse the amputated digits with Betadine solution
- B. Place the amputated digits directly into ice slurry
- C. Wrap the amputated digits in sterile gauze moistened with saline
- D. Store the amputated digits in a solution of sterile normal saline
Correct Answer: C
Rationale: Wrapping the digits in sterile gauze moistened with saline is a simple task that can be performed by an LPN/LVN.
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus.
- B. Opening the bottom of the pouch, allowing the flatus to be expelled.
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape.
- D. Assisting the client to ambulate to reduce the flatus in the pouch.
Correct Answer: B
Rationale: Opening the bottom of the pouch allows controlled release of flatus.