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When preparing a patient for sleep dimming the lights and decreasing the noise levels are examples of nursing interventions. What are these interventions designed to do?
- A. Mimic usual sleep patterns.
- B. Decrease environmental stimuli.
- C. Prepare the patient for sleep.
- D. Provide for more rest.
Correct Answer: B
Rationale: Environmental stimuli should be decreased when preparing the patient for sleep.
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The nurse is using a pain scale of 0 to 10 to assess pain in a postoperative patient. What is considered the maximum pain level at which a patient can usually function effectively?
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: C
Rationale: Most patients do not function effectively if the pain level exceeds 4 on a scale of 10.
The nurse teaches noninvasive pain relief techniques such as guided imagery biofeedback and relaxation. What is the primary advantage of these techniques?
- A. Can be done any time.
- B. Does not require a nurse.
- C. Gives the patient some control.
- D. Is most effective.
Correct Answer: C
Rationale: The greatest advantage of noninvasive pain relief techniques is that they give the patient some control.
A patient tells the nurse he is reluctant to report his pain because he does not want to be a bother. What problems is the nurse aware that unrelieved pain can cause?
- A. Decreased oxygen demand
- B. Depression
- C. Respiratory dysfunction
- D. Decreased GI motility
- E. Irritability
Correct Answer: B,C,D,E
Rationale: Pain, which is unrelieved, can cause many physical and psychological symptoms, including depression, respiratory dysfunction, decreased GI motility, and irritability. Pain causes increased oxygen demand.
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.
The nurse obtains information from a patient about the site severity and duration of the pain. What type of data is this considered?
- A. Patient data
- B. Objective data
- C. Focused data
- D. Subjective data
Correct Answer: D
Rationale: Information from the patient concerning site, severity, and duration of the pain is subjective data that only the patient knows.