Choice A rationale:

This statement is not indicative of an understanding of pain control. The client's concern about addiction may lead to undermedication, potentially compromising pain management. Opioid addiction is a valid concern but should be addressed separately from pain control.

Choice B rationale:

This statement demonstrates the client's understanding of pain control. The client acknowledges the need to call for pain medication when their pain becomes intolerable, which is an appropriate and effective approach to managing pain. It ensures that the client receives timely relief while preventing excessive medication use.

Choice C rationale:

Waiting for the nurse to evaluate pain before requesting more medication may result in inadequate pain management. Pain is subjective, and the client's perception is the most crucial factor in determining when pain medication is needed. Waiting for a nurse to evaluate may lead to delays in providing relief.

Choice A rationale:

This statement is not accurate and may confuse the client. In a Patient-Controlled Analgesia (PCA) system, a predetermined dose is delivered when the patient activates the device. The dose is usually controlled to prevent excessive medication administration.

Choice B rationale:

This statement is correct. The essence of PCA is that the patient has control over administering their pain medication within set limits or time intervals. The patient can self-administer doses when needed, ensuring effective pain management.

Choice C rationale:

Allowing the partner to push the PCA button for the patient is not recommended. PCA systems are designed to be controlled by the patient themselves to prevent potential overdosing. Involving someone else in the administration can lead to safety concerns.

Choice D rationale:

PCA systems do not deliver medication into the muscle. They typically deliver medication intravenously (IV) or subcutaneously. This statement is inaccurate and could lead to misconceptions about how the PCA system works.

Choice A rationale:

Placing electrodes on all four extremities is not the initial step in using a Transcutaneous Electrical Nerve Stimulator (TENS) unit. It may not be necessary for the specific pain management needs of the patient and can be uncomfortable or impractical.

Choice B rationale:

This is the correct initial step when starting TENS treatment. The nurse should adjust the settings to a level below the threshold at which the patient feels a tingling sensation. This ensures that the treatment is comfortable and safe for the patient. The goal is to provide pain relief, not to induce discomfort.

Choice C rationale:

Turning the unit on before attaching it to the patient is not advisable. It's essential to connect the electrodes to the patient first and then turn on the TENS unit. This sequence helps prevent accidental electrical stimulation before the device is properly set up.

Choice D rationale:

Applying conductive jelly to uncoated electrodes is a step in preparing the electrodes for use, but it should be done after attaching the electrodes to the patient's skin. This choice does not address the initial step in TENS treatment, which is setting the stimulation level. .

Choice A rationale:
Patient-controlled analgesia (PCA) is a method of pain management that allows the patient to administer their own pain medication within specified limits, but it doesn't reduce the workload of the nurse. The nurse is responsible for setting up and monitoring the PCA pump, educating the patient, assessing their pain, and ensuring safety. Therefore, this choice is incorrect.
Choice B rationale:
PCA does not completely eliminate pain. It provides the patient with control over their pain relief by allowing them to self-administer medication within preset limits. However, it does not guarantee the complete absence of pain. Pain relief is provided within a safe dosage range, but some level of pain may still be experienced. Therefore, this choice is incorrect.
Choice C rationale:
PCA does not eliminate the risk of adverse drug effects entirely. The nurse must monitor the patient for signs of adverse effects, such as respiratory depression or sedation. While the patient has control over medication administration, there are still risks associated with opioid analgesics. Therefore, this choice is incorrect.
Choice D rationale:
The principal advantage of using patient-controlled analgesia (PCA) is that it reduces patient anxiety about pain by giving the patient more control over its management. This choice is correct because PCA empowers the patient to self-administer pain medication when needed, which can lead to better pain control and reduced anxiety. The nurse sets safe dosage limits and monitors the patient, ensuring safety while providing a sense of control.

Choice A rationale:

If a patient with a Fentanyl patch is experiencing symptoms like abnormal sleepiness, slurred speech, and unsteadiness when ambulating, it could indicate an overdose or adverse reaction to the Fentanyl. In such cases, the patch should be removed immediately to stop the further absorption of the drug. Wiping off the skin can also help remove any residual medication. This is the correct choice as it addresses the issue at its source.

Choice B rationale:

Applying ice to the skin around the Fentanyl patch is not the appropriate action in this situation. Ice will not counteract the effects of a Fentanyl overdose or adverse reaction. The priority is to remove the patch and seek medical attention.

Choice C rationale:

Elevating the head of the bed and offering coffee or cola may be useful in combating some forms of sleepiness but would not be effective for someone experiencing an overdose or adverse reaction to Fentanyl. This choice does not address the problem's root cause and is not the appropriate action to take.

Choice D rationale:

Putting up the side rails on the bed does not address the issue of Fentanyl patch overdose or adverse reactions. This choice is not relevant to the situation and should not be chosen.

Choice A rationale:

It is not advisable to use sedative pills for long periods of time without consulting a primary care provider. Prolonged use of sedatives can lead to dependence and other adverse effects. Therefore, this choice is incorrect.

Choice B rationale:

Using sedative pills for short periods of time without physician approval is not a safe practice. Even nonprescription medications, including over-the-counter sedatives, should be used under the guidance of a healthcare provider. This choice is incorrect.

Choice C rationale:

The best advice for the patient is to use sedative pills for short periods of time, but it is best to check with the primary care provider first. This is the most appropriate choice as it emphasizes short-term use while also promoting communication with a healthcare provider to ensure the medication's safety and effectiveness.

Choice D rationale:

Using sedative pills for long periods of time without primary care provider approval is not recommended. It can lead to potential risks and side effects associated with prolonged sedative use. Therefore, this choice is incorrect.

Choice A rationale:

Sleeping with the window open for fresh air may not be the best solution in this scenario. While fresh air can be beneficial for sleep, it might not effectively block out the noise from the freeway and the nearby apartment complex. Furthermore, depending on the climate and location, having the window open might lead to discomfort or temperature-related issues.

Choice B rationale:

Performing exercise at bedtime is not a recommended solution for someone experiencing difficulty sleeping due to external noise. Exercise before bedtime can increase alertness and make it even more challenging to fall asleep, especially if it's vigorous exercise. It may exacerbate the problem rather than alleviate it.

Choice C rationale:

Having a couple of drinks at bedtime is not a suitable solution for sleep problems. Alcohol can disrupt sleep patterns and lead to poor-quality sleep. It may help the patient fall asleep initially but can lead to frequent awakenings and a less restful night's sleep.

Choice D rationale:

The correct choice is to wear soft earplugs for sleep. Soft earplugs can effectively reduce or block out external noise, providing a quieter sleep environment. This is a practical and safe solution to address the noise issue in the patient's apartment complex. It promotes better sleep quality without any negative side effects.

Choice A rationale:

A patient with a decreased level of consciousness from a stroke may not be able to provide feedback or recognize discomfort or pain, which can increase the risk of burn injury when using a heating pad. This choice increases the risk rather than reducing it.

Choice B rationale:

A patient with neuritis secondary to diabetes has a decreased sensitivity in the affected area due to nerve damage. While this can be a challenging condition, it reduces the patient's ability to perceive heat and pain, making them less likely to realize if the heating pad becomes too hot. As a result, this patient has the least risk for burn injury when using the Aquathermia K pad.

Choice C rationale:

A severely sprained ankle is not related to the risk of burn injury from a heating pad. This choice is not relevant to the assessment of burn injury risk with the Aquathermia K pad.

Choice D rationale:

Impaired peripheral circulation can increase the risk of burn injury from a heating pad. Patients with compromised circulation have a reduced ability to dissipate heat, which can lead to localized overheating and potential burn injury. This choice increases the risk of injury. .

Choice A rationale:

NREM (Non-Rapid Eye Movement) sleep is characterized by slow-wave sleep and is often considered restorative. It is the stage of sleep where the body repairs and regenerates tissues, and it is essential for feeling rested and rejuvenated. NREM sleep consists of three stages, with stages 3 and 4 being the deepest and most restful, also known as slow-wave sleep. These stages are essential for physical recovery.

Choice B rationale:

NREM sleep is not characterized by irregular respirations. Irregular breathing patterns are more commonly associated with certain sleep disorders, such as sleep apnea, rather than NREM sleep itself.

Choice C rationale:

NREM sleep is not characterized by increased heart rate. In fact, during NREM sleep, the body typically experiences a decrease in heart rate and blood pressure. The body's physiological functions tend to slow down during NREM sleep to promote rest and recovery.

Choice D rationale:

NREM sleep is not characterized by daytime activity. In contrast, NREM sleep occurs during the night and is a state of deep rest, during which the body is not engaged in daytime activities. It is essential for physical and mental recovery, especially after a day of activity.

Choice A rationale:

The nurse recommends that normal sleep and rest patterns can best be acquired by suggesting that the patient exercises in the mornings. Morning exercise can help regulate the circadian rhythm and improve sleep-wake patterns. It helps to reset the internal body clock, making it easier to fall asleep at night. However, exercise should not be too close to bedtime, as it may have a stimulating effect.

Choice B rationale:

Taking a nap during the day may provide a short-term boost in alertness but is not recommended as the primary method to acquire normal sleep and rest patterns. Daytime naps should be brief (20-30 minutes) and should not interfere with nighttime sleep. Excessive daytime napping can disrupt the regular sleep cycle.

Choice C rationale:

Drinking wine is not a recommended approach for acquiring normal sleep and rest patterns. Alcohol consumption, especially in the evening, can disrupt sleep cycles and negatively affect the quality of sleep. It may lead to frequent awakenings during the night and contribute to sleep disturbances.

Choice D rationale:

Smoking cigarettes is not a recommended approach for acquiring normal sleep and rest patterns. Nicotine is a stimulant that can interfere with sleep by increasing alertness and heart rate. Smoking can contribute to sleep difficulties and should be avoided, especially close to bedtime. .

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep, and his partner pressing the button to dispense a dose of analgesia. Which of the following responses should the nurse make? The correct answer is choice D: "Next time you think he needs more medication, call me, and I'll push the button.”.

Choice A rationale:
The nurse should prioritize the safety and autonomy of the patient. Allowing the partner to decide when more medication is needed is not appropriate. Patients who use PCA pumps are educated about how to use them and should have control over their pain management. The partner should call the nurse for assistance, but the patient should ultimately make the decision regarding additional medication.
Choice B rationale:
Questioning the partner's judgment is not the most appropriate response in this situation. Patients may require pain relief even while sleeping, and the partner may be aware of the patient's pain pattern or needs. However, it's essential to involve the patient in the decision-making process.
Choice C rationale:
While it's important to ensure the patient's comfort, this response does not prioritize the patient's autonomy or involve the patient in the decision-making process. The patient should have control over when to administer more analgesia, with assistance from the nurse as needed.
Choice D rationale:
This is the correct response. The nurse should encourage the partner to call for assistance when the patient needs more medication. However, the final decision should be made by the patient, as they have the right to control their pain management. The nurse can then push the button as requested by the patient, ensuring that the patient's needs are met while also promoting their autonomy.

Choice A rationale:

Taking a warm bath before trying to go back to sleep is a relaxation technique that may help with sleep but does not address the underlying causes of insomnia. It is more of a short-term coping strategy rather than a method for locating the reasons for the insomnia.

Choice B rationale:

Reviewing times in her life when she had no insomnia is not a practical approach to addressing the current issue of insomnia. It does not help in identifying the specific factors or triggers contributing to the patient's current sleep problems.

Choice C rationale:

Keeping a diary related to sleep and problems encountered is a practical and effective approach to identify the factors contributing to the patient's insomnia. This diary can help track patterns, such as bedtime routines, diet, stressors, and other variables that may be linked to the sleep problem. Identifying these factors can aid in developing a plan to address the specific causes of the insomnia.

Choice D rationale:

Discussing the problem with her friends may provide emotional support but is unlikely to help identify the root causes of the insomnia. Friends may offer advice or share their experiences, but a structured approach like keeping a sleep diary is more likely to yield valuable information.

Choice A rationale:

Bradycardia, a slow heart rate, is not typically associated with acute pain. In response to pain, the body usually experiences increased heart rate (tachycardia) as part of the stress response.

Choice B rationale:

A decreased respiratory rate is not an expected finding in response to acute pain. Acute pain often leads to increased respiratory rate as the body attempts to manage the pain and stress.

Choice C rationale:

Hypoglycemia, a low blood sugar level, is not a typical physiological response to acute pain. Acute pain is more likely to induce a release of stress hormones, such as cortisol and adrenaline, which can lead to increased blood sugar levels.

Choice D rationale:

Hypertension, or elevated blood pressure, is an expected physiological response to acute pain. Pain activates the body's stress response, leading to increased sympathetic nervous system activity, which can cause vasoconstriction and increased blood pressure. This response helps prepare the body to cope with the pain and stress. Monitoring blood pressure in a client reporting acute pain is essential to assess the impact of pain and determine appropriate pain management strategies.

Choice A rationale:

Some older adults may indeed have concerns about taking pain medication, but this is not a primary reason for their hesitance to express pain. The fear of taking medication is not a universal characteristic of older adults.

Choice B rationale:

While older adults may be reluctant to bother nursing staff, this is not the primary reason for their reluctance to express pain. It is a consideration but not the main factor.

Choice C rationale:

The unawareness of discomfort is not a common reason for older adults to avoid expressing pain. Most older adults are aware of their discomfort but may not express it for other reasons.

Choice D rationale:

Older adults may have been culturally trained not to complain about pain or discomfort. In some cultures, stoicism and not burdening others with one's pain are highly valued. This cultural training can lead older adults to underreport their pain.

Choice E rationale:

Believing pain is a natural consequence of aging is a misconception, but it is not the primary reason why older adults may not express their pain. They may believe this, but cultural and societal factors have a more significant impact.

Choice A rationale:

The Neonatal Infant Pain Scale (NIPS) is commonly used to assess pain in newborns and infants. It evaluates multiple indicators of pain, including facial expression, crying, breathing patterns, and arms and legs' movements, to determine if a baby is in pain.

Choice B rationale:

The FACES pain rating scale for children is not typically used for infants, as it relies on a child's ability to point to or describe their pain using facial expressions.

Choice C rationale:

The Premature Infant Pain Profile (PIPP) Scale is used primarily for preterm infants and not typically for all newborns. It is more specific to certain populations.

Choice D rationale:

The FLACC Scale (Face, Legs, Activity, Cry, Consolability) is used for assessing pain in young children who may not be able to self-report. It's not specific to infants, and the NIPS is more appropriate for this population.

The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by: The correct answer is choice A: supporting surface and internal tissues.

Choice A rationale:
An abdominal binder is primarily used to support surface and internal tissues. It provides gentle compression and support to the abdominal area, which can reduce pain and discomfort. By holding the incision site together and supporting the surrounding tissues, it can minimize movement and strain on the incision, helping to alleviate pain.
Choice B rationale:
While an abdominal binder may indirectly contribute to back support by stabilizing the abdominal area, its primary purpose is to support the surgical site. Enhancing early ambulation is more related to patient mobility and not the primary purpose of the binder.
Choice C rationale:
Abdominal binders do not increase warmth to the incision site. In fact, excessive warmth can lead to sweating and moisture, potentially increasing the risk of infection. The primary purpose is to provide support.
Choice D rationale:
An abdominal binder does not keep sutures and staples in place. The sutures and staples are used to secure the incision, and the binder is placed over them to provide support and compression. However, the binder itself is not responsible for keeping sutures and staples in place. .

Choice A rationale:
Fairness. Fairness in nursing pertains to treating all patients equally and without bias. It involves providing care based on need and not discriminating against any patient. While fairness is an essential component of professionalism, in the context of evaluating the effectiveness of pain medication, the focus is on individual patient care rather than a fairness issue.
Choice B rationale:
Responsibility. Responsibility in nursing is about being accountable for one's actions and duties. While assessing the effectiveness of pain medication is the responsibility of the nurse, it does not encompass the broader concept of professionalism being assessed in this question.
Choice C rationale:
Confidence. Confidence is an important attribute for a nurse, but it is not the primary component being demonstrated in this scenario. Confidence may be needed to carry out the assessment, but it does not capture the essence of professionalism.
Choice D rationale:
Advocacy. Advocacy in nursing is the act of supporting and standing up for the best interests of the patient. In this case, by evaluating the effectiveness of pain medication, the nurse is advocating for the patient's comfort and well-being. This demonstrates a key aspect of professionalism by prioritizing patient needs.

Choice A rationale:

Post-herpetic neuralgia. Post-herpetic neuralgia is a neuropathic pain that occurs as a complication of shingles (herpes zoster) and is characterized by severe, burning, or shooting pain in the affected area. It is not an example of nociceptive pain.

Choice B rationale:

Diabetic neuropathy. Diabetic neuropathy is another example of neuropathic pain and is caused by damage to the nerves due to diabetes. It typically presents as aching, burning, or tingling sensations and is not considered nociceptive pain.

Choice C rationale:

Phantom limb pain. Phantom limb pain is also a neuropathic pain that occurs after the amputation of a limb. Patients perceive pain or discomfort in the missing limb. It is not classified as nociceptive pain.

Choice D rationale:

Strained muscle. Strained muscle pain is a classic example of nociceptive pain. Nociceptive pain arises from the activation of pain receptors (nociceptors) due to tissue damage or inflammation. In the case of a strained muscle, the pain results from physical injury or overuse of the muscle, making it a nociceptive pain. Nociceptive pain can be further categorized into somatic and visceral pain. Somatic pain, as in the case of a strained muscle, arises from musculoskeletal structures, and it is typically well-localized, sharp, and aching. Understanding the nature of pain is essential for effective pain management and treatment selection. .

Choice A rationale:

True. As people age, it is common for them to experience more frequent awakenings during the night. This is often due to changes in sleep patterns, such as a decreased ability to maintain deep sleep, which can result in waking up more easily. Additionally, older adults may nap more during the day, which can affect their nighttime sleep patterns.

Choice B rationale:

False. Giving older adults hypnotics to induce better sleep is not a recommended approach as it may have adverse effects, including dependency and increased risk of falls. The focus should be on understanding and addressing the underlying causes of sleep disturbances in older adults.

Choice C rationale:

False. While it is important to assess and address sleep concerns in older adults, there is no fixed requirement of needing at least 10 hours of sleep a day to prevent fatigue. Sleep needs can vary, and older adults may require less sleep than younger individuals.

Choice D rationale:

False. Older adults may nap more during the day, but reducing daytime napping is not a guaranteed solution to improve nighttime sleep. Sleep patterns can change with age, and individual variations in sleep needs and habits should be considered.

Choice A rationale:

False. Pain should not be assessed only for patients who complain of pain. Pain assessment should be a routine part of patient care, as not all patients may be able to verbalize their pain or may underreport it. Identifying and addressing pain is crucial for patient well-being.

Choice B rationale:

False. Pain treatment does not necessarily end at discharge. The management of pain may continue beyond the hospital setting, and a plan for pain management post-discharge may be needed. This ensures that patients receive appropriate pain relief and support during their recovery.

Choice C rationale:

True. According to the Joint Commission's standards, all patients have the right to appropriate assessment of pain. This means that every patient, regardless of their condition or the presence of pain complaints, should have their pain assessed and managed as necessary.

Choice D rationale:

False. Pain treatment is not solely based on objective data collected by the nurse. Pain is a subjective experience, and it is essential to consider the patient's self-report of pain, in addition to any objective data, when determining the appropriate treatment. Objective data can help, but it should not be the sole basis for pain management.

Choice A rationale:

Excessive NREM sleep does not cause periodic pauses in breathing. NREM (Non-Rapid Eye Movement) sleep consists of stages 1 through 4 and is characterized by a decrease in physiological activity, including a decrease in muscle tone. There is no direct association with breathing interruptions in NREM sleep.

Choice B rationale:

Insomnia is a sleep disorder characterized by difficulty falling asleep or staying asleep, but it does not involve periodic pauses in breathing. It is unrelated to the symptoms described in the question.

Choice C rationale:

Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness and sudden episodes of muscle weakness (cataplexy). It is not associated with periodic pauses in breathing, as described in the question.

Choice D rationale:

Sleep apnea is the correct answer. Sleep apnea is a sleep disorder characterized by repeated episodes of paused or shallow breathing during sleep. The patient may stop breathing for brief periods, then start breathing again. This pattern is consistent with the symptoms described in the question. Sleep apnea can have serious health implications and is important to recognize and address.

Choice A rationale:

Constipation is not a common adverse effect of pain medication administered by the epidural route. Pain medication primarily affects the central nervous system and does not typically impact the gastrointestinal system in a way that would lead to constipation.

Choice B rationale:

Hypoventilation is the correct answer. When opioids or other potent pain medications are administered by the epidural route, they can depress the respiratory center in the brain, leading to hypoventilation (slow or inadequate breathing). This is a critical concern and the most important adverse effect to monitor because it can lead to respiratory compromise or even respiratory arrest.

Choice C rationale:

Nausea can be a side effect of some pain medications, but it is not the most important adverse effect to monitor in a patient receiving epidural pain medication. Nausea can often be managed with antiemetic medications.

Choice D rationale:

Headache is not a common adverse effect of epidural pain medication. The administration of pain medication into the epidural space is localized to the spinal area and does not typically lead to headaches.

Choice A rationale:

Asking the patient to rate their pain on a scale of 0-10 is a good initial response to assess the severity of pain. However, it should be followed by a more comprehensive assessment, which may include addressing the patient's concern about pain in the removed limb and providing appropriate interventions.

Choice B rationale:

Telling the patient that it is not possible to experience pain because the limb and nerves were removed is inaccurate and insensitive. This response does not address the patient's reported pain and may be perceived as dismissive.

Choice C rationale:

Telling the patient that they are not experiencing pain is both inaccurate and dismissive of the patient's reported pain. This response does not demonstrate empathy or a patient-centered approach to care.

Choice D rationale:

"I understand you are in pain, please rate your pain on a scale of 0-10, and I will get a mirror to assess the area" is the best response. This response acknowledges the patient's pain, uses a pain assessment scale to quantify the pain, and offers a solution to assess the area with a mirror. It demonstrates empathy and a proactive approach to addressing the patient's concern. .

Choice A rationale:

Keeping bright lights on in the room is not conducive to relaxation. Bright lights can be stimulating and may increase stress, which is counterproductive when trying to manage pain through relaxation techniques.

Choice B rationale:

Using relaxation techniques as a way to wake up in the morning is not the intended purpose of these techniques. Relaxation techniques are typically used to reduce stress, anxiety, and pain, especially when one is trying to rest or sleep.

Choice C rationale:

Tensing and relaxing individual muscle groups, starting with the toes and feet, is a common method for progressive muscle relaxation. This technique can help reduce muscle tension and promote overall relaxation. It is an effective approach to pain management.

Choice D rationale:

Trying to tense and relax all of the muscles of the body at the same time may be difficult for most individuals and is not a commonly recommended relaxation technique. It can be challenging to achieve the level of focus and control required for this method, and it may not be as effective as focusing on individual muscle groups.

Choice A rationale:

Culture can influence a person's perception and expression of pain. It's important to consider cultural factors when assessing and managing pain because beliefs and attitudes about pain can vary significantly among different cultural groups. This can affect how pain is experienced and communicated.

Choice B rationale:

Psychological factors, such as anxiety, depression, and coping mechanisms, play a significant role in the experience of pain. Assessing psychological factors is essential for a comprehensive understanding of the patient's pain experience and developing appropriate pain management strategies.

Choice C rationale:

Understanding the patient's history of pain is crucial for a focused pain assessment. Previous experiences with pain, including the cause, intensity, and effectiveness of previous pain management strategies, can provide valuable insights into the current pain situation.

Choice D rationale:

Assessing contributing factors, such as concurrent medical conditions, injuries, or environmental factors, is essential to determine the underlying causes of pain and develop an effective pain management plan.

Choice E rationale:

Verbal indicators are essential for assessing pain. Patients often describe their pain in words, and understanding their descriptions and expressions of pain is fundamental to evaluating its intensity, location, quality, and duration.