Pain
This pediatric pain scale is used for children ages 2 months to 7 years and assess what?
What is FLACC scale and means Face, Legs, Activity, Cry, and Consolability.
This gastrointestinal symptom is defined as having fewer than three bowel movements weekly or stools that are hard, dry, small, or difficult to pass.
What is constipation?
A nurse is caring for an older adult client with a history of a progressive, hypercapnic respiratory disease who is 2 days postoperative following an abdominal surgery under general anesthesia. The client exhibits diminished chest expansion, crackles at the lung bases, and a reduction in incentive spirometer volumes compared to yesterday. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.
A) Administer inhaled salmeterol to provide immediate rescue relief of bronchospasm. B) Encourage the client to utilize pursed-lip breathing on exhalation to create positive end-expiratory pressure. C) Titrate supplemental oxygen via nasal cannula to maintain a target SpO2 of 96%. D) Initiate chest physiotherapy, including percussion and vibration, to increase mucous clearance. E) Assist the client into a high-Fowler's position to use gravity to move the diaphragm away from the lungs.
What is 1.) B, D, E Rationale: The client is exhibiting signs of atelectasis (diminished expansion, crackles, reduced spirometer volumes) following general anesthesia, compounded by an underlying history of COPD (progressive hypercapnic disease).
A nurse is providing discharge teaching to a pregnant client with pregestational diabetes who is beginning a regimen of regular insulin. Which statement by the client indicates a need for further instruction?
A. "I will eat my breakfast within 30 minutes of injecting my regular insulin to prevent a reaction."
B. "If I feel sweaty, shaky, or irritable, I will drink 8 oz of milk and eat two crackers."
C. "I should avoid simple sugars like cake and cookies because they cause my blood glucose to rise too fast."
D. "I will call my doctor immediately if I experience a dry mouth, frequent urination, and rapid breathing, as these are signs my blood sugar is too low."
Answer: D Rationale: The symptoms described (dry mouth, frequent urination, and rapid breathing) are clinical manifestations of hyperglycemia, not hypoglycemia. The client should notify their healthcare provider for these symptoms because hospitalization may be needed. Options A, B, and C are correct actions: regular insulin requires eating within 30 minutes; sweating and irritability are signs of hypoglycemia treated with milk and crackers; and simple sugars should be avoided to maintain glycemic control
This condition, which affects 50% of men by age 60, causes post-renal acute kidney injury when the enlarged gland physically compresses the urethra and blocks urine flow.
What is Benign Prostatic Hyperplasia (BPH)?
Rationale: In BPH, the prostate hypertrophies (enlarges) over time. Because the prostate surrounds the urethra, this growth physically crushes the urethra, leading to incomplete bladder emptying, hydroureter, and urinary retention
This medication is considered the "drug of choice" for children experiencing moderate to severe pain.
What is morphine?
When assessing a new ostomy, the nurse looks for these three visual characteristics to ensure the stoma is healthy.
What are bright pink or beefy red, moist, and shiny?
A client with a long-standing history of a progressive respiratory disease characterized by irreversible airflow limitations presents to the clinic. The client reports increasing dyspnea at rest and constant nausea. Upon examination, the nurse notes bilateral lower extremity edema and a distended abdomen. Morning laboratory results reveal an elevated hemoglobin and hematocrit. What is the most likely pathophysiological mechanism responsible for these assessment findings? A) The destruction of alveolar walls has led to severe carbon dioxide retention and subsequent chronic respiratory alkalosis. B) Chronic systemic inflammation has triggered a bone marrow dysfunction, resulting in pathological polycythemia. C) A left ventricular impairment has significantly reduced systemic cardiac output, leading to severe venous congestion. D) Air trapping and stiff alveoli have increased pulmonary pressures, resulting in right-sided heart failure.
What is 2.) D Rationale: The client's presentation of bilateral lower extremity edema, distended abdomen, and nausea in the setting of an irreversible airflow limitation (COPD) indicates Cor Pulmonale, or right-sided heart failure.
A nurse is caring for a client at 30 weeks gestation who is admitted with a diagnosis of preterm labor. Which interventions and assessments should the nurse anticipate as part of the plan of care? (Select all that apply.)
A. Administration of betamethasone to promote fetal lung maturity.
B. Initiation of tocolytic therapy to prolong pregnancy for 2 to 7 days.
C. Monitoring for signs of a urinary tract infection (UTI).
D. Performing frequent serial vaginal examinations to monitor cervical dilation.
E. Prophylactic antibiotic administration if the client is positive for Group B streptococcus.
What is A, B, C, E Rationale: Betamethasone is a corticosteroid given between 24 and 34 weeks to decrease respiratory distress in the neonate. Tocolytics are used to delay birth for a few days to allow steroids to work. UTI symptoms are a subtle sign/risk factor associated with preterm labor and must be assessed. Antibiotics are indicated for those with Group B streptococcus. Option D is incorrect because nurses should avoid vaginal exams in clients experiencing preterm labor to prevent further cervical stimulation or infection
If a patient describes sudden, excruciating, wavelike colicky pain that radiates down their thigh to their genitalia, the nurse suspects a kidney stone is lodged in this specific anatomical structure.
What is the Ureter?
Rationale:The location of the stone changes the pain! Stones in the renal pelvis cause a deep, intense ache in the CVA (mid-back) region. However, stones that get stuck in the ureter cause acute, excruciating, colicky pain that radiates down the thigh to the genitalia.
This condition involves the perception of pain in a limb that is no longer there and can be managed using unique non-pharmacological interventions such as? (2 answers)
What is Phantom Limb Pain? What is Mirror Therapy or Virtual Reality.
This specific type of urinary retention is a common complication following surgery, often caused by anesthetic agents, spinal anesthesia, and opioids.
What is post-operative urinary retention (POUR)?
A clinical nurse educator is evaluating a newly hired graduate nurse’s understanding of managing clients with chronic airflow limitations and incomplete lung expansion disorders. Which of the following statements by the graduate nurse indicate a correct understanding of these conditions? Select all that apply. A) "Inhaled corticosteroids are highly recommended as a stand-alone daily therapy to reduce chronic airway inflammation." B) "Tiotropium bromide is a long-acting antimuscarinic agent that should be used as a daily maintenance medication to prevent bronchoconstriction." C) "Routine use of an incentive spirometer helps to imitate deep breathing, allowing the lungs to stretch and open to prevent alveolar collapse." D) "A complete blood count will likely show chronically elevated neutrophils as an adaptation to prolonged tissue hypoxemia." E) "Radiographic imaging for these structural disorders may reveal platelike horizontal lines or a flattened diaphragm.
3. B, C, E Rationale:
A nurse is assessing a pregnant client with Class III Congenital Heart Disease at 28 weeks gestation. Which finding is the most critical indicator of cardiac decompensation?
A. Fatigue and palpitations occurring after normal household chores.
B. New onset of rales (crackles) in the lung bases upon auscultation.
C. 1+ pitting edema in the lower extremities at the end of the day.
D. A maternal heart rate of 92 beats per minute.
What is Answer: B Rationale: While fatigue and palpitations are expected for a Class III cardiac client (symptomatic with normal activity), the development of rales indicates pulmonary congestion and is a major sign of cardiac decompensation. Edema can be a normal finding in pregnancy or a sign of cardiac issues, but new-onset rales are an acute, life-threatening indicator that the cardiovascular system is overstressed
When managing Continuous Bladder Irrigation (CBI) after a Transurethral Resection of the Prostate (TURP), the nurse must manually irrigate the catheter if the urine changes from the expected light pink to this appearance.
What is dark pink/red with clots?
Rationale: The primary goal of CBI after a TURP procedure is to keep the urine light pink and completely free of clots. If the urine becomes dark red or clotted, the irrigation is failing, and the nurse must immediately assess and manually irrigate to prevent obstructio
This six-step principle of pediatric pain assessment QUESTT stands for?
What is Questioning the child, Using a valid scale, Evaluating behavior, Securing parent involvement, Taking the cause of pain into account, and Taking action.
If a client with urolithiasis reports an intense, deep ache in the costovertebral angle (CVA) region, the stone is likely located in this specific area.
What is the renal pelvis?
While Beta-2 agonists work on the sympathetic nervous system to dilate the airways, medications like Tiotropium (a LAMA) keep the airways open by blocking these specific receptors, preventing the parasympathetic nervous system from causing bronchoconstriction.
What are Muscarinic receptors? Rationale: According to your lecture, the autonomic nervous system controls the diameter of the conducting airways. The parasympathetic nervous system naturally stimulates muscarinic receptors to decrease airway diameter (bronchoconstriction). Antimuscarinic maintenance medications (like Ipratropium or Tiotropium) are given to block these exact receptors, thereby keeping the airways open.
A nurse is reviewing the effects of substance abuse during pregnancy. Which fetal or neonatal outcomes are correctly matched with the substance of abuse? (Select all that apply.)
A. Alcohol: Leading cause of intellectual disability (FASD).
B. Cocaine: Vasoconstriction, placental abruption, and central nervous system defects.
C. Nicotine: Reduced uteroplacental blood flow and low birth weight.
D. Opiates: Maternal and fetal withdrawal and neonatal abstinence syndrome.
E. Caffeine: Documented teratogenic effects including limb deformities.
What is Answer: A, B, C, D Rationale: Alcohol (FASD) is the leading cause of intellectual disability. Cocaine causes vasoconstriction, which leads to abruption and CNS defects. Nicotine causes vasoconstriction and reduced blood flow, resulting in low birth weight. Opiates/Narcotics lead to neonatal abstinence syndrome. Option E is incorrect because research has not documented teratogenic effects of caffeine in humans, though it does cause maternal vasoconstriction and diuresis
While opioids are used to prevent shock from kidney stone pain, this class of medications is highly effective because it inhibits prostaglandin synthesis, which directly reduces localized swelling and facilitates the physical passage of the stone.
What are NSAIDs?
Rationale: NSAIDs are a dual-purpose powerhouse for renal calculi. By inhibiting prostaglandin synthesis, they not only relieve pain but actually reduce the tissue swelling around the stone, making it physically easier for the stone to pass out of the body
In Sickle Cell Anemia, pain is specifically triggered by this physiological sequence: sickling leads to increased blood viscosity, which causes obstruction, resulting in tissue hypoxia and ischemia.
What is the pathophysiology of a vaso-occlusive crisis?
This term describes the accumulation of nitrogenous waste products (noted by high BUN and creatinine levels) that occurs in chronic urinary retention due to BPH.
What is azotemia?
When evaluating a patient's Pulmonary Function Tests (PFTs), an abnormal increase in this specific lung volume measurement definitively indicates an obstructive disease (like COPD or Cystic Fibrosis) rather than a restrictive disease.
What is Reserve Volume?
Rationale: Your slides emphasize using PFTs to distinguish between obstructive diseases (unable to get air out) and restrictive diseases (unable to get air in). Because COPD causes chronic air trapping and a loss of lung elasticity, the air remains stuck inside the lungs after exhalation, which specifically causes an increase in the patient's reserve volume.
A nurse is monitoring a client in the second stage of labor. The client suddenly experiences a sharp, tearing pain in the abdomen, followed by a cessation of uterine contractions and the onset of sudden fetal bradycardia. Which obstetric emergency should the nurse prepare for immediately?
A. Placental Abruption
B. Amniotic Fluid Embolism
C. Uterine Rupture
D. Umbilical Cord Prolapse
What is Answer: C Rationale: The onset of sudden fetal bradycardia and the sharp pain followed by a cessation of contractions are classic signs of a uterine rupture. While placental abruption involves pain and fetal distress, it typically presents with uterine tenderness or rigidity rather than a complete cessation of contractions. Amniotic fluid embolism presents more with maternal respiratory distress, hypotension, and coagulopathy. Cord prolapse is characterized by sudden decelerations following the rupture of membranes, but not necessarily a "tearing" abdominal pain
A nurse is assessing a patient 24 hours post-op after the creation of an Ileal Conduit (Urostomy). Which of the following findings represent NORMAL, expected assessments for this specific urinary diversion? (SATA)
A) A urinary output of 0.2 mL/kg/hr
B) Mucus present in the urine drainage bag
C) A pale pink stoma that is perfectly flush with the skin
D) Trace hematuria (blood) in the urine
E) The patient denies feeling any urge to void
What are B, D, and E?
Rationale:Why B is correct: Because the conduit is surgically created from a piece of the intestine (ileum), it will naturally secrete mucus into the urine.