HESI Pain case study(Evolve) – Flashcards
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Wrenda's younger child is an infant who feeds every 3 hours.
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Introduction: During the RN's initial interview, Wrenda shares information about her home, career, and family. The RN evaluates the information to determine psychosocial factors that may impact management. 1) Which information obtained by the RN is most likely to influence Wrenda's perception of her pain?
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"What word best describes the pain you are experiencing?"
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2) To assess the quality of Wrenda's pain, the RN asks which question?
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Frequent guarding.
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3) Which behavior that Wrenda exhibits supports her subjective report of acute pain?
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Continue the interview with the client.
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4) To determine the etiology of Wrenda's anxiety, what is the priority nursing intervention?
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Client reports pain of 1 on a - scale.
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5) What is the best goal for the RN to include in the plan of care related to the problem statement of "Acute pain related to strain on muscles with movement?"
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Discuss the plan of care with the client.
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6) Before implementing any interventions, what action is most important for the RN to take?
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Acetaminophen does not have an antiinflammatory effect.
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7) The RN consults with the clinic director, a pain management physician, who recommends the use of NSAIDS and alternating heat and cold applications, as well as back exercises. The RN provides client teaching about these treatments. Wrenda tells the RN that she will take the acetaminophen that she already has at home.
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All aspirin products should be avoided in children unless specifically prescribed.
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8) Wrenda decides to purchase buffered aspirin and asks if this medication is also safe to give her 4-year-old son since he occasionally experiences viral infections and becomes feverish.
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"The dry heat provided by your heating pad will help relieve your pain by promoting muscle relaxation."
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9) Wrenda tells the RN that she has an electric heating pad at home that she used when she sprained her ankle.
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Excessive exposure to cold can damage the skin.
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Wrenda states that she has also been applying a cold pack an hour at a time to help heal her back as quickly as possible. 10) Which instruction is most important for the RN to provide?
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Reflex vasodilation occurs following the initial vasoconstricting effects of cold.
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11) How should the RN explain the mechanism that causes the skin to become reddened from prolonged exposure to cold?
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"Pain relief is actually provided by delivery of small electrical currents to the skin."
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TENS Unit: Wrenda returns to the pain clinic in a week and reports that her pain has worsened. The pain management physician recommends the use of a transcutaneous electrical nerve stimulator (TENS) unit and prescribes a schedule IV opioid analgesic. Wrenda states to the RN that she is familiar with the TENS Unit, calling it a biofeedbacktreatment. 12) What is the best response by the RN?
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-Be sure to use conducting gel or conductor pads when applying the electrodes to the skin. -Clean the skin where the electrodes will be placed and dry thoroughly.
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The RN explains the use of the TENS unit and demonstrates how to apply it. 13) Which instruction(s) should the RN include?
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There is a high potential abuse.
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In addition to the TENS unit, Wrenda has a prescription for a Schedule IV analgesic. The RN recognizes that specific protocols are followed when a client is receiving scheduled (controlled) medications. 14) What characteristic of scheduled drugs results in the need for these specific protocols?
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Review prescriptions for any scheduled drugs with all nurses with access to the medications to determine why the count is inaccurate.
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The clinic stocks a small number of scheduled medications, so the RN obtains a dose of the prescribed medication for Wrenda. At the end of the shift,the RN counts the remaining medications with the oncoming RN and notes that the count is not accurate. 15) What action should the RN implement?
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2
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16) The medication comes in a pre-loaded syringe labeled "30 mg/mL." How many mL should the RN expect to administer?
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Ventrogluteal
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17) Since Wrenda is fairly thin, which site is the best choice for the injection?
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The greater trochanter
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18) The RN will first place the palm of the hand on what anatomical spot to locate the injection site?
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-Pull back on syringe plunger and observe for blood. -Slowly inject the medication into the muscle mass. -Follow the facility policy regarding aspiration of IM injection.
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19) Once the needle is inserted in the skin, what intervention should the RN perform?
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Include as many sensory images as possible in the experience.
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20) To ensure that the exercise is most effective, what action should the RN implement?
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Tense the muscle fully.
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21) What instruction should the RN provide next?
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The day before the surgery is scheduled.
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22) When is the best time to teach Wrenda about use of the PCA?
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18mg.
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23) What is the total dosage of morphine that Wrenda has received in the last 4 hours?
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She is receiving adequate pain control without the additional doses.
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24) What is the most likely reason for this change?
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The synergistic effect of the two medications improves pain control.
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25) What is the rationale for combining these two ingredients?
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You may need to continue the docusate sodium because most opiod analgesics, including hydrocodone/acetaminophen, cause constipation.
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26) How should the RN respond?
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Arrange to continue the conversation in a more private location.
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27) What is the priority nursing intervention?
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Veracity.
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28) The RN's response demonstrates what ethical principle?
