The nurse recognizes which of the following client outcomes as being a result of ineffective pain management? (Select all that apply.)
1. Client expressing feelings of despair and hopelessness
2. Inability to self-ambulate distance from bed to bathroom
3. Stage 1 pressure ulcer development on coccyx and left hip
4. Client rating pain as 4 on a scale of 0 to 10 30 minutes after pain medication
5. Postponement of discharge because of the inability to perform activities of daily living
6. Postponement of physical therapy because of client's inability to tolerate knee flexion
ANS: 1, 2, 3, 5, 6
Acute pain seriously threatens a client's recovery by resulting in prolonged hospitalization, in-creased risks of complications from immobility, and delayed rehabilitation. Physical or psycho-logical progress is delayed as long as acute pain persists because the client focuses all energy on pain relief. A pain rating of 4 reflects tolerable pain, which may be a realistic expectation in some cases of chronic pain.
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Who has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified?
a. Physician b. Registered nurse c. Nursing assistant d. Licensed practical nurse/licensed vocational nurse
The patient is admitted with injuries that were sustained in a fall
During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right side, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are most consistent with which condition? 1. Paraplegia 2. Neurogenic shock 3. High cervical injury 4. Temporary hypovolemia
The coping styles used to protect the self from stress and maintain psychological homeostasis is:
1. adaptive coping. 2. maladaptive coping. 3. stress. 4. defense mechanisms.
A patient whose current behavior includes pacing and cursing tells a nurse, "I'm feeling edgy and can't concentrate.". The nurse can assess the patient's level of anxiety as:
a. mild. b. moderate. c. severe. d. panic.