A patient returning from surgery complains of incisional pain that is now rated 7 in intensity on the 1-to-10 pain scale. What should the nurse be aware that pain exemplifies?
a. General adaptation syndrome
b. Local adaptation syndrome
c. Counter-current response
d. Neuroendocrine response
B
Local adaptation syndrome is a short-term, local response to a specific stressor. Examples include pain, blood clotting, and wound healing.
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Which of these clinical situations would the nurse consider to be outside normal limits?
a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.
A patient with fecal incontinence should be taught the importance of maintaining good skin integrity. What should be the focus of a nurse's teaching?
a. Cleanse the perianal area thoroughly after each stool. b. Use a fecal pouch. c. Change incontinence undergarments once a day. d. Take an over-the-counter laxative daily.
Which drug would a nurse expect to produce a favorable response for both positive and negative symptoms?
a. Haloperidol (Haldol) b. Risperidone (Risperdal) c. Fluphenazine (Prolixin) d. Trifluoperazine (Stelazine)
A 72-year-old patient wants to know where her digoxin pill is because she always takes it for her heart. Which of the following is the best response by the nurse?
1. "The health care provider will likely order a different heart medication pill.". 2. "Digoxin doesn't work as well as it used to.". 3. "Digoxin is a bad medication to take.". 4. "Digoxin is no longer manufactured.".