A patient receiving opioid medication for cancer pain is experiencing increasing pain when being repositioned and changing bed linen. What should the nurse consider is occurring with this patient?
a. Tolerance
b. Addiction
c. Hyperalgesia
d. Breakthrough pain
ANS: C
Hyperalgesia is increased sensitivity to pain. Patients with hyperalgesia have pain at the slightest touch, such as the moving of sheets, and require further medical intervention. A. Tolerance is a normal biological adaptation and means that it takes a larger dose to provide the same level of pain relief. B, Addiction or psychological dependence is a disease of the brain that causes the compulsive pursuance of a substance, or behavior, in order to obtain reward or relief. D. Breakthrough pain is transient pain that arises during generally effective pain control and is seen most often in patients receiving timed-controlled pain medication.
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A client presents at the mental health clinic with complaints of experiencing a feeling of being unreal. The client is a 37-year-old female who lost her husband and two children in an automobile accident 3 months ago
The client retains insight and is aware that the experience is not real. The nurse knows that this client is displaying signs and symptoms of what? A) Dissociative amnesia B) Dissociative identity disorder C) Depersonalization disorder D) Dissociative fugue
An older patient is diagnosed with sensorineural hearing loss. The nurse knows that causes of sensorineural hearing loss include: (Select all that apply.)
a. tumors of the middle ear. b. cerumen impaction. c. infections of the external and middle ear. d. age-related hearing impairment. e. excessive and loud noise.
The best time to observe and count respirations is while:
a. the patient is answering questions. b. weighing the patient. c. palpating the pulse. d. the patient is sleeping.
Which of the following discipline or disciplines may be used in the design of a nursing theory?
A) Psychology B) Physical biology C) Sociology D) Psychology, physical biology, and sociology