In performing a pain assessment, the LPN would follow which steps?
1. Assess vital signs, status of pain, and aggravating factors.
2. Assess location, quality, and intensity on an identified scale.
3. Assess the intensity on an identified scale and record findings.
4. Assess vital signs and location, and report to the RN.
2
The assessment of pain requires the nurse to perform six specific steps. Vital signs are im-portant in addition, but are not part of the six steps.
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The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?
a. Athetoid b. Ataxic c. Spastic d. Mixed
The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions?
A) Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B) Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months C) Promoting communication with the patient and family along with addressing end-of-life issues D) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
After a recent history of shortness of breath that has become increasingly severe, a woman has been prescribed ipratropium by MDI while she undergoes a diagnostic workup. What patient teaching should the nurse provide to this patient?
A) "Make sure that you take this at the scheduled times, regardless of whether you feel short of breath." B) "Most people find that ipratropium cures their lung disease within a few months." C) "You should think of this as an 'emergency drug', and it should only be used when you experience symptoms." D) "It's important that you perform deep breathing exercises before and after taking ipratropium."
Which of the following questions is not used to diagnose an individual with anorexia?
A. "Do you think your current weight is normal or excessive?" B. "Do you think that any part of your body is still too fat?" C. "Do you have concern or fear about gaining weight even though you are underweight?" D. "Do you want to gain weight?"