TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 15: Pain Management Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse teaches the patient progressive self-relaxation techniques. Which would the nurse
implement first? a. Direct the patient to envision sailing on a sailboat. b. Instruct the patient to increase respiratory rate and depth. c. Establish the patient’s ability to participate and cooperate. d. Darken the patient’s room significantly and close the door. ANS: C
The nurse begins by assessing the patient’s ability to participate and cooperate to tailor the teaching techniques and vocabulary to him or her. This increases the likelihood of the patient benefiting from the instruction. Envisioning pleasant things is part of teaching guided imagery but is not the initial step. After assessing the patient, the nurse provides a brief overview of the technique and sets a proper learning environment. Deep respirations are an indication of relaxation; however, instructing a patient to take deep breaths would not precede assessing the patient’s ability to cooperate. DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
2. The nurse massages the patient to promote relaxation. Which is a suitable intervention for the
nurse to implement during the massage? N a. Use the friction technique over the spine. b. Assess for pain, anxiety, and discomfort. c. Instruct the patient to sit upright and forward. d. Knead the patient’s scalp with warm lotion. ANS: B
The nurse’s goal during a massage is to keep the patient comfortable and relaxed and induce a lingering sense of well-being and relaxation at the completion of the massage. If the patient is in pain, anxious, or uncomfortable, relaxation does not occur until the noxious stimuli are eliminated. The nurse asks the patient about pain and comfort during the massage and does not wait for the patient to offer such statements. The friction technique (i.e., strong, circular strokes enhancing perfusion at the skin’s surface) is contraindicated for bony prominences such as the spine because the regional skin is already thin and under tension by nature of its location over a bone. Sitting upright and forward can be contraindicated or uncomfortable for the patient. Occasionally the patient’s scalp is massaged with a few drops of oil on the fingertips; it is impossible to knead the scalp because the scalp is devoid of large, thick muscles. DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
3. The patient has hypotension, receives as much opioid analgesia as the prescription allows, and
continues to have difficulty sleeping at night because of pain. Which should the nurse implement to relieve pain and improve sleep?
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