Pain, sleep and H2T's

Check all appropriate nursing measures to promote restorative sleep in a critically ill patient.

• Dim the lights and close the door

• Encourage the patient to get some exercise

• Refrain from waking the patient for nursing care

• Silence alarms on equipment

• Provide medical pain relief before bedtime

Pain felt in the left arm/shoulder from a possible MI is referred to as :

• referred pain

• radiating pain

• acute pain

• intractable pain

what are the risk factors associated with not getting adequate and restorative sleep? check all that apply

• healing is slow and incomplete

• decreased immunity

• increased accidents

• pain tolerance increase

• work performance suffers

Which of the following nursing interventions demonstrates therapeutic nursing care to a patient with chronic pain?

• not medicating the patient with narcotics

• Verbalizing acknowledgment of the patient's pain

• Instruct patient to report developing/recurrent pain and not wait until pain is severe (for prn pain med)

• weaning patient off pain medication

If a patient is eupneic, this means that respirations are:

• between 20 and 24 per mn and the patient is using thoracic muscles

• require the use of accessory muscles

• very shallow and at a rate between 8-12 per min

• are considered to be normal in depth and rate with use of the abdominal muscles

The correct assessment sequence of the abdomen is as follows.

• inspection, auscultation, palpation

• inspection, palpation, auscultation

• palpation, inspection, auscultation

• auscultation, palpation, inspection

A patient is admitted with a dx of a stroke. She becomes frustrated because she is unable to respond verbally to the nurse's questions. This will be charted as:

• dysphagia

• aphasic

• dysphasia

• dyspneic

How would you document respirations that are regular, however they are abnormally deep and rapid.

• Cheyne-Stokes

• bradypnea

• biot

• Kussmauls

Post-operatively, a patient who has had knee replacement surgery exhibits slurred speech and c/o moderate pain, what is an appropriate nurse measure

• calls the dr immediately because she is having a stroke due to a blood clot that traveled from her legs post-op

• instructs the patient to let the nurse know if the pain or the slurred speech gets worse, then reassess the patient in 4 hours

• check the patient's chart to determine whether the slurred speech can be attributed to post-op medications. if not, summons MD to determine she is having post-op complications

• ask the dr to adjust the patient's pain meds to relieve the pain and prevent any further slurring of speech

What can be detected through palpation?

• distension of bladder

• skin turgor

• edema

• hyperinflated lungs

• pain