Download 1 - MedSurgFinal

Neuro, Pain, Eyes & Ears
By: Cynthia Fong, Madelene Funtanilla, Angela Minjarez, Carrie Shepherd & Nancy Yan
Pain Questions
1. An 85-year-old male patient with a history of prostate cancer and metastasis to the
lumbar spine is receiving current treatment of methadone (Dolophine) 10 mg 3 times a
day. The patient is seen in the clinic for re-evaluation. The patient's wife tells the pain
management nurse that her husband exhibits a lack of motivation, loss of appetite, and
inability to get out of bed. The nurse initially focuses on the:
a.
b.
c.
d.
assessment of pain.
need for antidepressants.
physical therapy evaluation.
psychological evaluation.
Rationale: While there may be a need for antidepressants, a physical therapy evaluation,
and a psychological evaluation, lack of motivation, loss of appetite, and inability to get
out of bed may be directly related to pain. Initial focus should be placed on assessment of
pain. Remember pain is the 5th vital sign!
2. Which medication is the best choice to treat breakthrough pain for a patient who is
currently receiving methadone (Dolophine) 10 mg every 8 hours?
a.
b.
c.
d.
Codeine
Controlled-release morphine
Immediate-release morphine
Transdermal fentanyl
Rationale: Immediate-release morphine is used to treat moderate to severe pain and
works faster than controlled-release morphine. Codeine is used for mild to moderate pain.
Transdermal fentanyl is used to treat moderate to severe chronic pain and is delivered
slowly through the skin. Of the available choices, immediate-release morphine would be
the best choice to treat breakthrough pain.
3. Which statement about the administration of acetaminophen to children is correct?
a.
b.
c.
d.
Acetaminophen affects platelet aggregation.
Acetaminophen causes gastric irritation.
Acetaminophen does not have an analgesic ceiling.
Acetaminophen has an analgesic ceiling.
Rationale: While acetaminophen has been shown to decrease platelet aggregation and
may cause gastric irritation, the main concern regarding administration has to do with an
analgesic ceiling. Acetaminophen has an analgesic ceiling, meaning that at a certain dose
there is no additional analgesic effect. (Higher doses will not provide any additional pain
relief, but may increase the likelihood of side effects. Pediatric dosages for pain: <1
month = 10-15 mg/kg/dose Q6-8H PRN, >1 month-12 years = 10-15 mg/kg/dose Q4-6H
PRN (NTE 5 doses in 24H), >12 years = 325-650 mg Q4-6H OR 1000 mg Q6-8H. Single
doses larger than 1 gm may not provide additional therapeutic benefit and alternative pain
medications may be necessary.)
4. Biofeedback is a therapy used to:
a.
b.
c.
d.
develop psycho-physiologic self-regulation.
enhance drug delivery.
increase release of serotonin.
promote neuronal regeneration.
Rationale: Biofeedback is a technique in which a person learns to use thoughts in order to
control his/her body. It is generally done to help with a health condition, physical
performance, or as a relaxation technique. Biofeedback may enhance drug delivery,
increase release of serotonin, and promote neuronal regeneration, however, the best
answer of the available choices is, in fact, the definition of the therapy, rather than its
possible effects.
5. A 72-year-old man with severe scoliosis is undergoing staging procedures to straighten
his neck. The physician ordered acetaminophen with codeine (Tylenol #3), 1 tablet by
mouth every 6 hours as needed for pain. Two hours after receiving a Tylenol #3 tablet,
the patient reports a neck pain which he rates as 8 on a numeric pain scale of 0 to 10. The
nurse:
a.
b.
c.
d.
calls the physician to increase the dose to 2 tablets.
contacts the physician to discuss modifications to the treatment plan.
explains to the patient that the next dose of analgesic is not due for 4 hours.
immediately administers a second dose of Tylenol #3.
Rationale: Since the patient is still reporting 8 out of 10 pain two hours after receiving a
Tylenol #3 tablet, contacting the physician to discuss modifications to the treatment plan
would be a good decision. The peak analgesic effect of the Tylenol #3 should be reached
two hours after administration. It would not help to reduce the patient’s pain to simply
explain that the next dose of analgesic is not due for 4 hours. Since the order is for 1
tablet by mouth every 6 hours as needed, the nurse would not be able to administer a
second dose of Tylenol #3 without receiving a new order from the physician. While
calling the physician to increase the dose to 2 tablets might be an option, the better option
would be to discuss the treatment plan in order to optimize pain management.
Neuro I Questions:
1. The nurse is caring for a client following a motor vehicle accident. During a
neurological assessment when eliciting the client’s response to pain, the client
pulls his arms inward and upward. This position represents: Select all that apply
a.
b.
c.
d.
e.
Decerebrate posturing
Decorticate posturing
Injury to the brainstem
Injury to the pons
Injury to the midbrain
Answer: B,E
Decorticate posturing is a late sign of significant deterioration in neurological
status and is manifested by client’s rigidly flexing their elbows and wrists (option
2). Decorticate posturing indicates injury to the midbrain (option 5).
Decerebration (option 1) frequently precedes brainstem herniation (option 3)
while option 4(pons) is not directly related to the question.
2. A client newly diagnosed with trigeminal neuralgia asks the nurse to explain why
it hurts so much when an episode occurs. Which of the following is the best
response by the nurse? “The pain is caused by:
a. Stimulation of the nerve by temperature or pressure”
b. Irritation due to cellular effects of hypoglycemia”
c. Release of epinephrine during the flight or fight response”
d. An immune system reaction to cold and influenza viruses”
Answer: A
The pain of trigeminal neuralgia is triggered by stimulation of sensory fibers of
the trigeminal nerve, causing excessive firing to the irritated nerve. Minimal
stimulation can evoke severe episodes of pain. Stimulation can be caused by
pressure-related triggering events including shaving, brushing your teeth, eating
or drinking. Temperature related triggers include environmental changes and hot
and cold foods and drinks (option 1). Hypoglycemia (option 2), epinephrine
(option 3) and immune response (option 4) are unrelated to trigeminal neuralgia.
3. A client is taking pheytoin (Dilantin) for seizure control. A sample is drawn to
determine the serum drug level, and the nurse reviews the results. Which of the
following would indicate a therapeutic serum drug range?
a. 5 to 10mcg/ml
b. 10 to 20 mcg/ml
c. 20 to 30 mcg/ml
d. 30 to 40 mcg/ml
Answer: B
The therapeutic serume drug level range for phenytoin is 10 to 20 mcg/ml
4. The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as
prescribed by the physician for the client with seizures. Which of the following
solutions will the nurse plan to use to dilute this medication?
a. Dextrose 5%
b. Normal saline solution
c. Lactated Ringers
d. Dextrose 5% and half normal saline (0.45%)
Answer: B
IV infusion of phenytoin should be administered by injection into a large bein.
The medication may be diluted with normal saline (Option 2). Dextrose solution
should be avoided because of medication precipitation.
5. The nurse is admitting a client with Guillain-Barre syndrome to the unit. The
client has an ascending paralysis to the level of the waist. Knowing the
complications of the disorder, the nurse brings which of the following items into
the clients room?
a. Nebulizer and pulse ox
b. Blood pressure cuff and flashlight
c. Flashlight and incentive spirometer
d. Electrocardiographic monitoring electrodes and intubation tray
Answer: D
The client with Guillain-Barre syndrome is at risk for respiratory failure because
of ascending paralysis. An intubation tray should be avialble for use. Another
complication of this syndrome is cardiac dysrhythmias which is why
electrocardiographic monitoring is needed.
Eyes Questions
1. Which client is in most need of immediate examination by an
ophthalmologist?
A. 58-year-old with glasses who reports an inability to see colors well and
feeling like his or her glasses are always smudged.
B. 40-year-old with glasses and a reddened sclera who reports brow pain,
headache, and seeing colored halos around lights
C. 76-year-old with seborrhea of the eyebrows and eyelids who reports burning
and itching of the eyes
D. 39-year-old with contacts who reports an inability to tolerate bright lights and
has visible purulent drainage on eyelids and eyelashes
Rationale: This client is exhibiting signs and symptoms of increased intraocular
pressure. This is a priority because the optic nerve can be damaged, which can cause
possible blindness.
2. The client with new-onset diminished vision is being discharged and is
concerned about living independently. Which technique best facilitates
independent self-care for the client?
A. Building on the remaining vision
B. Keeping the floor free of clutter
C. Suggesting a seeing eye animal companion
D. Teaching Braille
Rationale: Using large print books, talking clocks, and telephones with large, raised
block numbers are examples of building on the client’s remaining vision. Keeping the
floor free of clutter is important, but is too specific. A seeing-eye animal companion
may be assigned to those who are legally blind, not to those with diminished vision.
Braille is used by clients who are legally blind. This client, who has impaired vision,
will still be able to read using a magnification device, such as a visualizer.
3. That is the action of miotics in the client with glaucoma?
A. Decreases the inflammatory process
B. Enhances aqueous outflow
C. Increases the production of vitreous humor
D. Vasoconstricts the blood vessels in the eye
Rationale: Miotics improve the flow of fluid (aqueous humor) and decrease
intraocular pressure. Miotics do not decrease the inflammatory process, steroid
eyedrops do. Vitreous humor fills the space between the lens and the retina, is
stagnant, and is not replenished like aqueous humor. Miotics make the pupil smaller,
which makes more room between the iris and the lens.
4. The client has recently had cataract surgery. About which symptom does the
nurse instruct the client to notify the physician?
A. Increased tearing
B. Itching of the eye
C. Reduction in vision
D. Swollen eyelid
Rationale: A reduction in vision after cataract surgery indicates a problem, and the
client should notify the physician immediately. Increased tearing, itching of the eye,
and swollen eyelid are expected after cataract surgery.
5. Which information about a 65-year-old patient is most important for the nurse
working in the ophthalmology clinic to report to the physician?
A. The pupil size is 4 mm in normal light.
B. The patient has arcus senilis around the iris.
C. The patient has difficulty reading fine print.
D. The sclera is visible above the patient’s iris.
Rationale: The sclera should not be visible above the iris; the patient will need further
investigation to determine the cause of the exophthalmos. The other findings are
normal in older patients.
Ear Questions
1. What should you expect to notice in a patient with adequate sensation related to the ear
and hearing?
A. Startles when a loud or unexpected sound occurs in the environment
B. An elongated pinna
C. Engages in appropriate conversation
D. The ability to hear high frequency sounds
B - Rationale: The Pinna becomes elongated because of loss of subcutaneous tissue and
decreased elasticity.
2. The nurse should do the following to enhance therapeutic communication with the
hearing impaired (select all that apply)
A.
B.
C.
D.
Speak slowly and distinctly
Spend little time on teaching and change topics quickly
Turn the TV or radio down or off
Begin with casual topics then progress to more critical ones
A, C, D – Rationale: The nurse should not switch topics abruptly and she should spend
more time on teaching to ensure that the patient understands.
3. After the nurse has examined a patient’s ear using an otoscope, which finding is most
important to report to the physician?
A. The light reflex is triangular in shape
B. Light brown cerumen is present in the ear canal
C. Pain occurs when pulling the pinna up and back
D. Visible scarring is observed on the eardrum
C - Rationale: Pain when manipulating the pinna is an unexpected finding that should be
investigated further, since it may indicate acute problems such as otitis media. A and C
are normal findings, and B may be the result of an old middle ear infection or trauma
4. Which nursing action can the nurse working in the speech and hearing clinic delegate
to a medical assistant?
A. Interview the patient about current hearing problems
B. List risk factors for hearing loss based on patient history
C. Assess the external ear structures for abnormalities
D. Set up equipment for pure tome and speech audiometry
D - Rationale: A medical assistant can set up equipment for audiometry. The other
actions require more education and scope of practice and should be done by licensed
nursing staff.
5. Your patient is a 74-year-old man with a history of diabetes and hypertension. He had
an upper respiratory infection and is now complaining of pain in his left ear and
decreased ability to hear. Otitis media is diagnosed. He has been shown how to instill his
eardrops. He is being discharged on an antihistamine and a decongestant. He has been
readmitted because of a ruptured eardrum. What would you expect to give this patient for
pain?
A. Ibuprofen (Advil)
B. Aspirin
C. Acetaminophen (Tylenol)
D. Codeine
D – Rationale: Analgesics such as aspirin, ibuprofen (Advil), and acetaminophen
(Tylenol, Abenol)relieve pain and reduce fever, helping the patient feel better. When pain
is severe, opioid analgesics such as codeine and meperidine hydrochloride (Demerol) also
may be used.