NR-226 Patient Care Fundamentals - Set 4 - Part 1

Correct Answer: Ask him directly using a validated scale

Culture shapes how pain is expressed, not how much a person hurts. Asking the client directly and regularly with a validated tool obtains the self-report that observed behavior would otherwise hide and prevents undertreatment. Option a is incorrect because respecting a preference does not extend to skipping assessment altogether. A client may choose not to volunteer pain and still answer honestly when the nurse asks, and withholding the question guarantees undertreatment. Option b is incorrect because behavioral indicators only support a report when they appear. This client is deliberately suppressing them, so an observation-based score would read as comfort in someone who may be in severe pain. Option c is incorrect because surrogate report belongs further down the assessment hierarchy and applies when a client cannot answer. Routing the question through relatives who share the same expectation about stoicism adds a filter rather than information.

Correct Answer: "This drug can cause confusion and urinary retention."

First-generation antihistamines are strongly anticholinergic and sit on the list of medications to avoid in adults sixty-five and older. Confusion, falls and urinary retention are real, and retention is a particular hazard with prostatic enlargement. Option b is incorrect because occasional dosing still exposes an older man with outflow obstruction to anticholinergic harm. The nurse's job is to steer him away from the drug, not to ration it. Option c is incorrect because nonprescription status says nothing about safety in this age group. Sedating antihistamines sit alongside benzodiazepines and the newer hypnotics among the agents geriatric criteria tell clinicians to avoid. Option d is incorrect because tolerance to the sedating effect develops within days while the anticholinergic burden does not fade. Doubling the dose buys no extra sleep and multiplies the risk of delirium and a fall.

Correct Answer: REM sleep behavior disorder with lost atonia

Dream enactment late in the night with clear recall points to loss of the muscle paralysis that normally accompanies rapid eye movement sleep. Bedroom safety comes first, along with referral for a sleep study. Option a is incorrect because sleep terrors erupt in the first third of the night out of the deepest stage, with screaming, drenching autonomic arousal, inconsolability and no memory of the event afterward. Option b is incorrect because a confusional arousal leaves the person disoriented and slow rather than physically fighting, and it too belongs to early deep sleep. Recall is poor, which this husband's clear account rules out. Option d is incorrect because a focal seizure produces stereotyped, repetitive movements lasting a minute or two, often with postictal confusion. The behavior here is complex, varied and tied to reported dream content instead.

Correct Answer: A widened pulse pressure with stiffened arteries

Elastin in the great vessels is replaced by stiffer collagen, so the aorta cannot buffer ejection. Systolic pressure rises and pulse pressure widens, which is the expected hemodynamic signature of an aging arterial tree. Option a is incorrect because an irregular rhythm suggests atrial fibrillation, a treatable disease rather than a change of age. The aging ventricle fills poorly without atrial contraction, so this rhythm is tolerated badly. Option b is incorrect because reserve falls with age but resting and light activity should not produce symptoms. New breathlessness on a short walk is dyspnea on exertion, and that belongs in the provider's hands. Option c is incorrect because dependent swelling points to heart failure, venous disease or a drug effect. Aging redistributes subcutaneous fat and thins the skin, yet it does not by itself fill the tissues with fluid.

Correct Answer: Get up and do something quiet elsewhere

Stimulus control rebuilds the bed as a cue for sleep alone. When sleep does not come within about fifteen to twenty minutes, leaving the bedroom and returning only when sleepy breaks the conditioned arousal. Option a is incorrect because remaining awake in bed is the very behavior that maintains chronic insomnia. Each frustrating hour strengthens the link between the mattress and wakefulness rather than weakening it. Option b is incorrect because the bed is reserved for sleep and sex only. Reading there, like working or watching television, keeps the bedroom paired with alert activity, which is what this program dismantles. Option d is incorrect because clock-watching feeds anticipatory anxiety and raises arousal further. Standard teaching is the opposite: turn the face of the clock away so the client stops calculating how little sleep remains.

Correct Answer: Incisional pain rated higher than yesterday

Rising pain after surgery must be assessed on its own merits, since it can signal a developing complication. It also drives the cycle in which broken sleep lowers the pain threshold and worse pain breaks sleep further. Option b is incorrect because yawning is an ordinary expression of accumulated sleep pressure and carries no independent danger. It supports the picture of deprivation without pointing to anything that needs investigating today. Option c is incorrect because hand tremor sits on the standard list of neurological effects of sleep loss, alongside slowed reflexes and clumsiness. It will settle once the client obtains consolidated sleep. Option d is incorrect because irritability and emotional lability appear early in anyone losing sleep and are not themselves an emergency. Naming them for the client and protecting a block of rest addresses the source.

Correct Answer: Assess her airway, circulation and neurologic status

Assessment comes before movement after any fall. Airway, breathing, circulation and level of consciousness come first, and an anticoagulated client carries a real risk of intracranial bleeding that a rushed lift could worsen. Option a is incorrect because lifting a client before assessment can displace a hip fracture or worsen a spinal injury. She is safe on the floor for the minute it takes to examine her. Option b is incorrect because paperwork follows care rather than preceding it. The incident report is an administrative document kept outside the medical record, and filling it out does nothing for a client still on the floor. Option c is incorrect because the nurse needs assessment data before calling, and the provider will ask for it. Imaging may well be ordered for an anticoagulated client, but that decision rests on findings not yet gathered.

Correct Answer: I will wear the patch twelve hours and remove it.

The lidocaine patch is worn on intact skin for twelve hours and then left off for twelve. That schedule limits systemic absorption while delivering steady relief directly over the painful strip of skin. Option b is incorrect because a topical patch goes on clean, dry, intact skin only. Broken or blistered skin absorbs far more drug and raises the risk of systemic local anesthetic toxicity. Option c is incorrect because lidocaine delivered through the skin works where it is applied. Widespread pain calls for a systemic analgesic, and expecting whole body relief from one patch sets the client up for disappointment. Option d is incorrect because the patch is a co-analgesic added to the plan rather than a replacement for it. Stopping the other medicines without telling the prescriber would leave the nerve pain undertreated.

Correct Answer: Gastric bleeding, kidney injury and thrombotic events

The FDA class boxed warning for nonaspirin NSAIDs covers both serious gastrointestinal bleeding, ulceration and perforation and cardiovascular thrombotic events. Blocking renal prostaglandins also drops glomerular filtration, which this client's kidneys and heart cannot tolerate. Option a is incorrect because that cluster belongs to other drugs entirely. Hepatic necrosis is the acetaminophen hazard, while sedation and urinary retention are opioid effects, and none of the three is characteristic of naproxen. Option b is incorrect because Reye syndrome is tied to aspirin in children during a viral illness, not to naproxen in an older adult. Tinnitus signals salicylate excess, a different problem again. Option d is incorrect because those three findings together describe opioid toxicity. NSAIDs do not act on mu receptors, so they neither depress the brainstem drive to breathe nor constrict the pupils.

Correct Answer: Nonblanching redness over the right heel

Redness that does not blanch is a stage one pressure injury, not a normal age change. Age thins the padding over the heel, but a pressure injury signals unrelieved pressure and demands off-loading now. Option a is incorrect because lentigines are uneven melanocyte activity in sun-exposed skin and carry no urgency. What would warrant attention on a forearm is a lesion changing in size, border or color, which is not described. Option b is incorrect because reduced sebaceous and sweat gland output leaves aged skin dry and flaking. Comfort measures such as a mild cleanser and moisturizer on damp skin belong here, but no injury has occurred yet. Option c is incorrect because thinning epidermis and lost subcutaneous fat make superficial veins visible in nearly every older adult. That transparency raises skin tear risk and calls for careful handling rather than an intervention for injury.

Correct Answer: "I will get up at the same time every morning."

A fixed rise time is the strongest anchor for the internal clock, and holding it seven days a week stabilizes sleep timing more effectively than setting a bedtime does. Option a is incorrect because the body must shed heat to fall asleep, so a cool bedroom promotes onset while a warm one delays it. The night light is reasonable, but the temperature plan is wrong. Option b is incorrect because vigorous activity raises core temperature, heart rate and sympathetic tone just when the body needs them falling. Regular exercise helps sleep, provided the hard effort finishes a couple of hours earlier. Option d is incorrect because the bed should be paired with sleep alone. Screens in bed deliver light that suppresses melatonin and content that holds attention, so the habit trains the brain to stay alert there.

Correct Answer: Instrumental activities are failing before basic self-care

Instrumental activities such as managing money and medications carry the heaviest cognitive load, so they fail first. Intact bathing, dressing and feeding alongside these losses is the early functional signature of cognitive decline. Option b is incorrect because the client still performs every basic self-care task described. Bathing, dressing and feeding belong to the Katz index, and independence in all of them places her at the top of that scale. Option c is incorrect because slower name retrieval is expected while failing at a task once done reliably is not. A new dependence in any activity is the geriatric equivalent of a changed vital sign. Option d is incorrect because severe impairment describes someone dependent in most basic activities, which does not fit this picture. Naming her severely impaired now would overstate her needs and could cost her independence she still has.

Correct Answer: Autonomic adaptation typical of persistent pain

The sympathetic response to pain adapts over time, so vital signs normalize and clients with long-standing pain learn to appear composed. Normal findings and calm behavior never disprove the report; the pain is real and needs treatment. Option a is incorrect because nothing here suggests the client is overstating anything. Judging a rating against how composed someone looks replaces the only direct evidence of pain, which is what that person tells you. Option b is incorrect because drug-seeking is a behavioral pattern involving loss of control and use despite harm, none of which is described. Reporting a client to the provider for looking comfortable perpetuates undertreatment of chronic pain. Option d is incorrect because a rating of seven out of ten is the opposite of adequate control. The composed appearance reflects adaptation rather than success, and the regimen needs review against a functional goal.

Correct Answer: The client has delirium superimposed on his dementia

An abrupt change over hours, fluctuating alertness and lost attention are delirium, not dementia progression. Dementia advances over months and leaves consciousness clear, so this sudden overlay signals an acute physiological cause needing investigation. Option a is incorrect because dementia worsens gradually across months and years, never within a single evening. Late-stage decline brings loss of speech and total dependence, not a client who was calm all week. Option b is incorrect because sundowning is a description rather than a diagnosis. Even in dementia, a sudden behavior change must be evaluated as possible delirium before anyone attributes it to the time of day. Option c is incorrect because depressed older adults keep a clear sensorium and intact attention while mood drives the picture over weeks. Drowsiness alternating with agitation within one hour points away from a mood disorder.

Correct Answer: Multimodal analgesia using different drug mechanisms

Multimodal analgesia combines agents that act at different points in the pain pathway, so each drug can be given at a lower dose. The result is better relief with fewer adverse effects. Option b is incorrect because around the clock dosing describes the timing of a single agent, not the pairing of several mechanisms. This regimen does schedule two drugs, but its defining feature is mechanism variety. Option c is incorrect because equianalgesia refers to converting a dose from one opioid or route to an equivalent dose of another. No conversion is happening here; four separate classes are running together. Option d is incorrect because preemptive analgesia is defined by when the drug is given, before the painful stimulus begins. Timing is not what this order set describes; the mix of classes is.

Correct Answer: Neuropathic pain responds poorly to opioids alone

Burning, shooting sensations with allodynia point to damage of the somatosensory nervous system itself. Neuropathic pain responds poorly to opioids and preferentially to adjuvants such as anticonvulsants and antidepressants, so the class needs changing. Option a is incorrect because tolerance develops after a dose has been working and gradually loses its effect. This client got almost nothing from the drug at the start, which points to the wrong class rather than adaptation. Option b is incorrect because somatic pain originates in skin, muscle, bone and joints and is described as sharp or aching, not electric. Raising an opioid dose for nerve pain adds side effects without adding relief. Option c is incorrect because feet are not viscera. Visceral pain arises in internal organs and presents as cramping, squeezing and poorly localized discomfort, so an antispasmodic has no target in a damaged peripheral nerve.

Correct Answer: Assess the client's sedation and respiratory status

Proxy dosing removes the safety feature that a drowsy client stops pressing, so the immediate concern is oversedation and respiratory depression. Assessment of the client comes before teaching, reporting or any change to the pump. Option b is incorrect because teaching the spouse is required but does not come first. The spouse has already delivered the doses, and the client may be sedated right now while the teaching happens. Option c is incorrect because filing an occurrence report belongs at the end of this sequence. Documentation systems capture what happened; they do nothing about a client who may be hypoventilating at the bedside. Option d is incorrect because the pump settings were not the problem; unauthorized presses were. Lowering the demand dose could leave the client undermedicated once the family stops activating the pump.

Correct Answer: 4,000 mg in 24 hours

The traditional healthy adult ceiling is 4,000 mg in 24 hours from all sources combined. Current product labels often set a lower limit near 3,000 mg, but 4,000 mg remains the classic teaching. Option a is incorrect because 1,000 mg represents a single typical dose rather than a daily ceiling. Teaching this number would leave a client with treatable pain undermedicated for no safety benefit. Option b is incorrect because 2,000 mg is the reduced ceiling reserved for hepatic impairment, chronic heavy alcohol use, malnutrition or frailty. This client has none of those risk factors. Option d is incorrect because exceeding the daily ceiling saturates conjugation and drives acetaminophen down the pathway that forms NAPQI. Glutathione is overwhelmed, and centrilobular liver necrosis follows.

Correct Answer: Unmyelinated C fibers carrying second pain

C fibers are unmyelinated and conduct slowly, producing the delayed, diffuse, burning second pain that outlasts the injury. The immediate sharp jolt that triggered withdrawal came from the faster A-delta fibers. Option b is incorrect because A-delta fibers produced the first sensation, not the second. Their thin myelin allows fast conduction and small receptive fields, which is why that jolt was sharp, brief and easy to localize. Option c is incorrect because large A-beta fibers carry touch, pressure and vibration rather than nociceptive traffic. Stimulating them is what closes the spinal gate, which is why rubbing the burned hand actually eases the pain. Option d is incorrect because descending pathways travel downward from the brainstem to dampen incoming signals at the dorsal horn. They belong to modulation and carry nothing from the periphery toward the brain at all.

Correct Answer: The PAINAD behavioral scale

PAINAD was built and validated specifically on the behavioral repertoire of advanced dementia, scoring breathing, negative vocalization, facial expression, body language and consolability. Moaning and resisting care are exactly what it captures. Option a is incorrect because the faces scale is still a self-report tool that asks the client to pick the picture matching how much it hurts. A resident who cannot speak or comprehend cannot make that choice. Option b is incorrect because that tool was validated in critically ill adults and includes ventilator compliance as a scored item. A long-term care resident who is not critically ill falls outside the population it was designed for. Option d is incorrect because choosing among words like mild, moderate and severe requires speech and comprehension. That scale suits an older adult with mild impairment who still communicates, which this resident no longer does.