NURS 120 LCCC Midterm exam
The nurse is preparing to assess comfort for several clients. If the nurse, in addition to
assessing the client's physical experience of pain, assesses whether the client has a
present and reliable personal support network, then the nurse is assessing which
context of holistic human experience during this process?
A) Transcendence
B) Environmental
C) Psych spiritual
D) Sociocultural - answer Answer: D
Explanation: D) Comfort is the experience of having needs for relief and ease met in
four contexts: physical, psychospiritual, sociocultural, and environmental. Sociocultural
comfort is related to family and social relationships, which a personal support network
would exemplify. Transcendence is not a context of holistic human experience.
The nurse provides an in-service to peers regarding situations that can affect the
comfort level of the clients on the unit. Which client statement indicates that the client's
sense of well-being is negatively impacted?
A) "I feel like I have no energy today."
B) "I don't feel any physical pain today."
C) "I was able to sleep uninterrupted last night."
D) "I am so glad that playing cards takes my mind off my worries." - answerAnswer: A
Explanation: A) Fatigue is a lack of energy and motivation. A fatigued client is unable to
focus on healing and lacks the ability to cope in stressful situations. Restful sleep,
physical well-being without pain, and appropriate diversion all promote a sense of
comfort for the client.
A client is experiencing sudden-onset severe pain in the left lower quadrant of the
abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing
nausea, vomiting, and restlessness. Based on this data, the nurse concludes that the
client is experiencing which phenomenon?
A) Acute pain
B) Chronic pain
C) End-of-life pain
D) Fibromyalgia pain - answerAnswer: A
Explanation: A) Duration establishes the difference between acute and chronic pain.
Acute pain is defined as pain that lasts only through the expected recovery period,
which is usually 30 days to 6 months. Acute pain typically has a sudden onset related to
injury, surgery, or illness. Chronic pain outlasts the illness and extends beyond the
recovery period. End-of-life and fibromyalgia would most likely involve chronic pain.
The nurse is preparing to assess a 1-year-old client for signs of discomfort. When
conducting the assessment, which action by the nurse is the most appropriate?
,A) Asking the client to rate the pain on a scale of 0-10 during the assessment process
B) Asking the parent to hold the client in the lap during the assessment process
C) Reading a book to the client during the assessment process
D) Recommending that the parent leave the room during the assessment process -
answerAnswer: B
Explanation: A) Children may be fearful of physical assessment. To promote comfort,
allow the child to sit on the parent's or guardian's lap during the assessment process,
rather than asking the parent to leave the room. A numeric pain scale is not appropriate
until the client is older; a faces pain scale would be better. Reading a book during the
assessment process is not age appropriate.
The nurse is caring for a pediatric client with a surgical wound. The wound is red with
purulent drainage and is causing discomfort for the client. Which diagnostic test will
determine if the discomfort of the wound is caused by an infection?
A) White blood cell count
B) Hematocrit measurement
C) Urine analysis
D) X-rays of the site - answerExplanation: A) There are a few tests that can help the
medical team determine the source of the client's discomfort. In this case, a white blood
cell count will determine if the discomfort is being caused by an infection. An x-ray is
useful for determining the existence of physical injuries, not the presence of infection.
Urine analysis may indicate illness or malnutrition, whereas hematocrit measurement
may identify iron deficiency anemia.
An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed
on the examination table. The parent attempts to comfort the toddler, but nothing is
effective. Which action by the nurse is the most appropriate?
A) Allow the toddler to sit on the parent's lap and begin the assessment.
B) Allow the toddler to stand on the floor until the crying stops.
C) Ask another nurse in the office to hold the toddler because the parent is not able to
control the toddler's behavior.
D) Instruct the parent to hold the toddler down tightly to complete the examination. -
answerAnswer: A
Explanation: A) Toddlers are most comfortable when sitting with the parents.
Vaccinations can be administered in this way if the parent is taught proper therapeutic
holding techniques to keep everyone safe for the procedure. Allowing the toddler to
stand on the floor or holding the toddler down tightly are inappropriate. A nurse can
assist if the parent is unable to hold the child during the vaccinations to prevent injury
from movement.
The nurse is caring for a client who is experiencing acute chest pain that is rated as a 9
on a 0 to 10 pain scale. Based on this data, which medication does the nurse expect to
administer?
A) Acetaminophen
B) Morphine
C) Ibuprofen
,D) Naproxen - answerAnswer: B
Explanation: A) Acute pain is often treated with an opioid such as morphine. Morphine is
often used to treat chest pain that is associated with a myocardial infarction.
Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain,
not acute chest pain.
B) Acute pain is often treated with an opioid such as morphine. Morphine is often used
to treat chest pain that is associated with a myocardial infarction. Acetaminophen,
ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest
pain.
The nurse is designing a teaching plan for community members on ways to prevent
chronic pain. Which information should the nurse include in this teaching plan? Select
all that apply.
A) Eating a healthy diet
B) Obtaining adequate sleep
C) Avoiding illicit drug use
D) Limiting smoking to only before bedtime
E) Avoiding repetitive movements - answerAnswer: A, B, C, E
Explanation: A) Lifestyle habits that predispose individuals to chronic health alterations
increase an individual's risk for experiencing discomfort. Eating a healthy diet and
obtaining adequate sleep can prevent the development of chronic diseases that lead to
symptoms of discomfort. Using illicit drugs and smoking can cause emotional and
physical withdrawal symptoms when the drug is no longer used. It is wise to not engage
in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements
can increase the risk for injury and fatigue, leading to discomfort.
9) Which client is most likely to reject attempts at comfort?
A) An infant crying
B) A school-age child with abdominal pain who is anxious about a procedure
C) An adolescent with a sleep disorder who doesn't want his parents to be near him
D) An older adult with end-stage renal disease - answerAnswer: C
Explanation: A) Adolescents may respond to treatment and comfort better if you interact
with them as adults rather than as children. Some adolescents may reject any offer of
comfort, and an adolescent with a sleep disorder who has displayed antagonism toward
his parents' presence is probably irritable from his condition and may immediately reject
attempts at comfort, at least at first. An infant crying is verbalizing the need for comfort.
A school-age child anxious about a medical procedure craves reassurance. An older
adult with a terminal illness likely will welcome comfort measures even if she has
accepted that she is going to die.
Which of the following is a pharmacologic therapy for acute pain?
A) Antidepressants
B) Muscle relaxants
C) Opioid analgesics
D) Stimulants - answerAnswer: C
, Explanation: A) Pharmacologic pain management for acute pain involves opioid
analgesics, nonopioid analgesics, or nonsteroidal anti-inflammatory drugs (NSAIDs). It
does not involve antidepressants, stimulants, or muscle relaxants.
Which of the following statements best describes the therapeutic approach to acute and
chronic pain, fatigue, fibromyalgia, and sleep disorders?
A) Therapy is primarily psychosocial in nature.
B) Therapy involves both pharmacologic and nonpharmacologic approaches.
C) Therapy is essentially physiologically focused.
D) Therapy mostly involves the client avoiding risk behaviors. - answerAnswer: B
Explanation: A) For all of these conditions, therapy involves both pharmacologic and
nonpharmacologic approaches. Therapy for these conditions is both physiological and
psychosocial, addressing all components of client's conditions. Therapy involves
treatment of existing conditions, not just risk prevention measures on the client's part.
Which of the following best characterizes the sociocultural context of holistic human
experience?
A) Balance of physical processes
B) Connection to a higher power
C) Connection to others
D) Equilibrium with external circumstances - answerAnswer: C
Explanation: A) The sociocultural context of holistic human experience involves
connection with others in society. Connection to a higher power is involved in the
psychospiritual context. Homeostatic balance is involved in the physical context.
Equilibrium with external circumstances is involved in the environmental context.
What is an example of chronic pain?
A) Pain that precedes injury
B) Pain that follows injury and ends when healing is complete
C) Pain that is felt during injury and immediately after
D) Pain that outlasts the healing process - answerAnswer: D
Explanation: A) Chronic pain is pain that lasts beyond the expected time of healing,
usually for at least 6 months; it does not always have a known cause. Pain can range
from mild to severe, and autonomic responses decrease over time as the body adapts
to the persistent pain impulses. Chronic pain does not precede injury, nor does it
subside immediately after injury, and it may not be related to an injury. It does not end
when healing is complete.
2) What is the relationship between a full opioid agonist and the ceiling effect?
A) A full opioid agonist produces few withdrawal symptoms when the drug's effects
plateau and the client begins easing off the drug.
B) A client may use a full opioid agonist as much or as little as necessary to control
chronic pain with no ill effects.
C) Side effects may limit a full opioid agonist's use but not a plateau in the beneficial
effects it produces.
The nurse is preparing to assess comfort for several clients. If the nurse, in addition to
assessing the client's physical experience of pain, assesses whether the client has a
present and reliable personal support network, then the nurse is assessing which
context of holistic human experience during this process?
A) Transcendence
B) Environmental
C) Psych spiritual
D) Sociocultural - answer Answer: D
Explanation: D) Comfort is the experience of having needs for relief and ease met in
four contexts: physical, psychospiritual, sociocultural, and environmental. Sociocultural
comfort is related to family and social relationships, which a personal support network
would exemplify. Transcendence is not a context of holistic human experience.
The nurse provides an in-service to peers regarding situations that can affect the
comfort level of the clients on the unit. Which client statement indicates that the client's
sense of well-being is negatively impacted?
A) "I feel like I have no energy today."
B) "I don't feel any physical pain today."
C) "I was able to sleep uninterrupted last night."
D) "I am so glad that playing cards takes my mind off my worries." - answerAnswer: A
Explanation: A) Fatigue is a lack of energy and motivation. A fatigued client is unable to
focus on healing and lacks the ability to cope in stressful situations. Restful sleep,
physical well-being without pain, and appropriate diversion all promote a sense of
comfort for the client.
A client is experiencing sudden-onset severe pain in the left lower quadrant of the
abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing
nausea, vomiting, and restlessness. Based on this data, the nurse concludes that the
client is experiencing which phenomenon?
A) Acute pain
B) Chronic pain
C) End-of-life pain
D) Fibromyalgia pain - answerAnswer: A
Explanation: A) Duration establishes the difference between acute and chronic pain.
Acute pain is defined as pain that lasts only through the expected recovery period,
which is usually 30 days to 6 months. Acute pain typically has a sudden onset related to
injury, surgery, or illness. Chronic pain outlasts the illness and extends beyond the
recovery period. End-of-life and fibromyalgia would most likely involve chronic pain.
The nurse is preparing to assess a 1-year-old client for signs of discomfort. When
conducting the assessment, which action by the nurse is the most appropriate?
,A) Asking the client to rate the pain on a scale of 0-10 during the assessment process
B) Asking the parent to hold the client in the lap during the assessment process
C) Reading a book to the client during the assessment process
D) Recommending that the parent leave the room during the assessment process -
answerAnswer: B
Explanation: A) Children may be fearful of physical assessment. To promote comfort,
allow the child to sit on the parent's or guardian's lap during the assessment process,
rather than asking the parent to leave the room. A numeric pain scale is not appropriate
until the client is older; a faces pain scale would be better. Reading a book during the
assessment process is not age appropriate.
The nurse is caring for a pediatric client with a surgical wound. The wound is red with
purulent drainage and is causing discomfort for the client. Which diagnostic test will
determine if the discomfort of the wound is caused by an infection?
A) White blood cell count
B) Hematocrit measurement
C) Urine analysis
D) X-rays of the site - answerExplanation: A) There are a few tests that can help the
medical team determine the source of the client's discomfort. In this case, a white blood
cell count will determine if the discomfort is being caused by an infection. An x-ray is
useful for determining the existence of physical injuries, not the presence of infection.
Urine analysis may indicate illness or malnutrition, whereas hematocrit measurement
may identify iron deficiency anemia.
An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed
on the examination table. The parent attempts to comfort the toddler, but nothing is
effective. Which action by the nurse is the most appropriate?
A) Allow the toddler to sit on the parent's lap and begin the assessment.
B) Allow the toddler to stand on the floor until the crying stops.
C) Ask another nurse in the office to hold the toddler because the parent is not able to
control the toddler's behavior.
D) Instruct the parent to hold the toddler down tightly to complete the examination. -
answerAnswer: A
Explanation: A) Toddlers are most comfortable when sitting with the parents.
Vaccinations can be administered in this way if the parent is taught proper therapeutic
holding techniques to keep everyone safe for the procedure. Allowing the toddler to
stand on the floor or holding the toddler down tightly are inappropriate. A nurse can
assist if the parent is unable to hold the child during the vaccinations to prevent injury
from movement.
The nurse is caring for a client who is experiencing acute chest pain that is rated as a 9
on a 0 to 10 pain scale. Based on this data, which medication does the nurse expect to
administer?
A) Acetaminophen
B) Morphine
C) Ibuprofen
,D) Naproxen - answerAnswer: B
Explanation: A) Acute pain is often treated with an opioid such as morphine. Morphine is
often used to treat chest pain that is associated with a myocardial infarction.
Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain,
not acute chest pain.
B) Acute pain is often treated with an opioid such as morphine. Morphine is often used
to treat chest pain that is associated with a myocardial infarction. Acetaminophen,
ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest
pain.
The nurse is designing a teaching plan for community members on ways to prevent
chronic pain. Which information should the nurse include in this teaching plan? Select
all that apply.
A) Eating a healthy diet
B) Obtaining adequate sleep
C) Avoiding illicit drug use
D) Limiting smoking to only before bedtime
E) Avoiding repetitive movements - answerAnswer: A, B, C, E
Explanation: A) Lifestyle habits that predispose individuals to chronic health alterations
increase an individual's risk for experiencing discomfort. Eating a healthy diet and
obtaining adequate sleep can prevent the development of chronic diseases that lead to
symptoms of discomfort. Using illicit drugs and smoking can cause emotional and
physical withdrawal symptoms when the drug is no longer used. It is wise to not engage
in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements
can increase the risk for injury and fatigue, leading to discomfort.
9) Which client is most likely to reject attempts at comfort?
A) An infant crying
B) A school-age child with abdominal pain who is anxious about a procedure
C) An adolescent with a sleep disorder who doesn't want his parents to be near him
D) An older adult with end-stage renal disease - answerAnswer: C
Explanation: A) Adolescents may respond to treatment and comfort better if you interact
with them as adults rather than as children. Some adolescents may reject any offer of
comfort, and an adolescent with a sleep disorder who has displayed antagonism toward
his parents' presence is probably irritable from his condition and may immediately reject
attempts at comfort, at least at first. An infant crying is verbalizing the need for comfort.
A school-age child anxious about a medical procedure craves reassurance. An older
adult with a terminal illness likely will welcome comfort measures even if she has
accepted that she is going to die.
Which of the following is a pharmacologic therapy for acute pain?
A) Antidepressants
B) Muscle relaxants
C) Opioid analgesics
D) Stimulants - answerAnswer: C
, Explanation: A) Pharmacologic pain management for acute pain involves opioid
analgesics, nonopioid analgesics, or nonsteroidal anti-inflammatory drugs (NSAIDs). It
does not involve antidepressants, stimulants, or muscle relaxants.
Which of the following statements best describes the therapeutic approach to acute and
chronic pain, fatigue, fibromyalgia, and sleep disorders?
A) Therapy is primarily psychosocial in nature.
B) Therapy involves both pharmacologic and nonpharmacologic approaches.
C) Therapy is essentially physiologically focused.
D) Therapy mostly involves the client avoiding risk behaviors. - answerAnswer: B
Explanation: A) For all of these conditions, therapy involves both pharmacologic and
nonpharmacologic approaches. Therapy for these conditions is both physiological and
psychosocial, addressing all components of client's conditions. Therapy involves
treatment of existing conditions, not just risk prevention measures on the client's part.
Which of the following best characterizes the sociocultural context of holistic human
experience?
A) Balance of physical processes
B) Connection to a higher power
C) Connection to others
D) Equilibrium with external circumstances - answerAnswer: C
Explanation: A) The sociocultural context of holistic human experience involves
connection with others in society. Connection to a higher power is involved in the
psychospiritual context. Homeostatic balance is involved in the physical context.
Equilibrium with external circumstances is involved in the environmental context.
What is an example of chronic pain?
A) Pain that precedes injury
B) Pain that follows injury and ends when healing is complete
C) Pain that is felt during injury and immediately after
D) Pain that outlasts the healing process - answerAnswer: D
Explanation: A) Chronic pain is pain that lasts beyond the expected time of healing,
usually for at least 6 months; it does not always have a known cause. Pain can range
from mild to severe, and autonomic responses decrease over time as the body adapts
to the persistent pain impulses. Chronic pain does not precede injury, nor does it
subside immediately after injury, and it may not be related to an injury. It does not end
when healing is complete.
2) What is the relationship between a full opioid agonist and the ceiling effect?
A) A full opioid agonist produces few withdrawal symptoms when the drug's effects
plateau and the client begins easing off the drug.
B) A client may use a full opioid agonist as much or as little as necessary to control
chronic pain with no ill effects.
C) Side effects may limit a full opioid agonist's use but not a plateau in the beneficial
effects it produces.
