A nurse is caring for a terminally ill client experiencing moderate to severe pain. Providing opioids in this situation:

May cause addiction

Will probably be ineffective

Is an appropriate nursing action

Will likely hasten the client’s death

Answer and Explanation

The Correct Answer is C

Administering opioids to a terminally ill client with moderate to severe pain is both appropriate and ethical. At the end of life, the priority is comfort and pain relief, not concerns about long-term side effects such as addiction. Opioids are effective and commonly used to manage cancer pain and palliative symptoms, improving the quality of the client’s remaining life.

Rationale for Correct Answer:

C. Is an appropriate nursing action: Providing opioids for pain control is consistent with palliative and hospice care goals. Nurses play a vital role in relieving suffering and promoting dignity during the dying process.

Rationale for Incorrect Answers:

A. May cause addiction: In terminal care, addiction is not a concern. The focus is on adequate symptom management and comfort.

B. Will probably be ineffective: Opioids are among the most effective agents for managing moderate to severe pain, especially in cancer or end-of-life scenarios.

D. Will likely hasten the client’s death: When used correctly and titrated to pain, opioids do not hasten death. This myth is a common barrier to effective pain management.

Key Takeaways:

Opioid use in terminally ill clients is safe, appropriate, and essential for comfort.
Concerns about addiction or hastening death should not interfere with adequate pain control.
The nurse’s role includes advocating for and administering pain relief in alignment with palliative care goals.

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Correct Answer is A

Explanation

When assessing pain, it is important to evaluate associated symptoms that may accompany or result from the pain, such as nausea, vomiting, dizziness, or sweating. These symptoms provide contextual information that can help in determining the underlying cause, severity, and impact of the pain on the client’s functioning.

Rationale for Correct Answer:

A. Presence of associated symptoms: Asking about nausea or vomiting is an assessment of symptoms that occur alongside the pain, which may help in identifying the source (e.g., gastrointestinal, renal, or infectious origin) and guide further diagnostic or therapeutic interventions.

Rationale for Incorrect Answers:

B. Location of the pain: This involves asking where the pain is felt, which is not addressed by inquiring about nausea or vomiting.

C. Pain quality: Pain quality refers to the character of the pain, such as sharp, burning, cramping, or dull. Nausea or vomiting does not describe the pain itself.

D. Aggravating and relieving factors: These involve identifying what worsens or eases the pain, such as movement, eating, or positioning and not associated symptoms.

Key Takeaways:

Associated symptoms like nausea and vomiting provide important information about the context and cause of pain.
A comprehensive pain assessment includes location, quality, severity, timing, associated symptoms, and triggers.
Evaluating associated symptoms helps guide accurate diagnosis and effective treatment.

A. A hard knocking feeling B. An intermittent burning reaction C. A pleasant tingling sensation D. A small shock to the affected area

Correct Answer is C

Explanation

TENS therapy is a noninvasive method of pain control that uses low-voltage electrical currents delivered through electrodes placed on the skin. The most commonly reported sensation during TENS use is a pleasant tingling or buzzing feeling, which stimulates sensory nerves and helps block or reduce the perception of pain. The intensity can be adjusted to maintain comfort and effectiveness.

Rationale for Correct Answer:

C. A pleasant tingling sensation: This is the expected and desired sensation during TENS therapy. It should not be painful. The tingling distracts the nervous system from transmitting pain signals, providing relief for chronic or localized pain.

Rationale for Incorrect Answers:

A. A hard knocking feeling: This is not a typical or desired sensation with TENS. Such a sensation could indicate the intensity is too high or the electrode placement is inappropriate.

B. An intermittent burning reaction: A burning feeling is abnormal and may signal skin irritation, improper settings, or electrode malfunction. It should be reported and addressed immediately.

D. A small shock to the affected area: TENS does not deliver shocks. A shock-like feeling may indicate the intensity is set too high or the device is malfunctioning.

Key Takeaways:

TENS therapy produces a pleasant tingling sensation, not pain or shocks.
The goal of TENS is to modulate pain perception through gentle electrical stimulation.
Any discomfort, burning, or shocking sensation should be evaluated and may require adjustment of settings or electrode placement.

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A nurse is caring for a terminally ill client experiencing moderate to severe pain. Providing opioids in this situation:

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Naxlex Comprehensive Predictor Exams

A nurse is assessing the pain level of a client who presents to the emergency department with severe abdominal pain. The nurse asks whether the client has experienced nausea or vomiting. The nurse is assessing which of the following?

Correct Answer is A

Explanation

A client with chronic back pain is scheduled to begin transcutaneous electrical nerve stimulation (TENS) therapy. The nurse explains that the electrical sensation produced by the TENS unit will most likely feel like:

Correct Answer is C

Explanation

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