Chapter 9
A nursing instructor is teaching students how to assess a patient's pain. The instructor emphasizes that there are many misconceptions about pain. The instructor realizes that a student needs further direction when the student states:
"Nurses are the best authority on pain."
A client was administered PO pain medications at 1530. By what time should the nurse re-assess and document the effects of the pain medication?
1630
A mother calls the nurse practitioner to say, "I don't know what is wrong with my baby. He cried all night and kept pulling at his ear." How would the nurse respond?
"That means his ear hurts. Bring him in to be checked."
A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?
Acute
A client presents to the health care clinic with reports of a 2-day history of sore throat, ear pressure, fever, and stiff neck. The client states she has taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?
Acute pain related to sore throat
The nurse should clarify which medication order prescribed for a client with chronic back pain?
Angiotensin converting enzyme inhibitor
The nurse is caring for a patient who is experiencing visceral pain. What is this patient's most likely diagnosis?
Appendicitis
How may a nurse demonstrate cultural competence when responding to patients in pain?
Avoid stereotyping responses to pain by patients.
The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the patient's pain, what is the most appropriate pain assessment tool for the nurse to use?
FACES Pain Scale
A male client with a history of a back injury 2 months ago has been taking daily doses of narcotic pain medication. He is currently hospitalized with a leg fracture after falling down the stairs. He complains of 10/10 pain in his back and leg after taking pain medication one hour ago. What is the nurse's best action?
Consult with the healthcare provider about increasing the dose of medication.
A nurse is caring for a 4-year-old patient who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the patient to point to the one that best represents the pain he is experiencing. This is an example of which of the following:
FACES scale
The nurse is working in the post anesthesia care unit and assessing pain in a 6 month old infant. Which method should the nurse use to assess the infant's pain?
FLACC scale.
The nurse is caring for a 4-week-old postoperative patient. The most appropriate pain assessment tool would be the:
Face, Legs, Activity, Cry, Consolability Scale
A client complains of pain in several areas of the body. How should the nurse assess this client's pain?
Have the client rate each location separately.
A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?
How does the pain influence your overall mood?
A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain?
Neuropathic
The nurse understands the importance of performing an accurate pain assessment. In addition to having the patient rate the pain on a pain scale, other things to assess are the following: (Check all that apply.)
Location and duration Quality and description Alleviating and aggravating factors
A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?
Neuropathic pain
A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain?
Somatic
A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following?
Somatic pain
The nurse enters an older client's room to assess for pain and discovers the client is hard of hearing. What is the nurse's best action?
Speak to the client face to face.
A nurse is meeting for the first time a 42-year-old client whose visit to the clinic has been prompted by her chief complaint of ongoing lower back pain. Which of the following approaches to pain assessment should the nurse use when assessing the client's pain?
The nurse should use a pain assessment tool that is simple but still addresses the major parameters of pain.
A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client experiencing?
Visceral pain
When assessing the client for pain, the nurse should
believe the client when he or she claims to be in pain.
