Health Assessment Chapter 6 Pain

A client is experiencing acute pain and has asked the nurse for medication. The client rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the client that the nurse can expect is: A) Decreased pulse B) Diaphoresis C) Hypotension D) Flaccid muscles

B) Diaphoresis

The nurse prepares to update the care plan of a client recovering from abdominal surgery. Which diagnosis should the nurse select that most appropriately addresses the client's pain? A) Acute pain related to abdominal wound B) Chronic pain related to surgical procedure C) Impaired physical mobility related to abdominal pain D) Ineffective breathing pattern related to abdominal pain

A) Acute pain related to abdominal wound

Of the following individuals, who can best determine the experience of pain? A) The person who has the pain B) The person's immediate family C) The nurse caring for the client D) The physician diagnosing the cause

A) The person who has the pain

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort? A) The release of endorphins B) The release of insulin C) The release of melatonin D) The release of dopamine

A) The release of endorphins Explanation: Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that certain measures such as skin stimulation and relaxation techniques release endorphins.

The wife of a client with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the client is likely showing the effects of which of the following? A) Tolerance B) Addiction C) Physical dependence D) Drug interactions

A) Tolerance

Which statement by the client would the nurse consider to be an alleviating factor? Select all that apply. A) "Elevating my leg makes the swelling go down in my foot." B) "I picture myself on the beach listening to the waves." C) "Listening to music makes my pain much more tolerable." D) "Lack of sleep makes it harder for me to deal with the pain." E) "Being on my feet all day makes the swelling in my feet increase."

A) "Elevating my leg makes the swelling go down in my foot." B) "I picture myself on the beach listening to the waves." C) "Listening to music makes my pain much more tolerable." Explanation: Alleviating factors are factors that make symptoms better or more tolerable. Patient statements the nurse would consider to be an alleviating factors include elevation of the leg, imaging being on the beach, and listening to music. Lack of sleep and standing all day would be aggravating factors.

The nurse is caring for a client following left hip replacement. Which response by the client is appropriate when the nurse asks the client to identify a pain management goal related to the client's left hip pain? A) "I want my pain to be 3 or less." B) "I want to be able to sleep on my left side." C) "Climbing stairs makes my pain worse." D) "My pain is a 5 all the time."

A) "I want my pain to be 3 or less." Explanation: A desire to have a pain rating of 3 or less is a pain management goal. A functional goal reflects a specific activity or task the client would like to be able to accomplish. The client wanting to be able to sleep on their left side is an example of a functional goal. A pain rating of 7 describes the intensity of the client's pain. Climbing stairs is an aggravating factor.

The nurse is assessing a client's pain. Which question would be most appropriate to ask the client to identify precipitating factors that might have exacerbated the pain? A) "What were you doing when the pain first started?" B) "Do concurrent symptoms accompany the pain?" C) "When did you first notice the pain?" D) "Is the pain continuous or intermittent?"

A) "What were you doing when the pain first started?"

A post-operative client is observed breathing 24 breaths/minute while complaining of 10/10 abdominal pain. The client's oxygen saturation is 90% on 2 liters nasal cannula. What is the nurse's priority action? A) Administer prescribed analgesia as ordered. B) Teach and encourage incentive spirometry use. C) Explain why deep breathing and coughing is important. D) Manually ventilate client with ambu bag at bedside.

A) Administer prescribed analgesia as ordered.

The nurse is caring for a post-operative client with an order for morphine sulfate 2 mg IV push every 4 hours. The client's pain is unrelieved 30 minutes following administration of the morphine sulfate with the pain rating increasing from 7 to 10. Which action should the nurse take? A) Call the prescribing physician see about changing the pain medication. B) Instruct the client that it is too soon for another dose of morphine. C) Wait and medicate the client when the next dose of morphine is due. D) Administer another dose of the morphine sulfate immediately.

A) Call the prescribing physician see about changing the pain medication.

In preparing a care plan for a client receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use? A) Constipation B) Diarrhea C)Impaired urinary elimination D) Bowel incontinence

A) Constipation

The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the: A) Face, Legs, Activity, Cry, Consolability Scale B) FACES Pain Scale C) Numeric Pain Intensity Scale D) Combined Thermometer Scale

A) Face, Legs, Activity, Cry, Consolability Scale Explanation: -The Face, Legs, Activity, Cry, Consolability Scale is the appropriate pain assessment tool for a 4-week-old postoperative client.

A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action? A) Give the prn morphine B) Hold the medication and wait 30 minutes C) Call the physician to check the order D) Document the client's pain rating on a scale of 0 to 10

A) Give the prn morphine

Pain affects clients in different ways, with no boundaries. Which of the following are possible causes of pain? (Check all that apply.) A) Injury B) Surgery C) Chronic illnesses D) Gender E) No identifiable cause

A) Injury B) Surgery C) Chronic illnesses E) No identifiable cause

Which interventions should a nurse use to collect the subjective data from a client? Select all that apply. A) Listen carefully to the client's description of problem B) Maintain a quiet environment when interviewing C) Provide help if the client is unable to express him- or herself D) Maintain the client's privacy and ensure confidentiality E) Use the numeric rating scale to determine the client's pain

A) Listen carefully to the client's description of problem B) Maintain a quiet environment when interviewing D) Maintain the client's privacy and ensure confidentiality Explanation: The nurse should listen carefully to the client's description of the problem. The nurse should maintain a quiet environment when interviewing to collect subjective data from the client. The nurse should also maintain the client's privacy and ensure confidentiality when collecting subjective data. The nurse should never help the client verbally by adding words or putting words in the client's mouth if the client is unable to explain the problem. When collecting objective data, the nurse may use the numeric rating scale to determine the client's pain.

Which would the nurse recognize as an example of visceral pain? Select all that apply. A) Liver pain B) Gallbladder pain C) Pancreatic pain D) Burn pain E) Muscular pain

A) Liver pain B) Gallbladder pain C) Pancreatic pain

The nurse understands the importance of performing an accurate pain assessment. In addition to having the client rate the pain on a pain scale, other things to assess are the following: (Check all that apply.) A) Location and duration B) Quality and description C) Diet and allergies D) Alleviating and aggravating factors E) Urine output and pulse oximetry value

A) Location and duration B) Quality and description D) Alleviating and aggravating factors

Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric clients? A) Pain assessment may require multiple methods in order to ensure accurate pain data. B) The developing neurological system children transmits less pain than in older clients. C) Pharmacologic pain relief should be used only as an intervention of last resort. D) A numeric scale should be used to assess pain if the child is older than 5 years of age.

A) Pain assessment may require multiple methods in order to ensure accurate pain data.

Which assessment finding is consistent with the presence of pain? A) Restlessness B) Decreased blood pressure C) Decreased pulse D) Euphoria

A) Restlessness

Which would the nurse recognize as a barrier to assessing pain in the older adult? Select all that apply. A) The belief that pain is a normal part of the aging process. B) Older adults may not display an outward reaction to pain. C) Older adults with pain may fear becoming dependent on others. D) The unavailability of pain assessment tools for the older adult. E) Treatment of pain can lead to greater quality of life.

A) The belief that pain is a normal part of the aging process. B) Older adults may not display an outward reaction to pain. C) Older adults with pain may fear becoming dependent on others.

The nurse is explaining the difference between acute pain and chronic pain to the client. Which should the nurse include in the explanation? A) The cause of acute pain can be identified. B) The duration of chronic pain is short. C) Chronic pain is caused by damage to nerves. D) Acute pain lasts longer than 3 to 6 months.

A) The cause of acute pain can be identified. Explanation: Acute pain is of short duration and has an identifiable cause. Chronic pain lasts beyond the normal healing period of 3 to 6 months. Neuropathic pain results from damage to nerves in the peripheral or central nervous system.

The nurse recognizes that a barrier to successful pain management for the client with opioid tolerance is: A) The client does not experience pain relief with usual doses of opioids. B) The client has the normal physiologic response to painful stimuli. C) The repeated use of opioids causes their bodies to become less sensitive to pain. D) Appropriate pain assessment tools are unavailable for this type of client.

A) The client does not experience pain relief with usual doses of opioids.

A nursing instructor is teaching students how to assess a client'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: A) "Patients with chronic illnesses can have chronic pain." B) "Nurses are the best authority on pain." C) "Acute pain can be as intense as chronic pain." D)"Chronic pain can be referred to as persistent pain."

B) "Nurses are the best authority on pain."

A client is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to describe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers? A) C fibers B) A-delta fibers C) AC fibers D) P fibers

B) A-delta fibers Explanation: A-delta fibers are myelinated and conduct impulses rapidly, resulting in pain being described as sharp or stabbing. C fibers are unmyelinated and cause pain that is achy and ongoing. There are no known AC or P fibers related to pain.

An older adult client with osteoarthritis has tearfully admitted to the nurse that she is no longer able to climb the stairs to the second floor of her house due to her knee pain. What nursing diagnosis is suggested by this client's statement? A) Ineffective coping related to knee pain B) Activity intolerance related to knee pain C) Ineffective role performance related to osteoarthritis D) Situational low self-esteem related to osteoarthritis

B) Activity intolerance related to knee pain

A client recovering from a motor vehicle crash sustained right rib fractures and a fractured pelvis. The nurse is reviewing the client's metabolic panel lab results and notes a blood glucose of 130 mg/dL; the client has no history of diabetes. What is the nurse's best initial action? A) Request a prescription for regular insulin. B) Ask the client if she was in pain when the labs were drawn. C) Verify the result by performing a capillary stick. D) Assess for cold, clammy skin.

B) Ask the client if she was in pain when the labs were drawn.

A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What would the nurse do next? A) Ask the client to briefly explain his cultural background. B) Assess the client's pain using a mnemonic device. C) Assess the client's self-management skills. D) Assess the client's pain by obtaining a set of vital signs.

B) Assess the client's pain using a mnemonic device. Explanation: If the client acknowledges pain, further assessment parameters should be gathered according to a mnemonic device including but not limited to OLD CART or COLDSPA. This should precede other assessments, even though these should later be performed.

The nursing class is learning about pain assessment. Which of the following is a manifestation of pain? A) Confusion B) Bracing C) Pressured speech D) Apathy

B) Bracing Explanation: Six pain behaviors indicate pain in clients who cannot verbalize: (1) vocalizations, (2) facial grimacing, (3) bracing, (4) rubbing painful areas, (5) restlessness, and (6) vocal complaints.

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? A) Measure heart rate. B) FLACC scale. C) Count respirations. D) BPIQ tool.

B) FLACC scale. Explanation : The FLACC (Face, Legs, Activity, Cry, Consolability) scale was originally designed to measure acute postoperative pain in children 2 months to 7 years old. Heart rate and respirations are part of an infant pain assessment; however the FLACC scale is the most comprehensive tool. The BPIQ (brief pain impact questionnaire) is used mainly to assess chronic pain in adults.

Beliefs of health care providers can serve as barriers to an accurate assessment of a client's pain. Which of the following beliefs will not be likely to impair the assessment of pain? A) Old people have more pain which is to be expected. B) Infants can feel pain and may respond with crying or agitation. C) A sleeping person feels no pain. D) Persons asking for pain medication but who are showing no other evidence of pain are just addicted to the medication.

B) Infants can feel pain and may respond with crying or agitation. Explanation: It is hard to evaluate pain in neonates and infants. Behaviors that indicate pain are used to assess their pain. Crying and not being able to be consoled indicate pain in this population.

When clients report pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source is more than likely: A) Visceral B) Neuropathic C) Somatic D) Referred

B) Neuropathic Explanation: Visceral pain originates from abdominal organs and is often described as crampy or gnawing. Somatic pain originates from the skin, muscles, bones, and joints. Referred pain originates from a specific site, but the client experiencing the pain feels it at another site along the innervating spinal nerve. Neuropathic pain is described as burning, painful numbness, or tingling.

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain? A) Nociceptive B) Neuropathic C) Somatic D) Idiopathic

B) Neuropathic Explanation: Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.

When providing information to a client concerning the client's osteoarthritic, nociceptive pain, the nurse should include which statements about this type of pain? Select all that apply. A) The trigger is a direct injury to either the peripheral or central nervous systems. B) Neurotransmitters like endorphins and histamines regulate this pain. C) The pain is associated with the inflammatory process. D) This form of pain can be either chronic or acute in nature. E) It is a form of idiopathic pain.

B) Neurotransmitters like endorphins and histamines regulate this pain. C) The pain is associated with the inflammatory process. D) This form of pain can be either chronic or acute in nature.

When performing a pain assessment the client should be asked to provide all the following information except: A) Effects of pain on activities of daily living B) Physiological classification C) Treatment expectations D) Effectiveness of treatment

B) Physiological classification

Why is it important for a nurse to gather information about a client's past experiences with pain? A) Identify factors that increase or decrease the pain B) Provides insight into positive or negative expectations for relief C) Assess how much the pain impacts the client's lifestyle D) Understand the course of the pain for clues to patterns

B) Provides insight into positive or negative expectations for relief Explanation: Past experiences with pain may shed light on the previous history of the client in addition to possible positive or negative expectations of pain therapies. Identifying factors that increase or decrease pain, assessing how much it impacts the client's lifestyle, and understanding the course of the pain are questions that assist the nurse to elicit important information about the pain itself.

The client with a cognitive impairment sometimes cannot rate pain on a scale of 0 to 10. In such a case, the nurse is aware of other cues to assess the client's pain. Which of the following is correct? A) Showing signs of having a difficult personality and yelling B) Restlessness, guarding C) Loss of appetite and decreased urine output D) Decreased blood pressure and pulse rate

B) Restlessness, guarding

The nurse is assessing the client's perception of pain and its intensity and quality. Which dimension is the nurse evaluating? A) Physical B) Sensory C) Behavioral D) Cognitive

B) Sensory Explanation: The sensory dimension concerns the quality of the pain and how severe the pain is perceived to be. This dimension includes the client's perception of the pain's location, intensity, and quality. The physical dimension refers to the physiologic effects just described. This dimension includes the client's perception of the pain and the body's reaction to the stimulus. The behavioral dimension refers to the verbal and nonverbal behaviors that the client demonstrates in response to the pain. The cognitive dimension concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management."

A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain? A) Visceral B) Somatic C) Cutaneous D)Referred

B) Somatic Explanation: Pain nociception has various locations. Visceral pain originates from abdominal organs; clients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; clients usually describe somatic pain as sharp (D'Arcy, 2014). Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. It is often burning or sharp, such as with a partial-thickness burn. Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve.

While interviewing a client regarding his pain, the nurse asks, "Have you had any previous experience with pain?" What is the best rationale for asking this question? A) To identify factors that increase or decrease the pain B) To provide insight into positive or negative expectations for relief C) To assess how much the pain impacts the client's lifestyle D) To understand the course of the pain for clues to patterns

B) To provide insight into positive or negative expectations for relief

A nurse is performing a detailed pain assessment of a client who has sought care for debilitating migraines. When assessing for precipitating factors, what question should the nurse ask? A) "Is there anything that's given you relief in the past?" B) "Have your migraines gotten more severe in the last few months?" C) "What were you doing immediately before your last migraine?" D) "How long does a typical migraine last?"

C) "What were you doing immediately before your last migraine?"

A client presents to the health care clinic with reports of two-day history of sore throat pain, ear pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data? A) Anxiety related to prolonged pain B) Impaired Mobility related stiff neck C) Acute Pain related to sore throat D)Risk for Fluid Volume Deficit related to fever

C) Acute Pain related to sore throat

A client reports pain and rates it as a 9 on a scale of 0 to 10. The nurse administers medication as ordered and returns 20 minutes later to assess the severity of the client's pain. To assess the severity, the nurse would: A) Ask the client if he or she needs anything. B) Ask the client what makes the pain worse. C) Ask the client to rate the pain on a scale of 0 to 10. D) Ask about the location of the pain.

C) Ask the client to rate the pain on a scale of 0 to 10.

A client reports pain and rates it as a 9 on a scale of 0 to 10. The nurse administers medication as ordered and returns 20 minutes later to assess the severity of the client's pain. To assess the severity, the nurse would: A) Ask the client if he or she needs anything. B) Ask the client what makes the pain worse. C) Ask the client to rate the pain on a scale of 0 to 10. D)Ask about the location of the pain.

C) Ask the client to rate the pain on a scale of 0 to 10.

A client is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what? A) Check the client's record for allergies. B) Check the physician's orders to see what pain medication to administer. C) Assess the site and intensity of the pain. D) Call the physician.

C) Assess the site and intensity of the pain. Explanation: When a client reports pain, the nurse must do an immediate pain assessment. Such an assessment is the first step of the nursing process. The complete pain assessment will cover different characteristics of the pain; however, the very first aspect is to ask about the location and intensity of the pain. Checking for the client's allergies and what medication is ordered will follow after the assessment. The nurse would not call the physician at this point.

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus? A) Sharp, stabbing B) Aching, gnawing C) Burning, tingling D) Pain only on movement

C) Burning, tingling

A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain? A) Verbal Descriptor Scale B) Numeric Rating Scale C) Faces Pain Scale D)Visual Analog Scale

C) Faces Pain Scale

A nurse is creating a concept map of the pathophysiology of pain. The nurse should identify which of the following as being responsible for transmitting pain sensations to the central nervous system? A) Transduction B) Modulation C) Nociceptors D) Cytokines

C) Nociceptors

A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta primary afferent fibers transmit pain that is felt as which of the following? A) Burning B) Throbbing C) Sharp D) Aching

C) Sharp Explanation: A-delta primary afferent fibers transmit fast pain to the spinal cord that is felt as a pricking, sharp, or electric-quality sensation. C-fibers transmit slow pain felt as burning, throbbing, or aching.

One of the body's normal physiologic responses to pain is A) hypotension. B) pulse rate below 50 beats/minute. C) diaphoresis. D) hypoglycemia.

C) diaphoresis

A nurse is assessing the pain of a client who has had major surgery. The client also has been experiencing depression. Which of the following principles should guide the nurse's assessment of a client's pain? A)The client is likely experiencing less pain than he is reporting. B) The client's depression exists independently of the level of pain. C)It is likely that the client's pain rating will be influences by his emotional state. D) The degree of surgery will be the key indicator for level of pain experienced.

C)It is likely that the client's pain rating will be influences by his emotional state.

A 12-year-old boy has reported to the emergency department after having fallen off his bicycle and sustained what appear to be minor injuries. The nurse is assessing him for pain. Which of the following objective findings would most tend to indicate pain? A) Upright posture while sitting B) Sustained eye contact with the nurse C)Nodding up and down in response to questions D)Maintaining a consistent position and posture

C)Nodding up and down in response to questions

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? A) Anxiety related to prolonged pain B) Impaired physical mobility related stiff neck C) Risk for deficient fluid volume related to fever D) Acute pain related to sore throat

D) Acute pain related to sore throat

The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis? A) Shingles B) Bone fracture C) Myocardial infarction D) Appendicitis

D) Appendicitis

How may a nurse demonstrate cultural competence when responding to clients in pain? A) Treat every client exactly the same, regardless of culture. B) Be knowledgeable and skilled in medication administration. C) Know the action and side effects of all pain medications. D) Avoid stereotyping responses to pain by clients.

D) Avoid stereotyping responses to pain by clients.

A nurse is providing care for an 84-year-old client who has diagnoses of middle-stage Alzheimer disease and a femoral head fracture. What assessment tool should the nurse use to assess the client's pain? A) Graphic Rating Scale B) Numeric Rating Scale (NRS) C) Verbal Descriptor Scale D) Faces Pain Scale-Revised (FPS-R)

D) Faces Pain Scale-Revised (FPS-R) Explanation: The NRS has been shown to be best for older adults with no cognitive impairment, and the Faces Pain Scale-Revised (FPS-R) for cognitively impaired adults. Because of this client's Alzheimer disease, the FPS-R would be most appropriate.

A client complains of pain in several areas of the body. How should the nurse assess this client's pain? A) Ask the client to rate the area with the highest pain level. B) Mark each site on the client's body with a marker. C) If pain does not radiate, there is no need to rate that area. D) Have the client rate each location separately.

D) 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? A) What medical conditions do you have? B) Where is the pain located? C) What is the highest level of education you've completed? D) How does the pain influence your overall mood?

D) How does the pain influence your overall mood?

A nurse is providing care to a client who has been in a motor vehicle accident and who has facial lacerations and a pelvic fracture. How can the nurse best determine the reliability and accuracy of data obtained during a pain assessment? A) Ask the primary care provider to validate the assessment data. B) Compare the findings to the client's preinjury level of health. C) Compare the findings to the most recent previous pain assessment. D) Validate the assessment data with the client.

D) Validate the assessment data with the client.

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? A) What medical conditions do you have? B) Where is the pain located? C) What is the highest level of education you've completed? D)How does the pain influence your overall mood?

D)How does the pain influence your overall mood?

The nurse is using the Verbal Descriptor Scale to assess a client's pain. What data will the nurse prioritize? A) The client's facial expressions B)The client's report on a 0 to 10 numeric scale C)The client's rating on a 0 to 10 visual analog scale D)The client's explanation of how her pain feels

D)The client's explanation of how her pain feels