NURS 235 PrepU Chapter 9
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?
constipation
An elderly farmer has sustained severe injuries after a serious accident involving a combine harvester. At the hospital, he tells the nurse that he thinks the pain he is feeling now is "payback" for living a "mean, selfish life." The nurse recognizes that this response by the man indicates which dimension of pain?
spiritual dimension
A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain
neuropathic
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:
neuropathic
A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?
somatic
A client reports pain in the knee. The knee is warm, swollen, and red and the client describes the pain as aching and gnawing. The nurse determines the client is experiencing which of the following types of nociceptive pain?
somatic
A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what ty.pe 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
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
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?
Infants can feel pain and may respond with crying or agitation.
A nurse enters a client's room to conduct an assessment. The client is crying and states they have so much pain. What is the best response of the nurse?
"Could you tell me more about your pain?"
A nurse is performing a focused pain assessment on a new client. The nurse is using COLDSPA to better understand the etiology of the pain. Which of the following questions would the nurse ask to elicit information about the pattern of the pain?
"Does your pain come and go?"
A nurse is interviewing a 65-year-old client with a history of atrial fibrillation, type 2 diabetes, obesity, and congestive heart failure. The nurse determines the client is experiencing chronic neuropathic pain when the client makes which of the following statements?
"The burning sensation in my feet has gotten worse over the past year."
As a nurse is adjusting a client's hospital bed, the nurse accidently pinches a finger between the bed and the wall. Which of the following components is involved in the transduction of the pain the nurse feels?
A-delta and C fibers
How may a nurse demonstrate cultural competence when responding to clients in pain?
Avoid stereotyping responses to pain by clients.
The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis?
Appendicitis
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:
Ask the client to rate the pain on a scale of 0 to 10.
A nurse is assessing a young woman for injuries who appears to be a victim of domestic violence. The nurse observes from the client's health record that her baseline vital signs are within normal limits. Which of the following objective findings would most tend to indicate pain? Select all that apply.
Blood pressure of 140/90 mm Hg Edema at the elbow joint slumped shoulders
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 middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action?
Check the client's vital signs and connect her to a cardiac monitor.
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 client's pain, what is the most appropriate pain assessment tool for the nurse to use?
FACES Pain Scale
The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the:
Face, Legs, Activity, Cry, Consolability Scale
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?
Faces pain Scale
Nurses use the FLACC scale to assess pain in children ages 2 months to 7 years. This scale uses which of the following indicators? (Select all that apply.)
Facial Expression Leg movements Activity Cry Ability to console client
The nursing student asks the nurse what would be an example of visceral pain. What would be the correct response by the nurse?
Gallbladder pain
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?
Give the prn morphine
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 student nurse learns that especially in the very young and very old pain can be inadequately treated. What else would the student learn about inadequate pain treatment in the very young?
It can lead to neurodevelopmental problems
The U.S. government has created guidelines for health care providers caring for clients in pain. Which of the following reflect these guidelines?
Joint Commission Standards for Pain Management.
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.)
Location and duration Quality and description Alleviating and aggravating factors
Identify the steps in nociception. (Number 1 is the first step and number 4 is the last step.)
Noxious stimuli cause a nerve impulse perceived by free nerve endings. The neuronal signal moves from the periphery to the spinal cord and up to the brain. The impulses being transmitted to the higher areas of the brain are identified as pain. Inhibitory and facilitating input from the brain influences the sensory transmission at the level of the spinal cord.
Which of the following cultural expressions of pain would be likely to be found in a person of Hispanic culture?
Pain must be endured to perform gender role duties, but response to it is very expressive.
The client comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?
Referred 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?
The release of endorphins
The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?
The time it takes a pain medication to decrease pain intensity
A client injures his thumb by accidently slamming the car door shut on it. He arrives at the emergency department in intense pain. Which of the following processes is associated with the transduction process of this pain?
Tissue injury leading to inflammation
A nurse is collecting subjective data from a client who is reporting pain. Which of the following actions should the nurse take to determine the severity of the pain?
Use a pain scale to measure the pain.
A popular pain assessment scale for children is:
Visual Analog Scale.
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 nurse performs a focused assessment on a client reporting back pain after helping someone move into a new home. The nurse uses COLDSPA to further assess the client's pain. Character: sharp; onset: yesterday; location: lower back; duration: persistent since yesterday; severity: 8 out of 10 (on a scale 0-10, 10 being the worst); pattern: continuous; associated factors: movement. The nurse determines the client is experiencing which of the following classifications of pain?
acute inflammatory pain
What is the term used to describe a pharmaceutical agent that relieves pain?
analgesic
During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following?
analgesics
The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?
burning, tingling
The nurse is using the Brief Pain Inventory to help assess pain in a client. Which of the following clients will benefit from this assessment?
client admitted with bone cancer
A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing?
neuropathic
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
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:
neurophatic
A client reports pressure in the chest but describes pain in the jaw and right arm. Based on these findings, the nurse determines that the client may be experiencing which of the following types of pain?
referred
Mark is a 20-year-old college student who has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is Mark most likely experiencing?
visceral pain
