Week 4: Pain & Comfort/Rest

9 A client is receiving morphine to relieve chest pain. The order is for 4 mg IV now. The pharmacy supplies morphine sulfate at 5 mg per mL. How many mL will the nurse give the client? Enter the correct number ONLY.

0.8 Explanation: (4 mg/5 mg) X 1 mL = 0.8 mL.

2 The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis?

Appendicitis Explanation: Visceral pain originates from abdominal organs; clients often describe this pain as crampy or gnawing.

7 A client comes in for a therapy session and begins to have a panic attack. The therapist asks the client to relax in the chair and then gently asks the client to imagine the client in a very safe and calm place. This technique, often useful in anxiety disorders, is called what?

Deep breathing Explanation: Helping the client focus on deep breathing can decrease the hyperarousal involved in panic attacks. It is also an opportunity for the therapist to teach the client self-help and adaptive coping mechanisms for panic attacks.

1 A single mother with three young children is reluctant to leave her crying and upset 16-month-old daughter overnight in the hospital but needs to go home to care for the other children. Which suggestion from the nurse will best address the fears and concerns of both the child and mother?

Encourage the mother to give the child a personal item of the mother's to hold on to until she returns and to tell the child a specific time she will return, such as "when breakfast comes in the morning." Explanation: When the family caregiver must leave the toddler, it may be helpful for the adult to give the child some personal item to keep until the adult returns. The caregiver can tell the child he or she will return "when the cartoons come on TV" or "when your lunch comes." These are concrete times that the toddler will probably understand. The toddler is too young to understand that staying is important for her recovery. Distracting the child while the mother leaves may increase the child's anxiety when she realizes her mother is gone. Although the child will be watched closely in the hospital setting, toddlers explore their environment wherever they are.

10 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 Explanation: Children 2 years and older can identify pain and point to its location. You can use a facial expression scale for children starting at approximately 3 years. The FACES scale uses six faces ranging from happy with a wide smile to sad with tears on the face.

3 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 Explanation: Visceral pain originates from abdominal organs, such as the gallbladder. Burns cause cutaneous pain, which is derived from the dermis, epidermis, and subcutaneous tissues. Referred pain originates from a specific site, but is experienced in another site along the innervating spinal nerve, such as occurs with cardiac pain. Somatic pain originates from skin, muscles, bones, and joints, such as arthritic pain.

7 A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

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.

4 Which nursing action will best promote pain management for a client in the postoperative phase?

Performing relaxation techniques Explanation: Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase.

1 A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:

Prolonged in duration. Explanation: A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged.

7 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 Explanation: Referred pain originates from a specific site, but the person feels the pain at another site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigestion. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints.

9 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 Explanation: Somatic pain is caused by tissue damage, which would occur after abdominal surgery. Psychogenic pain relates to factors that influence the client's report of pain such as anxiety and depression. Idiopathic pain does not have an identified cause. Neuropathic pain results from direct injury to the peripheral or central nervous system.

1 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 Explanation: Somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissues. Visceral pain is poorly localized and originates in body organs. Phantom pain occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the client.

2 A dehydrated infant is receiving IV therapy. The parent tells the nurse about wanting to hold the infant but being afraid this might cause the IV line to become dislodged. How should the nurse respond?

Provide a comfortable chair for the parent to hold the infant while connected to the IV. Explanation: Infant bonding is very important, and the need increases when the child is ill. The parent should be provided with a comfortable chair with support to help hold the infant. The IV pump needs to be close to the chair with enough tubing to allow for movement. Placing a restraint over the IV site requires a prescription from the health care provider and is not necessary. The IV site can be protected with blankets or clothing. The nurse should encourage the parent to participate in the child's care whenever possible, not just during IV therapy. The IV should not be disconnected for bonding time. IV fluids should remain continuously at a rate prescribed by the health care provider.

3 A laboring client, 2 cm dilated and 50% effaced, is screaming in pain. The nurse caring for this client recognizes this woman's response to pain should be documented using which label?

low pain threshold Explanation: A person's response to pain is both individually and culturally determined. The pain threshold is the point at which the individual reports a stimulus is painful. Pain tolerance is the point at which an individual withdraws from a stimulus. Lack of pain control and inappropriate response to pain reflects the nurse's individual bias.

7 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 Explanation: Pain resulting from direct injury to the peripheral or central nervous system is termed neuropathic. Over time, neuropathic pain may become independent of the inciting injury and be described as burning. Somatic pain originates from skin, muscles, bones, and joints and is usually described as sharp. Referred pain is pain felt in a body area, away from the pain source. Visceral pain originates from abdominal organs and is usually described as cramping or gnawing.

5 A 12-year-old client will undergo surgery with spinal anesthesia. The client expresses a severe fear of needles. Which nurse response is appropriate and therapeutic for this client?

"I understand that you are nervous, but I'll hold your hand and be right there with you." Explanation: The best choice to is acknowledge the client's fears, use therapeutic touch, and demonstrate support. Talking down to the client, regardless of the age, is not a form of therapeutic communication. Rationalization will not be therapeutic if the client has a irrational fear.

7 A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?

"It distracts your brain from the sensations of pain." Explanation: Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.

8 The nurse is helping with the health assessment of a school-age client with special needs for attendance at summer camp. The mother tears up, saying that she wishes the child would not attend. What is the best response by the nurse?

"It is not unusual for you to have strong feelings about this." Explanation: Acknowledging the feelings of the mother indicates empathy and understanding and allows the parent to share more specific concerns to which the nurse can respond. The length of the camp session and the benefit for the child are true, but these comments do little to acknowledge the mother's feelings and promote dialogue. The camp health assessment has made the advent of camp "real" to the mother, but the "mental preparation" response by the nurse is a poor validation of her feelings.

6 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:

"Nurses are the best authority on pain." Explanation: Pain is what the client says it is, and it exists whenever the client says it does. The client is the best authority on pain, and self-report is the gold standard. Therefore, nurses are not authorities on pain. It is true that clients with chronic illnesses can and often do have chronic pain. It also is true that acute pain can be intense. Chronic pain is sometimes known as persistent pain.

1 A client with stage IV colon cancer reports back pain and appears to be anxious. What response should the nurse provide when asked if therapeutic touch may be beneficial?

"Therapeutic touch is a holistic practice that works to redirect energy in the body and may help with pain and anxiety." Explanation: Therapeutic touch involves "unruffling," or clearing, congested areas of energy in the body and redirecting this energy. After assessing a client's "energy field," the nurse uses therapeutic touch to promote comfort, relaxation, healing, and a sense of well-being. The nurse should not dismiss or belittle the use of alternative therapies.

8 Which is a correct rationale for encouraging a client with otitis externa to eat soft foods?

Chewing may cause discomfort. Explanation: The nurse encourages a client with otitis externa to eat soft foods or consume nourishing liquids because chewing may cause discomfort. Chewing will not react with the prescribed medications or cause complications such as otitis media and excessive drainage.

9 A client newly diagnosed with pancreatic cancer is admitted to begin treatment. Which pain descriptors can be associated with adenocarcinomas of the pancreas?

Dull epigastric pain accompanied by back pain, worse when lying flat and relieved by sitting forward. Explanation: The most common pain with pancreatic cancer is a dull, epigastric pain often accompanied by back pain, often worse in the supine position, and relieved by sitting forward. Sharp, stabbing pain with respirations could be pleurisy among other respiratory problems. Abdominal pain following a meal is usually associated with GERD or gastric ulcers. Cerebral edema causing headaches is not related to pancreatic cancer.

5 A client arrives in the emergency department reporting an injury to a calf muscle while running. What education will the nurse provide after a diagnosis of muscle strain? Select all that apply.

Keep the injured limb elevated. • Apply an elastic bandage to the injured area. Explanation: Elevation of an injured area will help to reduce edema. An elastic bandage for compression will help to reduce edema. Ice should be applied to minimize pain and edema. Ice, not heat, should be applied to minimize pain and edema. A physician should be contacted immediately to diagnose the extent of the injury. Exercising should be discontinued until the injury is healed.

4 A nurse is performing range-of-motion exercises on a client who is on bed rest. What would be the nurse's best action when the client reports: "I'm just too tired to do these exercises today."

Stop the exercises and reevaluate the nursing plan of care. Explanation: While the nurse is performing range-of-motion exercises, and the client reports feeling fatigued, stop the activity and reevaluate the nursing plan of care. Consider spacing the exercises out at different times of the day. Schedule exercise times for the parts of the day the client is typically feeling more rested. The nurse would not encourage the client to finish the exercises and then reevaluate the nursing plan. The nurse would not finish the exercises and report the incident to the primary care provider. The nurse would not modify the number of repetitions for each exercise and then modify the plan.

13 The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment?

The client reports that on a scale of 0 to 10, the current pain is a 3. Explanation: The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

7 The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment?

The client reports that on a scale of 0 to 10, the current pain is a 3. Explanation: The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

2 A client has been referred for a colposcopy by the primary care provider. The client wants to know more about the examination. Which information regarding a colposcopy should the nurse give to the client?

The test is conducted because of abnormal results in a Papanicolaou test. Explanation: The nurse should explain to the client that the colposcopy is done because the care provider has observed abnormalities in the Papanicolaou test results. The nurse should also explain to the client that the procedure is painless and there are no adverse effects, such as pain during urination. There is no need to avoid intercourse for a week after the colposcopy.

8 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 Explanation: Transduction of pain begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage, resulting in an inflammatory process. The transmission process is initiated by this inflammatory process, resulting in the conduction of an impulse in the primary afferent neurons to the dorsal horn of the spinal cord. The process of pain perception involves the hypothalamus and limbic system, which are responsible for the emotional aspect of the pain perception, and the frontal cortex, which is responsible for the rational interpretation and response to pain. Modulation changes or inhibits the pain message relay in the spinal cord.

12 The following statements are heard in a group: "You can't say that because you don't really know me." "I wonder if the therapist is going to leave?" and "I'm not sure whether or not I can really talk freely." These best reflect which group theme?

Trust and belonging Explanation: The theme expressed in these statements represents the latent lack of trust in the leader or other group members. These statements are not related to guilt and punishment, fear for safety, or loss and abandonment.

1 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 Explanation: The client is experiencing visceral pain, which is associated with disease or injury. It is sometimes referred or poorly localized as it is not experienced in the exact site where an organ is located. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

10 A client asks the nurse which vitamins should be taken daily for feelings of fatigue, anxiety, and depression 1 week before menses. Which of the following is the correct response by the nurse?

Vitamin B6 Explanation: The nurse should encourage taking Vitamin B6 daily, as it may be effective at relieving symptoms of irritability, fatigue, and depression related to the premenstrual period. Vitamin A supports growth and bone development, vision, reproduction, and development and maintenance of skin tissue. Vitamin C protects against immune system deficiencies, cardiovascular disease, prenatal health problems, eye disease, and even skin wrinkling. Vitamin C may protects against immune system deficiencies, cardiovascular disease, prenatal health problems, eye disease, and even skin wrinkling.

7 Which nursing action has a negative effect on fetal descent?

administering opioid pain medication Explanation: Opioid pain medication is known to help with the pain associated with contractions and childbirth but it is also known to slow or even stop the progression of the labor process. The opioid effect can provide the mother with a needed break and allow her to rest between contractions. The mother may lie in any position comfortable. Neither eliminating stool nor walking in the hall will slow fetal transport.

4 A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program. Explanation: NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

8 Although both vertigo and dizziness can result from peripheral or central vestibular disorders, vertigo is distinctly different because it causes:

an illusion of motion. Explanation: Vertigo or dizziness can result from peripheral or central vestibular disorders (proprioception) unrelated to hearing loss. Vertigo is a vestibular disorder in which a unique illusion of motion occurs. Persons with vertigo frequently describe it as a sensation of spinning or tumbling, a "to-and-fro" motion, or falling forward or backward. Light-headedness, faintness, and unsteadiness are different in that the person perceives weakness yet still has a sense of balance. Syncope (loss of consciousness) is not directly associated with the sensation of vertigo.

2 A client, who travels frequently for work, reports intense ear pain during ascent from and descent into airports. The health care provider will recommend which category of medications to help alleviate this symptom?

decongestant nasal spray such as phenylephrine Explanation: Barotrauma most often occurs in people who travel while suffering from an upper respiratory tract infection. Decongestants, such as nose drops or nasal sprays, may be used 30 to 60 minutes prior to ascent or descent to reduce congestion and open the eustachian tubes. Steroids are not recommended for barotrauma. They are helpful for inflammation and nasal polyps. Antihistamines are helpful for tinnitus and vertigo.

18 A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on how much time the client spends in bed during the day. Explanation: Setting limits on how much time the client may spend in bed and what time the client must get up in the morning lets the client know what is expected while conveying genuine concern. Talking with the client for a long time at night would interfere with sleep and give the client attention for not sleeping. Encouraging environmental stimulation in the evening would discourage rest and sleep at night. While most antianxiety agents have sedating adverse effects, they aren't intended for use as sleep-inducing agents.

9 A client asks about complementary therapies for relief of discomfort related to pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching?

herbal remedies Explanation: A pregnant woman should avoid all medication unless instructed by the physician. This includes herbal remedies, because their effects on the fetus have not been identified. Meditation, music therapy, and acupuncture have all proven to enhance relaxation without harm to the mother or baby.

7 The charge nurse is assisting the new graduate nurse in administering eye drops to a child. The charge nurse would stop the new graduate if which action was observed?

holds the eyelids apart for about 30 seconds Explanation: To prevent the conjunctiva from drying, the nurse should not hold the eyelids apart any longer than necessary. Therefore, the charge nurse would need to stop the new nurse. It is best to use the supine position. Instill the correct number of drops into the conjunctiva of the lower lid. Allow the eyelid to close. Avoid placing the drops directly on the cornea because that can be painful. To prevent the conjunctiva from drying, do not hold the eyelids apart any longer than necessary. After the child has blinked 2 or 3 times, allow the child to sit up.

16 The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

ondansetron Explanation: Ondansetron (Zofran) is used to treat nausea and vomiting.

6 Which statement is the goal of distraction techniques used to control pain?

to divert the child's attention away from the pain through controlled, purposeful behaviors Explanation: The goal of distraction interventions is to divert the child's attention away from the pain through controlled, purposeful behaviors. These behaviors assist in managing mild pain or to augment the effectiveness of pain medication for moderate to severe pain. Distraction interventions assist children to cope with pain and gives them a sense of mastery or control over the situation. Distraction interventions will not take the pain away nor is their purpose to reduce the amount of or not give pain medication. The goal of distraction interventions is not parent-focused and the purpose is not entertainment for the child.

3 A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:

visceral pain. Explanation: The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

4 The nurse places the above catheter at the client's bedside for use at which time?

when the oral cavity has thick secretions Explanation: The catheter is a Yankauer suction catheter, which removes oral secretions. It is unable to fit down the tracheostomy tube. It is not used for irrigation. A catheter is not introduced following a tonsillectomy due to potential for a postoperative bleed.

4 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 Explanation: The Face, Legs, Activity, Cry, Consolability Scale is the appropriate pain assessment tool for a 4-week-old postoperative client. This tool measures pain using observable behaviors as pain indicators. The FACES Pain Scale is appropriate for children age 3 and older, using six faces ranging from happy with a wide smile to sad with tears on the face. The other two scales are appropriate for use with older children and adults. The Numeric Pain Intensity Scale is a one-dimensional pain scale using an 11-poing Likert-type scale ranging from 0 to 10, where 0 means "no pain" and 10 means "worst possible pain." The Combined Thermometer Scale looks like a thermometer and has both numbers that increase from the bottom up and descriptor words to measure pain intensity.

6 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. Explanation: When assessing pain location, ask the client to point to the painful area. If more than one area is painful, have the client rate each one separately, and note which area is the most painful. Marking each site is not necessary practice for assessing pain. Pain is a subjective sensation for the client. Radiating pain is notable, because such radiation may affect treatment choices.

14 A nurse is caring for a 10-year-old intellectually challenged girl hospitalized for a scheduled cholecystectomy. The girl expresses fear related to her hospitalization and unfamiliar surroundings. How should the nurse respond?

"Tell me about a typical day at home." Explanation: It is important to continue the usual routine of the hospitalized child, particularly of children with intellectual challenge. By asking an open-ended question about a typical day, the nurse can identify the routine activities that can potentially be duplicated in the hospital. Telling the girl she will be going home soon or asking about art supplies does not address her concerns. Asking whether she has talked to her parents is unhelpful at this time.

19 The nurse is assessing the pain of a preschooler. Which pain scales would be appropriate for the nurse to utilize? (Select all that apply.)

FLACC Scale • Wong-Baker Faces Scale • COMFORT scale Explanation: When assessing the pain of a preschooler, the nurse could choose from the following pain scales: COMFORT, FLACC, and Wong-Baker Faces. The CRIES pain scale is for neonates, and the 0-10 Numeric scale is for adults and children over 9 years old.

8 A nurse attempts to assess a client's pain but finds the client is having difficulty describing the pain. Which interventions by the nurse may help with the collection of subjective data about the client's pain? Select all that apply.

Maintain a quiet and calm environment • Assure the client's privacy • Document the terms used by the client Explanation: To help the client describe the pain, the nurse should maintain a quiet and calm environment, maintain the client's privacy, ask questions in an open-ended format, listen carefully to the client's verbal descriptions, watch for facial grimaces, and not put words in the client's mouth.

10 A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?

Support the client's decision and call the provider. Explanation: Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

5 During descent, an airplane passenger is complaining that his "ears are plugged." What aspect of the structure and function of the ear best accounts for the passenger's complaint?

The Eustachian tubes must remain patent to equalize pressure between the middle ear and inner ear. Explanation: The Eustachian tubes between the middle ear and nasopharynx must be patent to allow for changes in atmospheric pressure. Pressure is not accommodated by changing the volume of the middle ear. The tympanic membrane is not selectively permeable to air.

5 In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea?

Use imagery, humor, and progressive relaxation Explanation: Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication. Offering small amounts of nourishment frequently will not help potentiate the effects of pain medication. Gentle massaging of the arms and legs helps to regulate body temperature. Encouraging the client to fall asleep will not help potentiate the effects of pain medication.

11 Which phrase can do much to instill hope in the dying client?

"Let me tell you about your illness." Explanation: Hope is the ingredient of life that enables an individual to consider a future and to actively bring that future into being. One way the nurse can enable hope in the dying client is to provide honest information about the progress of the illness.

6 A female client experiencing hot flashes during perimenopause asks the nurse about hormone therapy (HT). What is the appropriate response by the nurse?

Short term HT can be used to reduce symptoms. Explanation: Low-dose HT may be used for short term treatment of perimenopausal symptoms, including hot flashes, night sweats, palpitations, dizziness, and headache. Its use is not limited to after menses stops. Other less effective treatments include SSRIs, gabapentin, clonidine, and isoflavones (soy, red clover).

10 The nurse is caring for a client who underwent an episiotomy. What statement by the client indicates teaching was successful?

"I should refrain from using tampons until advised by my healthcare provider" Explanation: The nurse should emphasize the need to change peripads frequently and instruct the client not to use tampons until after seeing the healthcare provider (usually at the 6-week postpartum checkup). The client can sit in chairs, but adequate padding will increase comfort. Elevation of the legs is not directly related to the episiotomy care, but it can help if the client has peripheral edema. Episiotomy sutures are self-dissolving and do not need to be removed. Itching does not need to be reported; it is an expected sensation, especially as the sutures dissolve.

3 Recently, lung cancer has metastasized to the bones of a 68-year-old client, precipitating a sudden increase in his pain. The client's wife and daughter are concerned about the consequent increase in the amount of hydromorphone the client requires, citing the risk of addiction. How can the nurse best respond to the family's concern?

"There's a very minimal risk of addiction, and controlling his pain is our first concern." Explanation: Concerns about addiction are normally unfounded. Nonetheless, it is inaccurate to characterize the possibility of addiction as a myth, on one hand, or a very real risk, on the other. Tolerance would not necessitate discontinuation.

10 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 Explanation: The client describes pain of 2 days' duration, which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, or sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for deficient fluid volume.

9 A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.

6 Which condition is a downward displacement of the bladder toward the vaginal orifice?

Cystocele Explanation: A cystocele results from damage to the anterior vaginal support structures. A rectocele is a bulging of the rectum into the vagina. Vulvodynia is a painful condition that affects the vulva. A fistula is an abnormal opening between two organs or sites.

2 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 Explanation: The nurse should use the Faces Pain Scale (FPS) to rate the pain felt by the client. The FPS shows different facial expressions; the client is asked to choose the face that best describes the intensity or level of pain being experienced. This tool is best suited for cognitively impaired adults. A Verbal Descriptor Scale (VDS) ranges pain on a scale between mild, moderate, and severe. The Numeric Rating Scale (NRS) rates pain on a scale from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. It has been shown to be best for older adults with no cognitive impairment. The Visual Analog Scale (VAS) rates pain on a 10-cm continuum numbered from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.

20 The nurse is caring for an adult postoperative client. Which physiologic response is related to pain?

Heart rate of 110 beats/min Explanation: Pain medication can cause decreased bowel motility and cause constipation. However, pain itself can cause an increased heart rate which is indicated by the rate of 110 beats/min. Pain can cause decreased urinary output; 2500 milliliters of urine in 24 hours is an indication of increased output. Pain can increase the consumption of oxygen; an O2 saturation of 98% on room air would be a normal reading.

3 A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?

Opioid analgesics Explanation: The nurse would expect to administer opioid analgesics to a client with severe pain following a mastectomy. Nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are usually the drugs of choice for both acute and persistent moderate chronic pain. Corticosteroids would be used to address inflammation and swelling.

6 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. Explanation: When assessing the older client for pain, determine whether the client has any auditory impairment. If so, position your face in the client's view, speak in a slow, normal tone of voice, reduce extraneous noises, and provide written instructions. The FLACC scale is used primarily for infants. Hearing aids are expensive and suggesting to purchased one does not aid in the pain assessment at present.

1 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. Explanation: Pain assessment requires an instrument that is easy to use, clinically valid, and easy to evaluate. An instrument that is too detailed is a liability; while the nurse should be responsive to the client's priorities and identified needs, it would inappropriate to wholly delegate the character and direction of assessment to the client. Pain assessment is highly dependent on subjective data, and these findings would not be minimized or discounted.

5 A nurse is caring for a 60-year-old client who experiences headaches several times a month. Which additional characteristics would support a diagnosis of tension headaches? Select all that apply.

The pain is described as dull and aching. • The pain responds to NSAIDs. Explanation: Tension headaches are commonly described as dull, diffuse aching that occurs in a hatband pattern around the head. There are no neurologic symptoms such as aura, nausea and vomiting, or visual changes. Tension headaches respond to treatment with over-the-counter agents such as aspirin and NSAIDs. Cluster headaches tend to affect people in their 20s and 30s. The classic onset is sudden, with an intense increase of symptoms for the first 10-15 minutes. The pain behind the eye radiates to the temple cheek and gum on the same side. The eyelid may droop or be edematous and the eye may tear or be reddened. Nasal congestion, rhinorrhea, and forehead or facial sweating may occur. There is no direct correlation with the menstrual cycle, nausea and vomiting, or an aura as may be the case with migraine.

8 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 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.

8 A nurse who "unblocks" and "clears" congested areas of energy in a client's body to promote comfort is applying the phenomenon known as:

Therapeutic Touch (TT) Explanation: Therapeutic Touch (TT) involves "unruffling," or clearing, congested areas of energy in the body and redirecting this energy. After assessing a client's "energy field," the nurse uses therapeutic touch to promote comfort, relaxation, healing, and a sense of well-being.

10 When assessing the client for pain, the nurse should

believe the client when he or she claims to be in pain. Explanation: "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain.

5 A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?

client rated pain level as being a 5 using the rating scale. Explanation: The nurse should document the exact pain assessment finding which would be client rated pain level as being a 5 using the rating scale. The statement "client experiencing a moderate amount of pain" is a subjective statement made by the nurse and is inaccurate. The statement "client experiencing mild pain" is a subjective statement made by the nurse and is inaccurate. The statement "client stated pain level not that bad" is a subjective statement made by the client however does not identify that the client rated the pain level as being a 5 on the Numeric Rating Scale.

1 A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

referred pain Explanation: Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage. Acute pain is distinct from chronic pain and is relatively more sharp and severe and lasts from 3 to 6 months. Chronic pain is often defined as any pain lasting more than 12 weeks. Limited pain is not usually a term used.

8 While talking about their migraine headaches, two women have found that they have some common triggers for their migraines, which may include: Select all that apply.

their menstrual cycle. • consuming chocolate. Explanation: Although the pathophysiology of migraines is not well understood, it is thought that hormone levels, particularly estrogen levels, may underlie their increased prevalence in women. Fluctuations in hormone levels, particularly in estrogen levels, are thought to play a role in the pattern of migraine attacks. For many women, migraine headaches coincide with their menstrual periods. The greater predominance of migraine headaches in women is thought to be related to the aggravating effect of estrogen on the migraine mechanism. Dietary substances, such as monosodium glutamate, aged cheese, and chocolate, also may precipitate migraine headaches. Yoga, piercings, and drinking white wine are not known to be triggers for migraines.

1 Which substance reduces the transmission of pain?

Endorphins Explanation: Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

4 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 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.

9 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 Explanation: The client describes pain of 2 days' duration, which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, or sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for deficient fluid volume.

15 During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?

Providing a solution of viscous lidocaine for use as a mouth rinse Explanation: To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.

6 The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?

Respiratory rate and depth Explanation: The client receiving opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering opioids.

7 A client recently recovering from shingles states that he suffers from pain and burning along his back and sides where the lesions are dried and crusted and requests pain medication. What is the nurse's best response?

"Rate your pain on a 0-10 scale; 0 being no pain and 10 the worst." Explanation: BOX 6.2 Definitions of Pain Neuropathic pain: Pain that results from damage to nerves in the peripheral or central nervous system. Examples of neuropathic pain include diabetic peripheral neuropathy, post herpetic neuralgia, and postmastectomy pain. Shingles is herpes zoster; therefore post herpetic neuralgia is a real phenomenon the client could be suffering from. The nurse should assess the client's pain on a scale. Narcotics may be used to treat chronic pain. This client most likely suffers from post herpetic neuralgia given the history; versus visceral pain (originates from abdominal organs).

3 When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies?

"Tell me how you handled labor pain in your past deliveries." Explanation: When the nurse is collecting data, it is best to discuss previous experiences with labor pain. Other questions may include, "What was helpful?" or "What did you not like?" While it is true that every labor is different, understanding the client's perspective from past experiences is valuable in developing individualized strategies. Developing a plan is best as a collaborative effort, not by picking pre-prepared options. It is important to include a support person if desired.

4 The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client?

Pain Explanation: Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.

9 Malnutrition is not something that is considered common in the general population in the United States. However, certain populations are more prone to malnutrition than others. One of these populations is hospitalized clients. Why is this true?

Pain and medications can decrease appetite. Explanation: The hospitalized client often finds eating a healthful diet difficult and commonly has restrictions on food and water intake in preparation for tests and surgery. Pain, medications, special diets, and stress can decrease appetite. Even when the client is well enough to eat, being alone in a room where unpleasant treatments may be given is not conducive to eating.

10 Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?

Pain assessment may require multiple methods in order to ensure accurate pain data. Explanation: It is often necessary to use more than one technique for pain assessment in children. Though their neurologic system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all clients above a certain age; the assessment tool should reflect the client's specific circumstances, abilities, and development.

5 Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric clients?

Pain assessment may require multiple methods in order to ensure accurate pain data. Explanation: It is often necessary to use more than one technique for pain assessment in children. Though their neurological system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all clients above a certain age; the assessment tool should reflect the client's specific circumstances, abilities, and development.

4 The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level?

1630 Explanation: Pain should be assessed every 4 hours; reassessments after interventions should be done in 30 minutes after intervention.

5 A nurse is caring for a 4-year-old client 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 client to point to the one that best represents the pain he is experiencing. This is an example of which of the following:

FACES scale Explanation: The FACES scale is used for children who are 3 years or older. This tool allows the client to point to the picture of the face that best represents the pain he or she is feeling. The FLACC scale uses face, legs, activity, cry, and consolability to assess the pain. The visual analog scale uses a 100-mm line with "no pain" at one end and "worst pain" at the other. The numeric scale is the most commonly used scale--an example is an 11-point Likert scale with 0 meaning no pain and 10 meaning the worst pain ever.

10 What measure at home could help a child with an upper respiratory infection breathe more easily?

Increasing room humidity Explanation: A moist environment helps prevent respiratory secretions from drying and becoming difficult to raise.

3 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.

Neurotransmitters like endorphins and histamines regulate this pain. • The pain is associated with the inflammatory process. • This form of pain can be either chronic or acute in nature. Explanation: Pain related to tissue damage is termed nociceptive somatic. Nociceptive pain can be either acute and remitting or chronic and persistent. This form of pain is mediated by the afferent A-delta and C-fibers of the sensory system that respond to noxious stimuli and is modulated by both neurotransmitters and psychological processes. Modulating neurotransmitters include endorphins, histamines, acetylcholine, and monoamines like serotonin, norepinephrine, and dopamine. These afferent nociceptors can be sensitized by inflammatory mediators. Pain resulting from direct injury to the peripheral or central nervous system is termed neuropathic. Idiopathic pain is not a form of nociceptive pain but rather a specific form of pain that has an unidentifiable cause.

2 A newly pregnant woman reports to the nurse that her breasts are excessively tender and that her areolae and nipples are becoming darker and more prominent. The nurse should describe which cause of these changes?

Normal changes of pregnancy due to increased levels of estrogen and progesterone Explanation: During pregnancy, increased levels of estrogen and progesterone cause the areola and nipple to become darker and more prominent and the Montgomery glands to become more active. These changes persist throughout pregnancy and do not disappear during the second trimester. These changes are not attributable to the effects of hCG.

9 During assessment, the nurse is using a pain scale with the client, who tells the nurse that his pain is at 7 on a scale of 1 to 10. This type of one-dimensional pain scale is also called a:

Numeric pain intensity scale Explanation: When rating the intensity of the pain, the nurse can use a one-dimensional scale called the NPI or numeric pain intensity scale. The visual analog scale uses a 100-mm line with "no pain" at one end and "worse possible pain" at the other. The verbal descriptor scale uses words such as "mild, moderate, and severe" to measure pain. The combined thermometer scale combines elements of other rating scales.

6 A 10-year-old boy who had an appendectomy had expressed worry that following the procedure he would have lots of pain. Two days after the procedure the child is claiming he is having no pain. Which nursing intervention should the nurse prioritize when assessing this child?

Observe him for physical signs which might indicate pain. Explanation: Nursing judgment is in order. Some children may try to hide pain because they fear an injection or because they are afraid that admitting to pain will increase the time they have to stay in the hospital. To use the color scale, a child younger than 7 is given crayons ranging from yellow to red or black. Yellow represents no pain; the darkest color (or red) represents the most pain. The child selects the color that represents the amount of pain he or she feels. The most appropriate pain scale to use with this child would be the 1 to 10 (with 10 being the worst pain) or the faces scale.

1 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?

Administer prescribed analgesia as ordered. Explanation: The client is complaining of the highest level of pain at 10/10. Therefore, the increased respirations and low oxygen saturation are likely a result of hypoventilation due to pain. Acute pain that is not adequately treated can impair pulmonary function. When the client is suffering from an intense amount of time, the client may not be very receptive to teaching and explanations. The client may have the desire to cough and deep breathe but is unable to due to the intensity of pain. The client can still breathe on his/her own, so an ambu bag is not needed.

10 How may a nurse demonstrate cultural competence when responding to clients in pain?

Avoid stereotyping responses to pain by clients. Explanation: Culture influences an individual's response to pain. It is particularly important to avoid stereotyping responses to pain because the nurse frequently encounters clients who are in pain or anticipating it will develop. A form of pain expression that is frowned on in one culture may be desirable in another cultural group.

17 Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain?

Do not administer if respirations are less than 12 breaths per minute Explanation: The nurse should not administer the prescribed opiate therapy if respirations are less than 12 breaths per minute. The nurse should instruct a client who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose concentration when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests.

3 A 24-year-old female client states, "About a week before my period starts, I have recently started craving certain sweets, having terrible mood swings, and feeling fatigued and irritable." Which action will the nurse take next?

Educate the client on treatment for premenstrual syndrome. Explanation: The client is exhibiting symptoms of premenstrual syndrome and the nurse would provide education on treatment options for the client's specific symptoms, such as increased rest and exercise. The nurse would document the findings and education provided in the client's medical record and notify the primary health care provider; however, these are not a priority as the client is stable and in need of treatment options. The client does not have symptoms warranting hormone testing at this time. If the symptoms worsened or became intolerable, then testing may be needed.