Assessment Chapter 6

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? a. Acute b. Chronic c. Phantom d. Cutaneous

Acute Explanation: Acute pain results from tissue damage, whether through injury or surgery. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Phantom pain is pain in an extremity or body part that is no longer there. Cutaneous pain and phantom pain are not described as above. Chronic pain, also known as persistent pain, is a description of a pain that is present for more than six months, and can be described in many different terms, not just as above.

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

Somatic Explanation: Pain nociception has various locations. Visceral pain originates from abdominal organs; patients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; patients 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 specifi c site, but the person experiencing it feels the pain at another site along the innervating spinal nerve (Fig. 6.3).

The nurse is caring for a client diagnosed with chronic nonmalignant pain. The nurse should understand that this client has experienced this pain for at least how many months? 3 6 9 12

6 Explanation: Chronic nonmalignant pain usually is associated with a specific cause or injury and described as a constant pain that persists for more than 6 months.

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

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

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 fibers C-fibers K-fibers L-beta fibers

A-delta fibers *Explanation:* Nociceptors are located at the peripheral ends of both myelinated nerve endings of type A fibers and unmyelinated type C fibers, and there are three types that are stimulated by different stimuli: mechanosensitive nociceptors (of A-delta fibers), sensitive to intense mechanical stimulation (e.g., pliers pinching skin); temperature-sensitive (thermosensitive) nociceptors (of A-delta fibers), sensitive to intense heat and cold; and polymodal nociceptors (of C fibers), sensitive to noxious stimuli of a mechanical, thermal, or chemical nature. There are no "K-fibers" or "L-beta fibers."

The community health nurse is caring for an older patient who states that she has not been taking the postoperative pain medication that she was prescribed. What question is most likely to be relevant? A. Are you able to afford the prescribed medication? B. Is confusion causing you to refuse your pain medications? C. Are you too busy to take your prescribed pain medication? D. Will you take the medication if you are ordered to do so?

A. Are you able to afford the prescribed medication? Explanation: If a patient continues to refuse pain medication, you may consider asking the patient they can afford the prescribed medication.

A popular pain assessment scale for children is: a. Visual Analog Scale. b. Descriptive Pain Intensity Scale. c. FLACC Pain Assessment Scale. d. Memorial Pain Assessment Card.

A. Visual Analog Scale. *Explanation:* The visual analog scale is appropriate to assess pain in children.

A nurse is assessing the vital signs of a patient who is moaning with pain. What would be the expected findings? a. Decreased pulse and respirations b. Increased pulse and blood pressure c. Increased temperature d. No change from usual results

Increased pulse and blood pressure Explanation: A patient who is in pain will most often also have an increased pulse and blood pressure.

After describing the pathophysiology of pain, an instructor determines that the students have understood the teaching when they identify which of the following as being responsible for transmitting the sensations to the central nervous system? A. Transduction B. Modulation C. Nociceptors D. Cytokines

Nociceptors Explanation: The source of pain stimulates peripheral nerve endings or nociceptors, which transmit the sensations to the central nervous system. Transduction begins when a mechanical, thermal or chemical stimulus results in tissue injury or damage, stimulating the nociceptors. Modulation inhibits the pain message and involves the body's own endogenous neurotransmitters in the course of processing the pain stimuli. Cytokines are released due to an inflammatory process resulting from the painful stimulus.

The nurse is assessing hospitalized post-operative pain and has asked the client to rate his pain, describe it, state the location and onset of when it started. What other question should the nurse include in this pain assessment? A. Provoking and alleviating factors B. Availability of medication C. Financial resources to obtain medication D. Medications taken in the past

Provoking and alleviating factors Explanation: The nurse is conducting a focused pain assessment of a hospitalized client. Some burses prefer to use mnemonics to remember the elements of pain assessment. One of these is OPQRST : O: Onset P: Provocative or palliative Q: Quality R: Region and radiation S: Severity T: Timing The availiability of medication, past medications, and client's financial resources are not the most pertinent questions to include at this time.

The nurse is using the Verbal Descriptor Scale to assess a client's pain. What data will the nurse prioritize? A. Facial expressions B. 0 to 10 numeric scale C. 0 to 10 visual analog scale D. Ranges from no pain to worst possible pain

Ranges from no pain to worst possible pain Explanation: The Verbal Descriptor Scale rates pain from no pain up to the worst possible pain with mild, moderate, severe, and very severe in between the two end-points. The Faces Pain Scale uses facial expressions to rate pain. A numeric pain intensity scale rates pain using a 0 to 10 number scale. A visual analog scale rates pain along a 10 cm line from no pain to pain as bad as it could possibly be.

The wife of a patient 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 patient is likely showing the effects of which of the following? A. Tolerance B. Addiction C. Physical dependence D. Drug interactions

Tolerance Explanation: This patient is likely developing drug tolerance, which occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief. This is not a pathological finding and does not necessarily indicate physical dependence. Tolerance does not indicate addiction or a heightened risk of addiction. The phenomenon noted is not indicative of a drug interaction.

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 1

a. Give the prn morphine Explanation: Pain is what the client says it is, and it exists whenever the client says it does. It would not be appropriate to hold the medication for 30 minutes, call the physician to check the order, or just document the client's 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 Explanation: The client's limitation on moving around her house is suggestive of activity intolerance. The client is clearly emotional about this development, but this is not synonymous with ineffective coping. Role performance and self-esteem may be affected, but there is no direct evidence to support these diagnoses.

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 by gathering subjective data from the client. 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 by gathering subjective data from the client. *Explanation:* If the client acknowledges pain, further assessment parameters should be gathered from the patient. A mnemonic such as COLDSPA, OLDCARTS, or OPQRST can be used to help guide questioning when obtaining subjective data. This should precede other assessments, even though these should later be performed.

When patients report pain, it is important to find the source. When patients 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 patient experiencing the pain feels it at another site along the innervating spinal nerve. Neuropathic pain is described as burning, painful numbness, or tingling.

How may a nurse demonstrate cultural competence when responding to patients in pain? a. Treat every patient 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 patients.

d. Avoid stereotyping responses to pain by patients. Explanation: Culture influences an individual's response to pain. It is particularly important to avoid stereotyping responses to pain because the nurse frequently encounters patients 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.

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 stated?" B. "Do concurrent symptoms accompany the pain?" C. "When did you first notice the pain?" D. "Is the pain continuous or intermittent?"

"What were you doing when the pain first stated?" *Explanation:* Asking what the client was doing when the pain started might identify a precipitating factor. Asking about concurrent symptoms provides information about the possible source of the pain. Asking when the pain started provides information about the onset and duration of the pain. Asking if the pain is continuous or intermittent helps to identify the nature of the pain.

The patient asks the nurse about possible causes of neuropathic pain. Which is the best response by the nurse? A. "Patients with diabetes often develop neuropathic." B. "Surgical procedures can cause neuropathic pain." C. "Sickle cell pain is a type of neuropathic pain." D. "Orthopedic trauma is an example of neuropathic pain."

A. "Patients with diabetes often develop neuropathic." *Explanation:* Neuropathic pain results from damage to nerves in the peripheral or central nervous system. Examples include diabetic peripheral neuropathy, post-herpetic neuralgia, and post-mastectomy pain. Examples of acute pain include surgery, trauma, or injury. Examples of chronic pain include low back pain and sickle cell pain.

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.

Administer prescribed analgesia as ordered. Explanation: The client is complaining of a 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 is not adequatley 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.

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? A. Consult with the healthcare provider about increasing the dose of medication. B. Inform the client that the next dose of medication is due in one more hour. C. Request a psychiatric evaluation for drug seeking behavior. D. Tell the client to take his own prescription medication.

Consult with the healthcare provider about increasing the dose of medication. Explanation: Clients with a history of opioid tolerance pose difficult challenges for pain assessment (D'Arcy, 2014). They have an altered physiologic response to the pain stimulus, and the repeated use of opioids causes their bodies to become more sensitive to pain. This sensitivity is called opioid hyperalgesia and can occur as soon as 1 month after opioid use begins. Not only are clients with opioid tolerance more sensitive to pain, they face a high level of bias from health care providers. Because these clients are more sensitive to pain, they often report high levels of pain with little relief from usual doses of opioids. They are often labeled as drug seeking.

A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain? a. Nociceptive b. Neuropathic c. Somatic d. Idiopathic

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.

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

Injury Surgery Chronic illnesses No identifiable cause *Explanation:* Pain is one of the most common reasons patients seek medical care. It can affect everything about the patient, inculding quality of life and sense of well-being. Pain has many causes such as the result of injury, surgery, and chronic illnesses. In some cases, pain has no identifiable cause. Gender does not cause pain.

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

Nociceptors Explanation: The source of pain stimulates peripheral nerve endings or nociceptors, which transmit the sensations to the central nervous system. Transduction begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage, stimulating the nociceptors. Modulation inhibits the pain message and involves the body's own endogenous neurotransmitters in the course of processing the pain stimuli. Cytokines are released due to an inflammatory process resulting from the painful stimulus.

The patient 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 patient is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following? Visceral pain Referred pain Cutaneous pain Somatic pain

Referred pain *Explanation:* Referred pain originates from a specific site, but the person feels the pain at another site site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigeston. 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.

A nursing instructor is teaching students about the pain experience. The instructor informs the students that a patient experiencing pain will have a stress repsonse. The students are aware that this stress repsonse causes the following: A. Release of epinephrine, cortisol, and norepinephrine B. Decrease in oxygen and energy consumption C. Decrease in blood glucose and lactate levels D. Decrease in muscle tension and stress

Release of epinephrine, cortisol, and norepinephrine Explanation: The nurse must assess objective data as well as subjective data when assessing the patient for pain. Pain will induce a stress response that causes the release of epinephrine, cortisol, and norepinephrine. These hormones will have a metabolic and neuroendocrine response. Some of these effects are increased oxygen demand and consumption, as well as increased blood glucose and lactate levels and ketones. Muscle tension may also increase from the stress response.

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.

Validate the assessment data with the client. Explanation: It is important to validate pain assessment data that are collected with the client. Comparisons to previous assessments and consultation with other members of the care team do not determine the reliability and accuracy of data obtained during a pain assessment.

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 Explanation: While the effects of pain on activities of daily living and past experiences and future expectations for treatment should be elicited from the client, he or she would not be expected to classify pain according to physiology.

A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client? a. Occasional grimace or frown b. Whimpering c. Lying quietly d. Kicking

d. Kicking Explanation: According to the FLACC scale for pediatric pain assessment, kicking or the legs being drawn up is a strong sign indicating pain, as it would receive a 2. An occasional grimace or frown and whimpering are weaker signs of pain, as they would each warrant only a 1. Lying quietly is a normal activity and indicates the absence of pain; thus, it would receive a 0.

An emergency department nurse is assessing a client's complaint of upper abdominal pain. To assess the character of the pain, the nurse would begin with what assessment question? a. "Can you describe to me how your pain feels?" b. "How would you rate your pain on a 10-point scale?" c. "Is your pain affecting your ability to cope?" d. "Would you describe your pain as acute, or as chronic?"

"Can you describe to me how your pain feels?" *Explanation:* Information about the character of the paincan be elicited by asking the client to describe his or her pain.

A nursing instructor is teaching students how to assess a patient's pain. The instructor emphasizes that there are many misconceptions about pain. The instructor realizes that a student needs further direction when the student states: A. "Patients with chronic illnessess 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."

"Nurses are the best authority on pain." Explanation: Pain is what the patient says it is, and it exists whenever the patient says it does. The patient is the best authority on pain, and self-report is the gold standard. Therefore, nurses are not authorities on pain. It is true that patients 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.

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 nursing instructor is teaching students how to assess a patient's pain. The instructor emphasizes that there are many misconceptions about pain. The instructor realizes that a student needs further direction when the student states: a. "Patients with chronic illnessess 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."

"Nurses are the best authority on pain." Explanation: Pain is what the patient says it is, and it exists whenever the patient says it does. The patient is the best authority on pain, and self-report is the gold standard. Therefore, nurses are not authorities on pain. It is true that patients 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.

A mother calls the nurse practitioner to say, "I don't know what is wrong with my baby. He cried all night and kept pulling at his ear." How would the nurse respond? A. "Oh, he probably was just hungry and wet. Did you feed him?" B. "Babies at that age cry at night. Think nothing of it." C. "That means his ear hurts. Bring him in to be checked." D. "That probably means he had a tummy ache. How is he now?"

"That means his ear hurts. Bring him in to be checked." Explanation: Pain is frustrating for children because they are unable to understand the concept and cause of pain and may have difficulty describing it. Crying and touching or grabbing the painful body part are observations that may indicate pain in a child.

Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric patients? 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 patients. 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. 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 patients above a certain age; the assessment tool should reflect the patient's specific circumstances, abilities, and development.

A female client with advanced-stage vascular dementia has been showing signs of pain over the past several hours. The nurse is unable to obtain a self-report from the client due to her cognitive impairment. When applying the Hierarchy of Pain Assessment Techniques, how should the nurse proceed with assessment? A. Search for potential causes of pain. B. Ask the client's family if she is in pain. C. Perform interventions as if the client were in pain. D. Use a visual assessment tool rather than a verbal tool.

A. Search for potential causes of pain. *Explanation:* The second item on the Hierarchy of Pain Assessment Techniques is to search for potential causes of pain. A visual assessment tool is a form of self-report, which is noted to be unavailable. Interventions should not be undertaken in the absence of assessment data.

A nurse is caring for a client who was administered opioid narcotics. The client complains of constipation. Which of the following is another potential side effect of opioid narcotics? A. Sedation B. Anxiety C. Diarrhea D. Insomnia

A. Sedation *Explanation:* Opioids and opiates cause sedation, nausea, constipation, and respiratory depression, which is the main side effect to watch for with narcotics. Opioids and opiates do not lead to anxiety, diarrhea, or insomnia in clients.

The nurse recognizes that a barrier to successful pain management for the patient with opioid tolerance is: A. The patient does not experience pain relief with usual doses of opioids. B. The patient 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 patient.

A. The patient does not experience pain relief with usual doses of opioids. *Explanation:* A barrier to successful pain management for the patient with opioid tolerance is that the patient does not experience pain relief with usual doses of opioids. The patient with opioid tolerance has an altered physiologic response to painful stimuli, and repeated use of opioids causes their bodies to become more sensitive to pain. Pain assessment tools appropriate for use with the patient with opioid tolerance exist.

A patient 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 nurse is caring for a patient following an open reduction, internal fixation of the right hip. The nurse observes the patient moans when being repositioned. What type of pain indicator is moaning? A. Vocalization B. Verbalization C. Emotional D. Behavioral

A. Vocalization *Explanation:* Moaning is a vocalization pain indicator; other examples include groaning, gasping, and screaming. Verbalization would include the expression specific words, such as counting, praying, and swearing. Emotional pain indicators include excessive sleeping, anxiety, fear, and depression. Behavioral pain indicators include massaging, guarding, and immobilizing body parts.

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

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.

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

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.

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.

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 patients who cannot verbalize: (1) vocalizations, (2) facial grimacing, (3) bracing, (4) rubbing painful areas, (5) restlessness, and (6) vocal complaints.

A nurse is caring for a 4-year-old patient who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the patient to point to the one that best represents the pain he is experiencing. This is an example of which of the following: A. FLACC scale B. FACES scale C. VISUAL analog scale D. Numeric scale

B. FACES scale *Explanation:* The FACES scale is used for children who are 3 years or older. This tool allows the patient 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.

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? A. Utilize the FLACC scale. B. Speak to the client face to face. C. Suggest client purchase a hearing aid. D. Ask client to numerically rate pain in a high-pitched voice.

B. Speak to the client face to face. Explanation: When assessing the older patient for pain, determine whether the patient has any auditory impairment. If so, position your face in the patient'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

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 Explanation: The client describes pain on two-day 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, 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 fluid volume deficit.

A patient is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what? A. Check the patient'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 patient 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 patient'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 Explanation: The nurse should assess for neuropathic pain associated with diabetic neuropath. Neuropathic pain: Pain that results from damage to nerves in the peripheral or central nervous system (Staats, et al., 2004). Examples of neuropathic pain include diabetic peripheral neuropathy, post herpetic neuralgia, and postmastectomy pain. You should also be alert for the common terms that patients use to report neuropathic pain, such as burning, painful tingling, pins and needles, and painful numbness.

A client who has fractured her arm is describing her pain as "excruciating." The nurse determines that the client is experiencing what type of pain? A. Cutaneous B. Visceral C. Deep somatic D. Radiating

C. Deep somatic *Explanation:* Deep somatic pain is pain associated with ligaments, tendons, bones, blood vessels, and nerves. Cutaneous pain involves the skin or subcutaneous tissue. Visceral pain involves the abdominal cavity, thorax, and cranium. Radiating pain is perceived at the source and extending to other tissue.

A hospital's protocols for assessment have been modified in light of standards established by the Joint Commission. What change would bring practice into alignment with these standards? A. Teaching all new clients about the basic pathophysiology of pain B. Assessing clients' pain objectively rather than subjectively C. Identifying pain as the fifth vital sign and assessing clients accordingly D. Triaging clients according to the type of pain that they are experiencing

C. Identifying pain as the fifth vital sign and assessing clients accordingly *Explanation:* Recent literature has emphasized the importance and undertreatment of pain and has recommended that pain be the fifth vital sign. Type of pain is not the primary basis for the triage process. Pain assessment should combine objective data with subjective data, and there is not normally a need to teach clients about the pathophysiology of pain.

A nurse assesses a non-English-speaking 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 B. Numeric Rating C. Wong-Baker Faces D. Visual Analog Scale

C. Wong-Baker Faces *Explanation:* The nurse should use the Wong-Baker Faces Scale (FACES) to rate the pain felt by the client. FACES scales show different facial expressions, where 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 children and clients who are unable to communicate in the same language as the nurse. 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, where 0 reflects no pain and 10 reflects pain at its worst. The Visual Analog Scale (VAS) rates pain on a 10 cm continuum numbered from 0 to 10, where 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.

The nurse is caring for a post-operative patient with an order for morphine sulfate 2 mg IV push every 4 hours. The patient'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 patient that it is too soon for another dose of morphine. C. Wait and medicate the patient when the next dose of morphine is due. D. Administer another dose of the morphine sulfate immediately.

Call the prescribing physician see about changing the pain medication. Explanation: Untreated or undertreated acute pain may lead to chronic pain syndrome (CRPS). Patients who have had surgery are at increased risk for developing CRPS. The nurse works diligently to find acceptable strategies to address a patient's pain, while observing the rights of medication administration. The nurse may need to contact the physician for adjustments in dosing, frequency of dosing, or acquiring an order for another pain medication to obtain optimal pain management for the patient. The other three options do not address the patient's pain.

A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action? A. Alert the healthcare provider to the client's somatic pain complaints. B. Administer an antacid and apply a topical anesthetic for the arm pain. C. Check the client's vital signs and connect her to a cardiac monitor. D. Request a strong narcotic analgesic for the client's visceral pain complaints.

Check the client's vital signs and connect her to a cardiac monitor. Explanation: Pain nociception has various locations. Visceral pain originates from abdominal organs; patients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; patients 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. An example is cardiac pain that a person experiences as indigestion, neck pain, or arm pain. Phantom pain is pain in an extremity or body part that is no longer there (e.g., a patient who experiences pain in a leg with an amputation). The client is presenting with atypical chest pain and should be assessed for pain of a cardiac origin.

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

D. Acute pain related to abdominal wound *Explanation:* Since the client is recovering from abdominal surgery, the most appropriate diagnosis at this time would be Acute pain related to abdominal wound. A period of at least 6 months needs to transpire before identifying the client's pain as being chronic. The client may have impaired physical mobility or an ineffective breathing pattern related to the abdominal pain however these diagnoses may need to be added later once the client is permitted out of bed and engaging in more activity.

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? Explanation: The question regarding the influence of the pain on mood would address the client's affective dimension, which includes feelings and emotions that result from the pain. The question regarding medical conditions would help assess the client's physical dimension. The question regarding the location of the pain would address the client's sensory dimension. The question regarding the client's education would address his cognitive dimension.

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? a. Cognitive dimension b. Sociocultural dimension c. Affective dimension d. Spiritual dimension

D. Spiritual dimension Explanation: The spiritual dimension refers to the meaning and purpose that the person "attributes to the pain, self, others, and the divine." In this case, it seems that the man is interpreting his accident and subsequent pain as divine retribution for his past wrongdoings. The cognitive dimension concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management." The sociocultural dimension concerns the influences of the patient's social context and cultural background on the patient's pain experience. The affective dimension concerns feelings, sentiments, and emotions related to the pain experience.

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. *Explanation:* It is important to validate pain assessment data that are collected with the client. Comparisons to previous assessments and consultation with other members of the care team do not determine the reliability and accuracy of data obtained during a pain assessment.

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

Diaphoresis Explanation: Diaphoresis is an expected physiological response to pain resulting from sympathetic nerve stimulation. Decreases in pulse, blood pressure, and muscle tension are not expected findings when a patient is experiencing pain.

The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the patient's pain, what is the most appropriate pain assessment tool for the nurse to use? A. Face, Legs, Activity, Cry, Consolability Scale B. Visual Analog Scale C. FACES Pain Scale D. Numeric Pain Intensity Scale

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.

A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. Which of the following scales should the nurse use to assess the client's pain? A. Numeric scale B. Word scale C. Linear scale D. FACES scale

FACES scale Explanation: The nurse should use the Wong-Baker FACES scale, which is best for children and clients who are culturally diverse or mentally challenged. Nurses generally use a numeric scale, a word scale, or a linear scale to quantify the pain intensity of adult clients who can express their pain intensity in words, numbers, or linear fashion with the help of the respective scales.

The nurse is caring for a 4-week-old postoperative patient. 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

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 patient. 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.

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

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.

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

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.

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 Burn pain Cardiac pain Arthritic pain

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.

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

Give the prn morphine Explanation: Pain is what the client says it is, and it exists whenever the client says it does. It would not be appropriate to hold the medication for 30 minutes, call the physician to check the order, or just document the client's pain.

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.

Have the client rate each location separately. Explanation: When assessing pain location, ask the patient to point to the painful area. If more than one area is painful, have the patient 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 radation may affect treatment choices.

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.

Have the client rate each location separately. Explanation: When assessing pain location, ask the patient to point to the painful area. If more than one area is painful, have the patient 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 radation may affect treatment choices.

The nurse is teaching the patient about the importance of treating pain and informs the patient that if pain is not treated adequately, it can lead to many different complications. Which of the following are some examples? (Check all that apply.) Impaired pulmonary function Decreased immune response Decreased hematocrit count Longer hospital stays Chronic regional pain syndrome

Impaired pulmonary function Decreased immune response Longer hospital stays Chronic regional pain syndrome *Explanation:* Pain can cause physical and emotional harm. If not treated, it can impair pulmoary funciton, decrease the immune response, and prolong the hospital stay. If pain is from a surgery or crush injury, a patient is at risk for developing chronic regional pain syndrome (CRPS).

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.

It is likely that the client's pain rating will be influences by his emotional state. Explanation: Although pain perception is poorly understood, studies have shown that the emotional status of a client, such as depression or anxiety, directly affects the level of pain perceived and thus reported by clients. The nurse needs to be conscious of and able to react to the possibility that a client with depression is experiencing more pain, or less pain, than he or she is reporting.

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.a.

It is likely that the client's pain rating will be influences by his emotional state. Explanation: Although pain perception is poorly understood, studies have shown that the emotional status of a client, such as depression or anxiety, directly affects the level of pain perceived and thus reported by clients. The nurse needs to be conscious of and able to react to the possibility that a client with depression is experiencing more pain, or less pain, than he or she is reporting.

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

Liver pain Gallbladder pain Pancreatic pain Explanation: Examples of visceral pain include pain associated with the liver, gallbladder, and pancreas. Pain associated with a burn is an example of cutaneous pain. Muscular pain is a type of somatic pain.

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

Location and duration Quality and description Alleviating and aggravating factors *Explanation:* In a pain assessment. the nurse asks the patient to use a pain scale to rate the intensity of the pain. Other areas to assess are location and duration, quality and description, and any alleviating or aggravating factors. Although the nurse would want to assess the patient's allergies before giving pain medications, diet is not included, nor is urinary output or oxygenation.

The nurse is using a multidimensional pain assessment tool that combines indices measuring pain intensity, mood, pain location (via body diagram), and verbal descriptors, and which includes questions about medication efficacy. Which of these tools is a multidimensional pain assessment tool? A. McGill Pain Questionnaire B. Visual Analog Scale C. Numeric Pain Intensity Scale D. Combined Thermometer Scale

McGill Pain Questionnaire Explanation: The MPQ was developed to measure pain in experimentally induced circumstances, following procedures, and with several medical-surgical conditions. It consists of a set of verbal descriptors used to capture the sensory aspect of pain, a VAS scale, and a present pain intensity rating made up of words and numbers. The tool has been found reliable and valid, and has been translated into several languages.

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? a. "Even when he becomes addicted, we can take comfort knowing that his pain is controlled." b."It's actually a myth that clients can become addicted to hospital narcotics." c. "If he ends up needing higher doses to resolve the pain, we will discontinue the drug." d. "There's a very minimal risk of addiction, and controlling his pain is our first concern."

d. "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.

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? a. somatic b. referred c. visceral d. neuropathic

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.