ATI Pain
A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client's knee for how long? 60 min 20 min 30 min 45 min
20 min MY ANSWER The nurse should apply heat therapy for no more 20 min at a time with at least a 20-min break after usage.
A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter "R"? "Can you rate your pain on a scale of 0 to10, with 0 being no pain and 10 being the worst pain you can imagine?" "Can you point to where you are having your pain?" "What does your pain feel like?" "What were you doing when your pain started?"
B The nurse should use the PQRST mnemonic to obtain more information about the client's pain. This question evaluates the region of the client's pain.
A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client's pain? Cancer pain Acute pain Chronic pain Neuropathic pain
Chronic pain Chronic pain is pain that has been present usually for 3 to 6 months or longer after the injury or damage has healed. Examples of chronic pain are arthritis pain or pain from a back injury. Chronic pain can physically and emotionally debilitate a client.
A nurse is contributing to a plan to teach staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make? "Justice allows the client the freedom of choice." "Justice allows the client the opportunity to be treated fairly." "Justice is causing no harm to the client." "Justice is doing good for the client."
"Justice allows the client the opportunity to be treated fairly."MY ANSWERJustice requires that all clients be treated fairly in regard to their pain management regardless of age, ethnicity, or history, such as substance use disorder or limited social and economic resources. Pain relief should be available to all clients.
A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include? "You should write down the pain interventions you use and your pain rating before and after." "You should understand that it is impossible to fix everyone's pain." "Your provider is best at determining whether your pain treatments are effective." "Your care partner should manage your pain control because you are unable."
"You should write down the pain interventions you use and your pain rating before and after." Keeping a pain diary or a pain log can be helpful for the client to determine if medications or treatments are helping over time.
A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression? A client who has chronic pain and recently started taking paroxetine A client who has cancer and has taken oxycodone PRN for several months A client who has been accidentally taking twice the amount of prednisone as prescribed A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN
A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN Use of an opioid medication can decrease the respiratory rate, and the first 4 hr postoperative are when the client is at highest risk for surgical complications. Therefore, the nurse should identify that the client who had surgery 3 hr ago and is receiving IV hydromorphone is at greatest risk for respiratory depression.
A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take? Administer 1 mg IM. Request a prescription to give the medication IV instead. Request a prescription for a different medication. Administer 2 mg IM.
Administer 1 mg IM. When a client has a prescription that includes a range, and the client has never taken the medication previously, the nurse should administer the lowest dose to the client. If the dose is ineffective, the nurse can increase the dosage up to the maximum amount in the range prescribed by the provider.
A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control? (Select all that apply.) Consider each client's cultural preferences. Determine the effectiveness of nonpharmacological strategies. Record the clients' subjective reports rather than the nurse's objective observations. Recognize that older adult clients over-report their pain level. Use a pain scale specific to each client's cognitive abilities.
Consider each client's cultural preferences is correct. The nurse must consider client factors that can affect their perception, response to, and report of pain, such as culture and socioeconomic status. Determine the effectiveness of nonpharmacological strategies is correct. The nurse should evaluate the effectiveness of each individual pain strategy, including both pharmacological and nonpharmacological. This helps determine which strategies are ineffective so that more effective strategies can be used consistently. Use a pain scale specific to each client's cognitive abilities is correct. The nurse should ensure that the pain scale used to measure a client's pain level is appropriate to their abilities, whether performing an initial pain assessment or evaluating pain effectiveness.
A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take? Use the Crying, Requires Oxygen, Increases Vital Signs, Expression, Sleeplessness (CRIES) pain scale. Reassure family members that older adult clients have a decreased ability to sense pain. Evaluate the client for pain by observing their behavior. Assign a pain scale number based on the FACES pain scale.
Evaluate the client for pain by observing their behavior. Clients who have cognitive impairment might be unable to appropriately report their pain. The nurse should observe for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes.
A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.) Face Legs Alert Circulation Consolability
Face is correct. Face is one of the categories included in the FLACC pain assessment. The nurse should observe the client's facial expression and determine a score.Legs is correct. Legs is one of the categories included in the FLACC pain assessment. The nurse should observe the client's position, tone, and extremities and determine a score. Consolability is correct. Consolability is a category included in the FLACC pain assessment. The nurse should observe the client to determine if they are consolable and assign a score.
A nurse is collecting data from a client who is nonverbal to determine the presence of pain. Which of the following assessment findings indicates an increased level of discomfort? (Select all that apply.) Grimacing Restlessness Elevated temperature Increased diaphoresis Bradycardia
Grimacing is correct. Clients who have cognitive impairment or communication challenges (e.g., expressive aphasia) require careful nursing assessment. The client might not report pain effectively, and the nurse should look for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes. Restlessness is correct. Clients who have cognitive impairment or communication challenges (e.g., expressive aphasia) require careful nursing assessment. The client might not report pain effectively, and the nurse should look for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes. Increased diaphoresis is correct. Objective indicators of pain include crying, sweating, restlessness, grimacing, or guarding by the client. Objective indicators are manifestations that can be observed by the nurse using their senses of sight, hearing, smell, and touch.
A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.) Muscular pain Active bleeding Backache Menstrual discomfort Swollen extremity
Muscular pain is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain. Backache is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain. Menstrual discomfort is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain.
A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take? Administer another 5-mg dose of the oral opioid now. Administer 10 mg of oxycodone every 2 hr. Inform the provider that the client's pain medication is not effective. Offer to assist the client with nonpharmacological relief strategies.
Offer to assist the client with nonpharmacological relief strategies. MY ANSWER The oxycodone would not have had time to peak and to be effective after 15 min. The nurse should offer to assist the client with nonpharmacological pain relief strategies until the medication has had time to work. Oral oxycodone peak effects should be noted 60 to 90 min after administration.
A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.) Stress Dietary practices Culture Social support Disease severity
Stress is correct. Stress levels are psychological factors that can affect a client's experience with pain. Other psychological factors include mood/affect, catastrophizing (assuming the worst), and coping.Dietary practices is incorrect. Factors that can affect a client's experience with pain include biological, psychological, and social factors. Culture is correct. A client's identified culture is a social factor that can affect a client's experience with pain. Social factors also include economic factors, the social environment, and social support. Social support is correct. The availability of support from family and or friends is a social factor that can affect a client's experience of pain. Social factors also include cultural and economic factors and the social environment. Disease severity is correct. The severity of a client's disease is a biological factor that can affect a client's experience of pain. Biological factors also include nociception, inflammation, and brain function.
A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to collect data about the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with? Malpractice Negligence Nonmaleficence Beneficence
Negligence. Negligence means failure to perform in a manner that a reasonable person would have. By failing to assess the client's pain and administer the client's pain medication, the nurse was negligent.
A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions? "I can use the morphine as needed as long as I don't take it more than six times a day." "I will use my household teaspoon to measure the correct amount of morphine." "I will monitor for high blood pressure while taking the morphine." "I will keep the morphine bottle in a locked cabinet in my kitchen."
"I will keep the morphine bottle in a locked cabinet in my kitchen." Morphine is a medication that carries significant risks to others, including children, and should only be accessible and used by the client for whom it is prescribed. Storing the medication in a high cabinet prevents accidental access to the morphine by others.
A nurse is assisting with providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family? "Your family member will not require pain medication." "Your family member can inform the provider about their decision for pain management." "Your family member has the right to receive effective pain management." "Your family member will not be able to tolerate the effects of pain medications."
"Your family member has the right to receive effective pain management." According to the American Society for Pain Management Nursing and the Hospice and Palliative Nurses Association position statement, end-of-life effective pain management is a basic human right. Clients who are receiving end-of-life care should receive special consideration for pain management.
A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply.) A 12-year-old client who has had an appendectomy A 3-year-old toddler who has a fractured femur A 6-day-old infant who had a surgical repair of a heart defect A 14-year-old client who has severe cognitive and developmental delays A 5-year-old preschooler who is experiencing pain during a sickle cell crisis
A 12-year-old client who has had an appendectomy is incorrect. A 12 year old would be able to cognitively report their pain level using a Numeric Rating Scale (NRS) or a Visual Analog Scale (VAS). The FLACC Pain Scale is recommended for children from 2 months to 7 years and for cognitively disabled children. A 14-year-old client who has severe cognitive and developmental delays is correct. Even though this client is of an age greater that than the ages recommended for use of the FLACC, this client has cognitive and developmental delays and might not be able to appropriately rate their pain using a NRS or VAS. The FLACC Pain Scale is recommended for children who are cognitively disabled.A 5-year-old preschooler who is experiencing pain during a sickle cell crisis is correct. A 5-year-old child might not be able to accurately report their level of pain using other pain scales. The FLACC Pain Scale is recommended for children from 2 months to 7 years.
A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy? A nurse allows a client to wait longer for their pain medication than other clients. A nurse does not properly clean a vial of pain medication prior to withdrawing medication from the vial, which results in the client contracting an infection. A nurse administers scheduled pain medication and provides therapeutic distraction techniques for a client in pain. A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.
A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief. MY ANSWER This is an example of autonomy. The nurse is providing the client their right of self-determination by permitting the client an ability to make an informed decision.
A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.) "You can be taught how to use TENS therapy at home." "We will insert very small sterile needles into your skin to block your pain." "This therapy may result in you having some temporary bruising at the site of application." "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas." "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy."
A, D, E "You can be taught how to use TENS therapy at home" is correct. TENS therapy can be provided by the nurse or the client can be taught to use the TENS unit and self-administer in the home setting. Localized bruising, swelling, pain, or numbness to the area of application are adverse effects of extracorporeal shock-wave lithotripsy (ESWL). No adverse effects of TENS are expected. The skin electrodes used to deliver the low-voltage impulses can produce an allergic reaction in some clients. "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas" is correct. These low-voltage electrical impulses reduce the nervous system's ability to transmit pain from the area of application to the brain. In addition, these impulses stimulate the body to produce endorphins, which also assist in relieving pain. "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy" is correct. The intensity, pulse rate, and duration of each pulse of treatment with TENS therapy can be adjusted by the nurse or the client.
A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain? The client is diaphoretic. The client is experiencing stabbing pain. The client is nauseated. The client states feeling dizzy.
The client is diaphoretic The nurse should identify that sweating is an objective manifestation of pain. Objective data is information the nurse can gather by using their five senses. Sweating can be visually noticed by the nurse.
A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain? A client who has osteoarthritis and reports difficulty ambulating for the past 6 months A client who had surgery to repair a fractured tibia and reports incisional pain A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury A hospice client who has prostate cancer and reports pelvic pain
A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury. Neuropathic pain is often referred to as nerve pain and arises from the somatosensory system. Neuropathic pain includes diabetic neuropathy, phantom limb pain, and pain associated with a spinal cord injury. Neuropathic pain is frequently described as intense, shooting, or burning.
A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management? (Select all that apply.) Fear of addiction Belief that pain is an expected part of their illness Inability to sleep Lack of support Inadequate pain assessment
A,B,E Fear of addiction is correct. Barriers to end-of-life pain management from a client or their family include fear of addiction. This leads to pain being undertreated or not treated at all. Every client has the right to effective pain management as they near the end of life. Belief that pain is an expected part of their illness is correct. Barriers to end-of-life pain management from a client or their family include the belief that pain is an expected part of their illness. This leads to pain being undertreated or not treated at all. Every client has the right to effective pain management as they near the end of life. Inadequate pain assessment is correct. The client's pain assessment can be inadequate due to several factors, such as the client's denial of pain, the client being unable to verbally express their level of pain due to unconsciousness or aphasia, or the client's or nurse's fear of causing adverse effects from the prescribed medications.
A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply.) "A client's religious beliefs might affect the way they respond to pain." "Herbal therapies are not permitted for a client receiving prescription pain medication." "The client's past pain experiences are not related to their current pain and pain management." "If a client can rate their pain using a numeric pain scale, there is no need to note nonverbal findings." "Pain control might be harder to achieve if the nurse and client speak different primary languages."
A,C & D client and prevent pain control, such as differences in ethnic backgrounds or religious beliefs. "The client's past pain experiences are not related to their current pain and pain management" is correct. The client's past pain experiences are not related to their current pain and pain management. "Pain control might be harder to achieve if the nurse and client speak different primary languages" is correct. The nurse should be aware of factors that could inhibit communication with the client and prevent pain control, such as language barriers or educational differences.
A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)? (Select all that apply.) Bowel sounds Deep tendon reflexes Respiratory rate Capnography Oxygen saturation
C,D,E Bowel sounds is incorrect. While opioid medications can affect bowel sounds, bowel sounds do not provide information about OIVI. Deep tendon reflexes is incorrect. Deep tendon reflexes are an indicator of neurologic function and do not provide information about OIVI. Respiratory rate is correct. The nurse should plan to monitor the respiratory rate frequently. A finding below the expected reference range could indicate OIVI. Capnography is correct. The nurse should recognize that capnography (measuring carbon dioxide) can assist with identifying OIVI. Oxygen saturation is correct. The nurse should plan to monitor the client's oxygen saturation frequently or continuously, depending on policy. A finding below the expected reference range could indicate OIVI.
A nurse is assisting with the care of a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression? Naloxone Lidocaine Prednisone Amitriptyline
Naloxone MY ANSWER Naloxone is a reversal agent for respiratory depression caused by opioids. It works quickly to reverse the effects of opioids on the client's respiratory system.
A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.) Transcutaneous electronic stimulating unit (TENS unit) Distraction techniques Massage Acupuncture Cold therapy
Transcutaneous electronic stimulating unit (TENS unit) is correct. The nurse should include transcutaneous electronic stimulating unit (TENS unit) as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain. Massage is correct. The nurse should include massage as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain.Acupuncture is correct. The nurse should include acupuncture as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain.Cold therapy is correct. The nurse should include the application of cold therapy as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain.
