Ch.6 Pain Assessment
A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta primary afferent fibers transmit pain that is felt as which of the following?
Sharp
How may a nurse demonstrate cultural competence when responding to clients in pain?
Avoid stereotyping responses to pain by clients.
The nurse is using the Verbal Descriptor Scale to assess a client's pain. What data will the nurse prioritize?
The client's explanation of how her pain feels
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
The nurse is caring for a client following left hip replacement. Which response by the client is appropriate when the nurse asks the client to identify a pain management goal related to the client's left hip pain?
"I want my pain to be 3 or less."
A nursing instructor is teaching about the gate control theory of pain. The instructor realizes that a student needs more information when the student states:
"In the limbic system the stimulus is identified as pain and a response is created."
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."
The client asks the nurse about possible causes of neuropathic pain. Which is the best response by the nurse?
"Patients with diabetes often develop neuropathic."
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."
A nurse is performing a detailed pain assessment of a client who has sought care for debilitating migraines. When assessing for precipitating factors, what question should the nurse ask?
"What were you doing immediately before your last migraine?"
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?
"What were you doing when the pain first stated?"
The nurse is caring for a child with pain. Which is a consequence of pain in children? Select all that apply.
- Depressive symptoms - Lack of appetite - Disruption of family functioning
Pain affects clients in different ways, with no boundaries. Which of the following are possible causes of pain? (Check all that apply.)
- Injury - Surgery - Chronic illnesses - No identifiable cause
A nurse is assessing a young woman for injuries who appears to be a victim of domestic violence. The nurse observes from the client's health record that her baseline vital signs are within normal limits. Which of the following objective findings would most tend to indicate pain? Select all that apply.
- Slumped shoulders - Blood pressure of 140/90 mm Hg - Edema at the elbow joint
A client is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to describe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers?
A-delta fibers
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
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
The community health nurse is caring for an older client who states that she has not been taking the postoperative pain medication that she was prescribed. What question is most likely to be relevant?
Are you able to afford the prescribed medication?
The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis?
Appendicitis
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?
Assess the client's pain by gathering subjective data from the client.
A client is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what?
Assess the site and intensity of the pain.
The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?
Burning, tingling
A male client with a history of a back injury 2 months ago has been taking daily doses of narcotic pain medication. He is currently hospitalized with a leg fracture after falling down the stairs. He complains of 10/10 pain in his back and leg after taking pain medication one hour ago. What is the nurse's best action?
Consult with the healthcare provider about increasing the dose of medication.
A client is experiencing acute pain and has asked the nurse for medication. The client rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the client that the nurse can expect is:
Diaphoresis
The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the client's pain, what is the most appropriate pain assessment tool for the nurse to use?
FACES Pain Scale
The nursing student asks the nurse what would be an example of visceral pain. What would be the correct response by the nurse?
Gallbladder pain
A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action?
Give the prn morphine
A 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?
It is likely that the client's pain rating will be influences by his emotional state.
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?
Kicking
A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?
Neuropathic
A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?
Neuropathic pain
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?
Nociceptors
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?
Nociceptors
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.
When performing a pain assessment the client should be asked to provide all the following information except:
Physiological classification
The nurse is using the Visual Analog Scale to assess pain of an adult client. The nurse instructs the client to:
Place a mark on a 100-mm line with "no pain" at one end and "worst possible pain" at the other
What is the main issue that a nurse should consider when choosing a pain assessment tool to collect objective data?
Produce accurate results each time it is used
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?
Provoking and alleviating factors
A nursing instructor is teaching students about the pain experience. The instructor informs the students that a client experiencing pain will have a stress response. The students are aware that this stress response causes the following:
Release of epinephrine, cortisol, and norepinephrine
The client with a cognitive impairment sometimes cannot rate pain on a scale of 0 to 10. In such a case, the nurse is aware of other cues to assess the client's pain. Which of the following is correct?
Restlessness, guarding
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.
An elderly farmer has sustained severe injuries after a serious accident involving a combine harvester. At the hospital, he tells the nurse that he thinks the pain he is feeling now is "payback" for living a "mean, selfish life." The nurse recognizes that this response by the man indicates which dimension of pain?
Spiritual dimension
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?
The release of endorphins
The wife of a client with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the client is likely showing the effects of which of the following?
Tolerance
The nurse is caring for a client following an open reduction, internal fixation of the right hip. The nurse observes the client moans when being repositioned. What type of pain indicator is moaning?
Vocalization
When assessing the client for pain, the nurse should
believe the client when he or she claims to be in pain.
