Chapter 6: pain assessment

The nurse is explaining the pathophysiology of pain to a nursing student. The nurse determines understanding of the main concepts when the student nurse makes which of the following statements?

"Nociceptors at the peripheral nerve ending transmit pain."

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 we're you doing immediately before your last migraine?"

The nurse is assessing a client's pain. Which question would be the most appropriate to ask the client to identify precipitating factors that might have exacerbated the pain?

"What we're you doing when the pain first started?"

The nurse is assessing a clients pain. Which question would be most appropriate to ask the client to identify precipitating factors that might have exacerbated the pain?

"What we're you doing when the pain first started?"

A nurse is collecting subjective data from a client with acute appendicitis. Which interventions should the nurse use for this task?

Listen carefully to the client's description of problem Maintain a quiet environment when interviewing Maintain the client's privacy and ensure confidentiality

As a nurse is adjusting a clients hospital bed, the nurse accidentally pinches a finger between the bed and wall. Which of the following components is involved in the transduction of the pain the nurse feels?

A-delta and C-fibers

A client 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 nice is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers?

A-delta fibers

Four physiological processes involved in pain perception. In the correct order

Transduction Transmission Perception Modulation

An older with osteoarthritis has tearfully reported to the nurse that she is no longer able to climb the stairs to climb the stairs to the second floor of her house due to her knee pain. Which actual client concern should the nurse address based on the client's statement?

Activity intolerance associated with knee pain

The nurse prepares to update the care plan of a client recovering from abdominal surgery. Which client need should the nurse meet that most appropriately addresses the clients pain?

Acute pain associated with abdominal wound

A nurse reviews the vital signs of a new client: temperature 99.3 F (37.38 C), pulse 105 beats/min, blood pressure 143/83 mmHg, and respiratory rate 22 breaths/min. What action should the nurse take first?

Ask the client if they are experiencing any discomfort

A nurse is admitting a client to the postsurgical unit from the post anesthetic 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 clients pain by gathering subjective data from the client

The nursing class is learning about pain assessment. Which of the following is a manifestation of pain?

Bracing

The nurse should assess for which pain complaints from a client diagnosed with Type 2 Diabetes Mellitus?

Burning, tingling

A client is admitted for treatment of pneumonia. When conducting a pain assessment, which area on the diagram provided should the nurse expect the client to experience referred pain because of this health problem?

Clavicle, neck area

The nurse is using the Brief Pain Inventory to help assess pain in a client. Which of the following clients will benefit from this assessment?

Client admitted with bone cancer

A female client with bone cancer is experiencing pain that has become more severe over the past several days. When modifying the clients plan of care, the nurse identifies a need to assess the affective dimension of the clients pain. How can the best accomplish this goal?

Closely monitor the effects of the clients pain on her emotions

All the following are signs or symptoms reported by clients with chronic pain except:

Confusion

A male client with 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 on hour ago. What is the nurse's best action?

Consult with the healthcare provider about increasing the dose of medication.

The nurse prepares to assess a 5-month-old client for pain. When using the Behavioral Pain Scale (BPS), what should the nurse observe to determine the presence of pain in this client?

Cry Face Legs

A client is experiencing acute pain and has asked the nurse 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 in the post anesthesia care unit and assessing pain in a 6 month old infant. Which method should the nurse use to assess the infant's pain?

FLACC scale

A clients complains of pain in several areas of the body. How should the nurse assess this client's pain?

Have the client rate each location separately

A nurse is assessing the effect of a clients chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?

How does the pain influence your overall mood?

An instructor is teaching students enrolled in a health assessment class the physiological response to pain. The instructor determines understanding when the student identify which of the following responses?

Increased blood glucose Increased heart rate Urinary retention

Beliefs of health care providers can serve as barriers to an accurate assessment of a clients pain. Which of the following beliefs will not be likely to impair the assessment of pain?

Infants can feel pain and may respond with crying or agitation.

Pain affects clients in different ways, with no boundaries. Which of the following are possible causes of pain?

Injury Surgery Chronic illnesses In identifiable cause

A client experiences pain regardless of the type or amount of medication provided. How should the nurse classify the clients pain?

Intractable

A client who was in an automobile accident a week ago is at home recovering from her injuries. She contacts her primary care providers office to report that she still has severe pain in her back, resulting from an injury to that region, that has not been lessened by two different pain relievers that the physician had prescribed for her. The nurse recognizes this as which type of pain?

Intractable

The nurse is using a multidimensional pain assessment tool that combines indices measuring pain intensity, mood, pain location (via body diagram), and verbal descriptors, which includes questions about medication efficacy. Which of these tools is a multidimensional pain assessment tool?

McGill pain questionaire

A construction worker in his mid-40s suffered a severe laceration on his leg while on the job site. Soon after he arrives at the emergency room, a nurse assesses his pain. The client states that pain, although severe, has lessened since the accident first occurred. The nurse knows that the pain message likely has been inhibited by release of endorphins and other neurotransmitters. Which physiological process does this represent?

Modulation

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

Neuropathic

When clients reports pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source of more than likely:

Neuropathic

When attempting to assess a clients pain, what would the nurse do first?

Obtain a client self-report

A client enters the emergency department moaning and complaining of severe pain in his lower back. Which of the following clinical manifestations should the nurse expect to see in the this client as a physiological response to pain?

Perspiration Increased heart rate Sleeplessness

When preforming a pain assessment the client should be asked to provide all the following information except:

Physiological classification

Patients have different levels of tolerance for pain. Research has proven an increased sensitivity to pain in which of the following groups?

Preterm newborns

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

In addition to pain intensity, what is another basic element of a pain assessment?

Quality

The nurse is using the Verbal Descriptor Scale to assess a clients pain. What data will the nurse prioritize?

Ranges from no pain to worst possible pain

The client comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Refereed pain

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 is assessing the clients perception of pain and it's intensity and quality. Which dimension is the nurse evaluating?

Sensory

The nurse recognizes that a barrier to successful pain management for the client with opioid tolerance is:

The client does not experience pain relief with usual doses of opioids

A client is admitted with right lower abdominal pain with rebound tenderness. The nurse suspects appendicitis and documents this type of pain as which of the following?

Visceral

The nurse is observing a clients posture and facial expression for evidence of pain. Which of the following would most likely lead the nurse to suspect that the client may be experiencing pain?

Slumped posture

A client reports pain in the knee. The knee is warm, swollen, and red and the client describes the pain aching and gnawing. The nurse determines the client is experiencing which of the following types of nociceptive pain?

Somatic

A nurse enters a clients room or conduct an assessment. The client is crying and states they have so much pain. What is the best response of the nurse?

"Could you tell me more about your pain?"

The nurse is caring for a client presenting to the emergency department who is reporting jaw pain due to a myocardial infarction. What consideration should the nurse take into account while addressing the clients jaw pain?

It is distant from the actual source from the painful stimulus

The U.S. government has created guidelines for health care providers caring for clients in pain. Which of the following reflect these guidelines?

Joint Commission Standards for Pain Management

A client reports after a back massage that his lower back pain has increased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?

The release of endorphins