Chapter 6 : Pain assessment

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?

Faces Pain Scale-Revised (FPS-R)

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?

McGill Pain Questionnaire

Which of the following best describes neuropathic pain?

May be labelled as central pain

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

"Rate your pain on a 0-10 scale; 0 being no pain and 10 the worst."

Which would the nurse recognize as a barrier to assessing pain in the older adult? Select all that apply.

- The belief that pain is a normal part of the aging proces. - Older adults with pain may fear becoming dependent on others. - Older adults may not display an outward reaction to pain.

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 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 using a mnemonic device.

A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action?

Check the client's vital signs and connect her to a cardiac monitor.

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

Which of the following is not released during the stress response?

Dopamine

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

When providing information to a client concerning the client's osteoarthritic, nociceptive pain, the nurse should include which statements about this type of pain? Select all that apply.

Neurotransmitters like endorphins and histamines regulate this pain. The pain is associated with the inflammatory process. This form of pain can be either chronic or acute in nature.

Identify the steps in the Gate Control Theory. (Number 1 is the first step and number 5 is the last step).

The "gate" opens through depolarization of the nerve. The pain stimulus passes from the peripheral nervous system to the central nervous system. The painful stimulus passes up to the cerebral cortex and the structures of the limbic system. The stimulus is identified as pain in the cerebral cortex and a response is created . The response is passed down the efferent pathway to create a reaction to the pain.

The nurse is explaining the difference between acute pain and chronic pain to the client. Which should the nurse include in the explanation?

The cause of acute pain can be identified.

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

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?

Validate the assessment data with the client.

When assessing the client for pain, the nurse should

believe the client when he or she claims to be in pain.

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 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

In preparing a care plan for a client receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use?

constipation

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?

Activity intolerance related to knee pain

A client presents to the emergency department after falling off a ladder and reports pain in the right shoulder. He says that he has not taken anything for the pain yet. The nurse recognizes this as what type of pain?

Acute

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?

Acute Pain related to sore throat

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

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.

Beliefs of health care providers can serve as barriers to an accurate assessment of a client's 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.

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

Neuropathic

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.

A client just underwent a left below-the-knee amputation (BKA). The client now reports pain in the missing left foot. What type of pain is the client describing?

Phantom

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

Physiological classification

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

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

Ranges from no pain to worst possible pain

Based on the analysis of assessment data from a client with pain, the nurse writes a health promotion diagnosis. Which diagnosis would be most appropriate?

Readiness for enhanced spiritual well-being related to coping with prolonged physical pain

A client in the Emergency Department is diagnosed with a myocardial infarction (heart attack). The client describes pain in his left arm and shoulder. What name is given to this type of pain?

Referred 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?

Referred pain

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 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

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 client is diagnosed with chronic non-malignant pain. The nurse understands that this client has experienced this pain for at least how many months?

6

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

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

Avoid stereotyping responses to pain by clients.

The nurse is assessing a female client diagnosed with fibromyalgia. The nurse should assess for which physiological indicators of pain? (Select all that apply.)

Blood pressure 180/75. Heart rate 115 beats/minute.

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.

The nurse is observing a client for evidence of pain. Which finding would lead the nurse to suspect that the client is experiencing pain?

Slumped posture

A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain?

Somatic

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?

"Can you describe to me how your pain feels?"

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?"

A post-operative client is observed breathing 24 breaths/minute while complaining of 10/10 abdominal pain. The client's oxygen saturation is 90% on 2 liters nasal cannula. What is the nurse's priority action?

Administer prescribed analgesia as ordered.

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?

A client recovering from a motor vehicle crash sustained right rib fractures and a fractured pelvis. The nurse is reviewing the client's metabolic panel lab results and notes a blood glucose of 130 mg/dL; the client has no history of diabetes. What is the nurse's best initial action?

Ask the client if she was in pain when the labs were drawn.

A nurse is caring for a 4-year-old client who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the client to point to the one that best represents the pain he is experiencing. This is an example of which of the following:

FACES scale

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 nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?

Faces Pain Scale

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

Have the client rate each location separately.

A client complains of aching all over her body. The client's health record indicates that she is otherwise healthy, with her baseline vital signs all well within normal limits. The nurse is assessing her for pain. Which of the following objective findings would most tend to indicate pain?

Heart rate of 110 beats per minute

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?

How does the pain influence your overall mood?

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.

The nurse understands the importance of performing an accurate pain assessment. In addition to having the client rate the pain on a pain scale, other things to assess are the following: (Check all that apply.)

Location and duration Quality and description Alleviating and aggravating factors

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

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

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 client's perception of pain and its intensity and quality. Which dimension is the nurse evaluating?

Sensory

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?

Wong-Baker Faces

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?

acute

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 II Diabetes Mellitus?

burning, tingling

One of the body's normal physiologic responses to pain is

diaphoresis.

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 this client as a physiologic response to pain? Select all that apply.

increased heart rate sleeplessness perspiration

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

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

quality

The nurse is assessing the client's perception of pain and the client's description of its intensity and quality. Which dimension of pain is the nurse evaluating?

sensory