Prep U Chapter 6

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:

"Nurses are the best authority on pain."

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

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

Avoid stereotyping responses to pain by patients.

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

Neuropathic

Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric patients?

Pain assessment may require multiple methods in order to ensure accurate pain data

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.

Perspiration Increased heart rate Sleeplessness

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

Physiological classification

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?

Referred pain

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

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

A nurse is attempting to apply the principles of cultural competency in the care of a 72-year-old Asian-American woman who has a spinal cord compression. Which of the following statements should guide the nurse's care?

The client may be reluctant to accept opioids

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

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?

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 was administered PO pain medications at 1530. By what time should the nurse re-assess and document the effects of the pain medication?

1630

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?"

A client who is cringing says that the pain is the worse that it has ever been. If using the numeric pain intensity scale, which number is the client describing?

10

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 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?

Acute pain related to abdominal wound

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.

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

Bracing

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

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:

Diaphoresis

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)

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 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 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?

Identifying pain as the fifth vital sign and assessing clients accordingly

A client rates his pain as "9" on a scale of 1 to 10. The nurse would expect to assess which of the following?

Increased serum glucose

A patient who was in an automobile accident a week ago is at home recovering from her injuries. She contacts her primary care provider's 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

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 young patient is experiencing pain and uses the FACES scale to rate it. The patient points to the picture that signifies "Hurts whole lot." Other expected assessment findings for this patient with this level of pain would be which of the following? (Check all that apply.)

Lack of sleep Lack of appetite Depression Anxiety

Which interventions should a nurse use to collect the subjective data from a client? Select all that apply.

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

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 Alleviating and aggravating factors

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

Health care providers often rate pain scores lower in patients of racial and ethnic minority groups than they do in Caucasian patients. Studies have shown that this disparity may be the result of which of the following variables? (Check all that apply.)

Nociceptive differences Communication processes Pain behaviors

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?

Sedation

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 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?

Tolerance

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 Face

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

diaphoresis.