ATI RN pain assessment 2.0

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." "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."

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 point to where you are having your pain?"

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 will keep the morphine bottle in a locked cabinet in my kitchen."

A nurse is teaching 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 opportunity to be treated fairly."

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." "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 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."

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?

20 min

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 Inadequate pain assessment

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? (Select all that apply.)

Grimacing Restlessness Increased diaphoresis

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 Backache Menstrual discomfort

A nurse is caring for 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

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?

Offer to assist the client with nonpharmacological relief strategies.

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.)

Respiratory rate Capnography Oxygen saturation

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 Culture Social support Disease severity

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.

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) Massage Acupuncture Cold therapy

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.

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?

Evaluate the client for pain by observing their behavior.

A nurse is 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 has the right to receive effective 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 3-year-old toddler who has a fractured femur 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 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 had surgery 3 hr ago and is receiving IV hydromorphone PRN

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 diabetes mellitus and reports bilateral burning foot pain without signs of injury

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 provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.

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?

Chronic pain

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 Consolability

A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with?

Negligence

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 Use a pain scale specific to each client's cognitive abilities.