EXAM 1

The nurse is assessing a postoperative client that reports a pain level of 10 on a 1 to 10 scale. The client is grimacing and appears anxious. Which of the following actions should the nurse perform first? 1. Administer pain medication if it has been longer than the ordered interval. 2. Offer to call the pastoral service to provide spiritual counseling. 3. Obtain an order for an anti-anxiety medication. 4. Call the family to come in and stay with the client.

1. Administer pain medication if it has been longer than the ordered interval. Pain needs to be well managed and pain should be assessed with vital signs. Pain is the 5th vital sign. Pain needs to be well managed with pain medications given on a scheduled basis, so that the pain does not get out of control. Once the pain is under control, the nurse can assess other factors influencing the clients pain response.

The nurse is examining a client is in the Emergency Department. The client has recently been discharged after a right above-the-knee amputation. The client tells the nurse that her right foot hurts. The nurse suspects what type of pain? 1. Phantom pain 2. Radiating pain 3. Intractable pain 4. Cutaneous pain

1. Phantom pain The client is describing phantom pain, which is a painful sensation perceived in an absent body part or a body part that is paralyzed.

The nurse is caring for a client complaining of a backache and administers ibuprofen. The client asks the nurse how the medication will help the pain. The nurse understands that ibuprofens effect occurs during which phase of nocioception? 1. Transduction 2. Transmission 3. Perception 4. Modulation

1. Transduction Rationale 1: Since ibuprofen blocks the production of prostaglandin, it acts during the transduction phase.

The nursing student is discussing an assigned clients pain responses with the nursing instructor. The student reports feeling amazed about how the client has continued to avoid taking any analgesics only hours after surgery. What response by the nursing instructor is indicated? 1. Sometimes clients just dont need any analgesics. 2. Have you seen any nonverbal cues that might indicate the client is experiencing pain? 3. We will need to contact the healthcare provider to report the clients continued refusal of analgesics. 4. Do the clients vital signs indicate the client is experiencing pain?

2. Have you seen any nonverbal cues that might indicate the client is experiencing pain? Rationale 2: Have you seen any nonverbal cues that might indicate the client is experiencing pain? The nurse will need to promote a comprehensive assessment of the clients pain experience. Nonverbal behaviors will need to be considered. Some clients may be stoic with the pain experience.

The nurse is caring for a teenager and is assessing pain level with the vital signs. The client is reporting pain but when the nurse asks for a description of the pain the client says, It just hurts. Why cant I have something? The nurse would choose to do which of the following next? 1. Leave the room and come back later. 2. Provide questions that require yes or no answers related to pain. 3. Ask the client what they would like to have for pain. 4. Continue with the vital signs assessment.

2. Provide questions that require yes or no answers related to pain. People who are not feeling well or who are in pain may have difficulty with open-ended questions, such as Describe. The nurse may be better able to obtain an accurate description of their pain by having them respond to descriptive words.

The client is in the triage area of the Emergency Department when a client arrives complaining of chest and arm pain. The client also reports jaw pain, but states that the chest pain hurts more. The nurse observes the client rubbing his left arm. The nurse suspects what type of pain? 1. Phantom pain 2. Radiating pain 3. Intractable pain 4. Cutaneous pain

2. Radiating pain The client is describing radiating pain, which has an origin in one part of the body and then spreads to other adjacent body parts.

Which of the following assessment data will be most reflective of a clients pain response following open-heart surgery? 1. Family report of pain 2. Response from the client based on use of a pain tool 3. Observations of the clients behaviors while asleep 4. Measurement of vital signs

2. Response from the client based on use of a pain tool Rationale 2: The use of a standardized pain tool that has been discussed with the client preoperatively will provide the most useful data.

The parents of a 13-month-old infant requiring a veinipuncture for laboratory studies ask the nurse what they can do to help with pain during the procedure. Which of the following would be the best action for the nurse to take? 1. Have the parents leave the area during the procedure. 2. Tell the parents to touch and reassure the infant during the procedure. 3. Wait until the infant is asleep to do the procedure. 4. Administer an analgesic 30 minutes before the procedure.

2. Tell the parents to touch and reassure the infant during the procedure. Rationale 2: The nurse understands that the presence of supportive people may affect the infants perception of the severity of the pain, and provide reassurance and security.

The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the clients rates his pain as a 7 out of 10 (1 is no pain and 10 is the worst pain possible). This client is moving around easily and is eating well, but has asked for pain medicine. The nurse would choose which of the following actions? 1. Wait 30 minutes and see if the client is still requesting the pain medicine. 2. Administer half the ordered does of pain medication. 3. Administer the pain medication if it is has been longer than the ordered interval. 4. Notify the healthcare provider that the client is faking his pain.

3. Administer the pain medication if it is has been longer than the ordered interval. Since pain occurs whenever the experiencing person says it does and is whatever the experiencing person says it is, the nurse should accurately assess and treat the pain with the pain medication if that is what is ordered.

A nurse is orienting to a new position in an infant nursery. When the healthcare provider is preparing to perform a circumcision on a 2-day-old newborn who was born 2 weeks early, the nurse asks about the administration of pain medication prior to the procedure. The healthcare provider states: Newborns do not have pain at this age, so why should we give any medication? The nurses best response would be: 1. I would think it would make the parents feel better to know it had been given. 2. I am going to have to report you to the ethics board. 3. Pain transmission has been documented in infants of this age. 4. What will it hurt to just go ahead and give it?

3. Pain transmission has been documented in infants of this age. Rationale 3: Research has changed the perception that infants do not feel pain. Performing procedures that may induce pain necessitates that pain management interventions should be implemented. An infant may have pain interventions based upon behavioral responses exhibited.

The nurse is caring for a client who denies having pain. The nurse has noticed the client grimacing and clenching his teeth when moving. The clients spouse has asked the nurse why some people deny obvious pain. What response by the nurse is most appropriate? 1. You should try to find out why your husband is denying the pain. 2. Have you talked to the healthcare provider about this? 3. Some people feel reporting their pain is a sign of weakness. 4. Maybe we are wrong and pain is not really bad.

3. Some people feel reporting their pain is a sign of weakness. Adult clients may deny the presence of pain. Sometimes the denial is an effort not to appear weak.

A 19-year-old Arab male is in the hospital for a ruptured appendix. His parents are at the bedside the majority of his waking hours. The nurse caring for him during the day observes that he denies any pain during the day shift. The night nurse reported that the client had requested pain medication every 4 hours during the night. The nurse considers the most probable explanation for this to be: 1. The night nurse had more time to spend with the client. 2. The client must be afraid or lonely at night and is trying to get attention. 3. The client may not report pain in the presence of his parents based on their influence or cultural beliefs. 4. The client was asking for medication at night to help him sleep.

3. The client may not report pain in the presence of his parents based on their influence or cultural beliefs. Rationale 3: A client may have ethnic or cultural beliefs that influence the response to pain. Some clients may be verbal and open, while some clients may choose to be quiet and suffer with the pain. The presence of family members, especially adult family members in this situation, may influence the reporting of pain. The client may have not wanted to contradict the perceived parental expectations of how an adult Arab male was to respond to pain.

A nursing student is reviewing the home medications of a client who has just been admitted with chronic back pain. When asked by the nursing instructor why there is a tricyclic antidepressant on the clients list, which response by the student is most likely the accurate reason? 1. I would think having chronic pain would make the client depressed. 2. It may be to prevent depression due to physical limitations. 3. This type of medication can help inhibit painful stimuli. 4. The client is at risk for suicidal thoughts related to the chronic pain

3. This type of medication can help inhibit painful stimuli. Rationale 3: Tricyclic antidepressants can inhibit the reuptake of norepinephrine and serotonin. This would assist with the modulation phase of pain response by decreasing the pain stimuli response.

The nurse is working at pain clinic and is preparing an orientation for new staff nurses. Which of the following definitions of pain would the nurse correctly choose to include in this orientation? Pain is: 1. Validated by the nurse determining the cause of the pain. 2. Unpleasant sensations, typically experienced upon movement. 3. Whatever the experiencing person says it is. 4. Very subjective so observations must be used to assess levels and intensity.

3. Whatever the experiencing person says it is. The most widely accepted definition of pain is the one offered by McCaffery: whatever the experiencing person says it is, existing whenever he or she says it does

A nurse working in a healthcare providers office is interviewing a client that reports experiencing daily migraines. The nurse decides to further assess the impact of the clients pain. An appropriate choice of assessment tools would be which of the following? 1. Psychologic well-being inventory 2. Body Diagram tool 3. Intensity rating scale 4. Brief Pain Inventory

4. Brief Pain Inventory Rationale 4: Migraine pain is chronic in nature and, therefore, a multidimensional tool such as the Brief Pain Inventory is the most useful for assessing two or more elements of the pain and the impact of pain on daily living.

A 45-year-old client continues to request intravenous pain medications 4 days after being placed in skeletal traction due to a complex fracture of the hip. While giving report to the next shift, the nurse who cared for the client during the day states, I just do not know why he still needs medication 4 days after surgery. The client we had last month with the same type situation did not need any medication after 2 days. Which of the following responses by a nursing peer is the best example of being a client advocate? 1. I just think this client needs more because of his age. 2. Have you tried getting the doctor to order oral pain medications to see if they work? 3. Wouldnt you want all of the pain medication you could have if you were in traction? 4. Everyone does not have the same pain perception or response to a similar injury.

4. Everyone does not have the same pain perception or response to a similar injury. Based on the definition by McCaffery & Pasero pain is whatever the experiencing person says it is, existing whenever he or she says it does. This definition supports each clients need for individualized pain management approaches.

A client with chronic pain from spinal stenosis has asked the nurse for assistance with pain management. The client is well dressed and composed, with normal vital signs. The nurse observes that the client grimaces when sitting but rates the pain at only a 2. The nurse suspects which of the following? The client: 1. Needs to exercise instead of taking pain medication. 2. Is not in severe pain and does not need treatment. 3. Is getting better. 4. Has adapted to the pain and is able to control behaviors.

4. Has adapted to the pain and is able to control behaviors. People with chronic pain develop their individual coping styles to deal with pain, discomfort, or suffering. Also, physiologic responses may be marked in acute pain but because of central nervous system adaptation, physiologic responses are likely to be absent. Therefore, behavioral and physiologic responses are not good indicators of pain.

A 12-year-old client is brought to the emergency room after falling on his arm during a football game. When the nurse tells the client that she is going to administer pain medication through the intravenous line, the client begins to scream and wave his unhurt arm. The parents ask the nurse why their child is behaving this way. The nurses best response would be: 1. He is just immature for his age. 2. I am sure he is just scared. 3. It looks like he may have hurt his head during the fall. 4. He may be remembering another time when he got a shot.

4. He may be remembering another time when he got a shot. Rationale 4: A clients nervous system responds to pain, but many times there are also behavioral responses. A clients pain reaction may be a behavioral response to a similar or previous situation when pain was experienced. This is a learned response and method of coping with the pain. Many children remember getting a shot for pain, or getting an immunization. Seeing the syringe and/or needle may trigger this pain reaction.

The nurse is interviewing a 75-year-old client who is in the healthcare providers office for complaints of joint pain. The client verbalizes that the pain has been present for a few years. When planning interview questions to ask concerning the pain, the nurse recognizes which of the following? 1. Clients start to complain of many types of pain as they age. 2. The joint pain is probably not the real reason the client is in the office. 3. The client is most likely depressed. 4. Older adults frequently avoid seeking treatment for their pain.

4. Older adults frequently avoid seeking treatment for their pain. Rationale 4: The older adult may perceive pain as part of the aging process. They may fear that the treatment prescribed may limit their independence.

A recently licensed nurse states, My client keeps saying he is in pain. I dont believe him because I had the same surgery last year and didnt feel nearly as bad as he claims. What response by the more experienced nurse is most appropriate? 1. It sounds as if your client is a drug seeker. 2. You should contact the healthcare provider. 3. I would call the nursing supervisor for this one. 4. Pain differs from person to person.

4. Pain differs from person to person. Pain has been defined as whatever the experiencing person says it is, existing whenever he or she says it does. Pain reports will vary between people.

The nurse is assessing a client admitted with severe abdominal pain. Which of the following would the nurse include as essential components of the pain assessment? Standard Text: Select all that apply. 1. Description of the pain 2. Temperature, pulse, respirations, and blood pressure 3. Pain intensity rating 4. Family medical history 5. Previous pain experience

Correct Answer: 1,2,3,5 1: Description of the pain. The nurse assessing the client will need to determine characteristics of the pain. These characteristics expressed by the client will aid in the management of the condition Rationale 2: Temperature, pulse, respirations, and blood pressure. The vital signs of the client reporting acute pain will likely provide supportive information concerning the pain being experienced. Rationale 3: Pain intensity rating. An integral part of the definition of pain is that it is what the individual reports it to be. The degree of intensity will be needed to determine the level of pain being experienced. The degree of pain intensity assessment will be a key component in the interventions being used to manage the pain. Rationale 5: Previous pain experience. An individuals past experience with pain is a determining factor in the ability to manage pain. Past experience will also impact reports of pain by the client.

A client has multiple fractures following a motor vehicle accident. One of the client outcomes of the nurses plan of care includes reducing the perception of pain. Which of the following nursing interventions would apply to reaching this outcome? Standard Text: Select all that apply. 1. Offering a selection of musical CDs 2. Assisting with guided imagery 3. Administering Demerol (Meperidine) intravenously 4. Providing instruction on deep breathing techniques 5. Administering an anti-inflammatory medication

Correct Answer: 1,2,4 Rationale 1: Offering a selection of musical CDs. The use of music is a means to assist the client to shift the focus from the pain to something else. This will help in reducing the perception of pain. Rationale 2: Assisting with guided imagery. Guided imagery allows the client to focus on a calmer, more positive place or sensation. This allows the focus to divert from the pain. This is a means to reduce the perception of pain. Rationale 4: Providing instruction on deep breathing techniques. The use of therapeutic techniques will reduce the clients sensation of pain being experienced.

The nurse is performing a physical assessment on a client with undiagnosed back pain. The client is unable to communicate verbally. Which of the following vital sign values would indicate to the nurse that the client is in acute pain? Standard Text: Select all that apply. 1. Temperature of 100.6 degrees: 2. Pulse rate 94 3. Respiratory rate 32 4. Blood pressure 158/92 5. Facial grimacing

Correct Answer: 2,3,4,5 Rationale 2: Pulse rate 94. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Rationale 3: Respiratory rate 32. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Rationale 4: Blood pressure 158/92. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Rationale 5: Facial grimacing. Facial grimacing may be noted in the expressions of the client experiencing acute pain.

The nurse is caring for a 3-year-old child who has been hospitalized for internal fixation of a fractured arm. The nurse is considering nonpharmacological pain management techniques to implement. What interventions should be included in the plan of care? Standard Text: Select all that apply. 1. Offer a glucose-coated pacifier. 2. Sit with the child and allow her to blow bubbles. 3. Explain to the child the cause of the pain. 4. Teach the use of guided imagery. 5. Hold the child.

Correct Answer: 2,5 Rationale 2: Sit with the child and allow her to blow bubbles. Blowing bubbles is an age-appropriate activity for the preschool-age child. The child can be encouraged to blow the pain away. Rationale 5: Hold the child: The preschool-age child will find comfort in being held during the pain.

The nurse is preparing to complete the admission assessment for a client who is being admitted to the acute care facility for complaints of severe pain. As the nurse plans actions relating to this task, the following steps will be taken. Organize in order the actions that should be taken by the nurse. Standard Text: Click and drag the options below to move them up or down. Choice 1. Contact the healthcare provider. Choice 2. Discuss the unit routine with the client and family. Choice 3. Ask the client when the pain first began. Choice 4. Ask the client what helps to relieve the pain. Choice 5. Assess the clients past coping methods for pain throughout her life.

Correct Answer: 3,4,5,2,1

The nurse understands amount of pain stimulation that is needed for an individual to feel pain is referred to as: 1. Pain threshold. 2. Pain tolerance. 3. Somatic interval. 4. Cephalgia reporting.

1. Pain threshold. Rationale 1: The pain threshold is the amount of pain stimulation a person requires in order to feel pain.

A client with a history of cardiac problems is brought to the emergency room by the paramedics with a tentative diagnosis of myocardial infarction (MI, or heart attack). The paramedic tells the nurse that the client had pain in the jaw area that was not relieved with nitroglycerin. The client asks the nurse how jaw pain is related to having a heart attack. The nurses best explanation is: 1. The doctors would rather treat you as a cardiac client until they find out why the nitroglycerin did not work. 2. Sometimes cardiac pain is not just in your chest, but in your jaws, arms or back. 3. You may have been so stressed that you clenched your jaws and not realized if you had any chest pain or not. 4. It may not be related, but cardiac pain is so serious to investigate and treat.

2. Sometimes cardiac pain is not just in your chest, but in your jaws, arms or back. Rationale 2: Referred pain may result when pain is felt in tissues that are not in close proximity to the primary cause or site of the pain. This may be especially true of cardiac pain. It may be exhibited in the jaw, shoulders, arms, or back.

The nurse is assessing a client admitted with chronic back pain. Which of the following would the nurse associate with this type of pain? Standard Text: Select all that apply. 1. Sudden onset 2. Interferes with daily activities 3. Lower intensity 4. Prolonged in duration 5. Sharp elevations in body temperature

Correct Answer: 2,4 Rationale 2: Interferes with daily activities. Chronic pain invades the life of a client. The daily activities of the client with chronic pain are impacted. Rationale 4: Prolonged in duration. By definition, chronic pain lasts for a period of 6 months or longer.

The nurse is performing an assessment on a 23-year-old client who is being seen for chronic back pain. During the assessment, which of the following findings can be anticipated? Standard Text: Select all that apply. 1. Increased pulse rate 2. Increased respiratory rate 3. Normal pulse rate 4. Normal blood pressure 5. Diaphoresis

Correct Answer: 3,4 Rationale 3: Normal pulse rate. The pulse rate of the client experiencing chronic pain will likely be within normal limits. Elevations in pulse rate are seen in clients experiencing acute pain. Rationale 4: Normal blood pressure. The blood pressure findings in the client experiencing chronic pain will most likely be within normal limits. Elevations are most often seen in clients experiencing acute pain.

The nurse is caring for two clients involved in a motor vehicle accident. Both clients required explorative abdominal surgery. Neither has received any pain medication in six hours and both have asked. However, one client is in greater distress than the other. Which pain theory is useful in explaining this phenomenon? The theory of: 1. Pattern. 2. Specificity. 3. Stress. 4. Gate control.

Gate control theory attempts to explain the involvement of the brain as well as nerve fibers in the pain experience. The involvement of the brain helps explain why painful stimuli are interpreted differently by people experiencing pain

The nurse has completed a shift assessment on a client who has terminal breast cancer with extensive metastasis. The client tells the nurse, Nothing helps the pain. What best describes the pain being experienced by the client? 1. The client is experiencing referred pain. 2. The client is experiencing intractable pain. 3. The client is experiencing retractable pain. 4. The client is experiencing radiating pain.

Rationale 2: Intractable pain refers to pain that is not controllable. It is often associated with an advanced malignancy.