PrepU Chapter 6

The community health nurse is caring for an older patient 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? Will you take the medication if you are ordered to do so? Is confusion causing you to refuse your pain medications? Are you too busy to take your prescribed pain medication?

Are you able to afford the prescribed medication?

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

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: "Chronic pain can be referred to as persistent pain." "Nurses are the best authority on pain." "Patients with chronic illnessess can have chronic pain." "Acute pain can be as intense as chronic pain."

"Nurses are the best authority on pain."

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

Neuropathic

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? "If he ends up needing higher doses to resolve the pain, we will discontinue the drug." "Even when he becomes addicted, we can take comfort knowing that his pain is controlled." "There's a very minimal risk of addiction, and controlling his pain is our first concern." "It's actually a myth that clients can become addicted to hospital narcotics."

"There's a very minimal risk of addiction, and controlling his pain is our first concern."

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 L-beta fibers C-fibers K-fibers

A-delta fibers

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? Ineffective role performance related to osteoarthritis Ineffective coping related to knee pain Activity intolerance related to knee pain Situational low self-esteem related to osteoarthritis

Activity intolerance related to knee pain

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? Risk for deficient fluid volume related to fever Anxiety related to prolonged pain Impaired physical mobility related stiff neck Acute pain related to sore throat

Acute pain related to sore throat

The nurse is caring for a patient who is experiencing visceral pain. What is this patient's most likely diagnosis? Appendicitis Bone fracture Shingles Myocardial infarction

Appendicitis

A patient is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what? Call the physician. Check the physician's orders to see what pain medication to administer. Check the patient's record for allergies. Assess the site and intensity of the pain.

Assess the site and intensity of the pain.

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

Avoid stereotyping responses to pain by patients.

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus? Pain only on movement Burning, tingling Sharp, stabbing Aching, gnawing

Burning, tingling

The nurse is caring for a post-operative patient with an order for morphine sulfate 2 mg IV push every 4 hours. The patient's pain is unrelieved 30 minutes following administration of the morphine sulfate with the pain rating increasing from 7 to 10. Which action should the nurse take? Administer another dose of the morphine sulfate immediately. Wait and medicate the patient when the next dose of morphine is due. Call the prescribing physician see about changing the pain medication. Instruct the patient that it is too soon for another dose of morphine.

Call the prescribing physician see about changing the pain medication.

A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action? Request a strong narcotic analgesic for the client's visceral pain complaints. Check the client's vital signs and connect her to a cardiac monitor. Administer an antacid and apply a topical anesthetic for the arm pain. Alert the healthcare provider to the client's somatic pain complaints.

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

In preparing a care plan for a patient receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use? Bowel incontinence Constipation Diarrhea Impaired urinary elimination

Constipation

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. Inform the client that the next dose of medication is due in one more hour. Request a psychiatric evaluation for drug seeking behavior. Tell the client to take his own prescription medication

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 FLACC Behavioral Scale, what should the nurse observe to determine the presence of pain in this client? Select all that apply.

Cry Face Legs

The nurse is caring for a child with pain. Which is a consequence of pain in children? Select all that apply. Increased restorative sleep Lack of appetite Increased levels of play Disruption of family functioning Depressive symptoms

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: Decreased pulse Flaccid muscles Diaphoresis Hypotension

Diaphoresis

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 patient's pain, what is the most appropriate pain assessment tool for the nurse to use? Face, Legs, Activity, Cry, Consolability Scale Numeric Pain Intensity Scale FACES Pain Scale Visual Analog Scale

FACES

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? Graphic Rating Scale Faces Pain Scale-Revised (FPS-R) Verbal Descriptor Scale Numeric Rating Scale (NRS)

Faces Pain Scale-Revised (FPS-R)

When reviewing a client's medication administration record, the nurse should plan to administer a medication containing which substance that blocks pain sensations? Substance P Bradykinin Gamma-aminobutyric acid Glutamate

Gamma-aminobutyric acid

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? Where is the pain located? What is the highest level of education you've completed? What medical conditions do you have?

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 would the nurse need to keep in mind when assessing the client's pain? The degree of surgery will be the key indicator for level of pain experienced. The depression will have minimal impact on the client's level of pain. It is likely that the client's pain rating will be less than what he is feeling. The client is likely experiencing less pain than he is reporting.

It is likely that the client's pain rating will be less than what he is feeling

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.) Quality and description Location and duration Diet and allergies Urine output and pulse oximetry value Alleviating and aggravating factors

Location and duration Quality and description Alleviating and aggravating factors

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 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. The developing neurological system children transmits less pain than in older patients. A numeric scale should be used to assess pain if the child is older than 5 years of age. Pharmacologic pain relief should be used only as an intervention of last resort.

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

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? Visceral pain Cutaneous pain Referred pain Somatic pain

Referred pain

When performing a pain assessment the client should be asked to provide all the following information except: Effectiveness of treatment Treatment expectations Effects of pain on activities of daily living Physiological classification

Physiological classification

When assessing a client's pulse, the nurse should be alert to which of the following characteristics? Rate, rhythm, amplitude and contour, and elasticity. Rate rhythm, temperature, rigidity, color, and elasticity. Pain, temperature, amplitude and contour, and elasticity. Tenderness, moistness, contour, elasticity, pressure.

Rate, rhythm, amplitude and contour, and elasticity.

A female client with advanced-stage vascular dementia has been showing signs of pain over the past several hours. The nurse is unable to obtain a self-report from the client due to her cognitive impairment. When applying the Hierarchy of Pain Assessment Techniques, how should the nurse proceed with assessment? Ask the client's family if she is in pain. Search for potential causes of pain. Perform interventions as if the client were in pain. Use a visual assessment tool rather than a verbal tool.

Search for potential causes of pain

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 Insomnia Anxiety Diarrhea

Sedation

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. Ask client to numerically rate pain in a high-pitched voice. Utilize the FLACC scale. Suggest client purchase a hearing aid.

Speak to the client face to face.

The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate? The cuff is wrapped loosely around the arm. The cuff is placed about 1 inch above the antecubital area. The nurse can fit three to four fingers under the inflated cuff. The bladder inside the cuff encircles 50% of the arm circumference.

The cuff is placed about 1 inch above the antecubital area

The nurse is caring for a patient following an open reduction, internal fixation of the right hip. The nurse observes the patient moans when being repositioned. What type of pain indicator is moaning? Emotional Behavioral Verbalization Vocalization

Vocalization

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? Physical dependence Drug interactions Addiction Tolerance

Tolerance

Below are the four physiological processes involved in pain perception. Put them in the correct order.

Transduction Transmission Perception Modulation

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? Compare the findings to the most recent previous pain assessment. Validate the assessment data with the client. Ask the primary care provider to validate the assessment data. Compare the findings to the client's preinjury level of health.

Validate the assessment data with the client.

A popular pain assessment scale for children is: Descriptive Pain Intensity Scale. Visual Analog Scale. Memorial Pain Assessment Card. FLACC Pain Assessment Scale.

Visual Analog Scale.

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? Teach and encourage incentive spirometry use. Explain why deep breathing and coughing is important. Manually ventilate client with ambu bag at bedside. Administer prescribed analgesia as ordered.

administer prescribed analgesia as ordered.

Which of the following is not released during the stress response? Cortisol Norepinephrine Epinephrine Dopamine

dopamine

Upon assessing a patient who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs? Decreased pulse rate Increased temperature Increased pulse rate Decreased temperature

increased pulse rate

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 visceral somatic referred

somatic

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