Ch.9 PrepU
The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level? A) 1630 B) 1730 C) 2000 D) 2030
1630 Explanation: Pain should be assessed every 4 hours; reassessments after interventions should be done in 30 minutes after intervention.
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? A) What medical conditions do you have? B) Where is the pain located? C) What is the highest level of education you've completed? D) How does the pain influence your overall mood?
How does the pain influence your overall mood? Explanation: The question regarding the influence of the pain on mood would address the client's affective dimension, which includes feelings and emotions that result from the pain. The question regarding medical conditions would help assess the client's physical dimension. The question regarding the location of the pain would address the client's sensory dimension. The question regarding the client's education would address his cognitive dimension. Ref: (ch.9 pg.147)
A nurse is assessing the vital signs of a client who is moaning with pain. What would be the expected findings? A) Decreased pulse and respirations B) Increased pulse and blood pressure C) Increased temperature D) No change from usual results
Increased pulse and blood pressure Ref: (ch.9 pg.143)
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? A) By end of shift B) 1630 C) 1930 D) 2130
1630 Explanation: The JCAHO has set a standard that states that nurses must assess and reassess pain regularly. Most hospitals have a standard timeframe for reassessment, such as 1 hour for oral medication and 30 minutes for pain medication given intravenously. They base these timeframes on the time it takes a pain medication to provide a noticeable decrease in pain intensity.
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? A) Give the prn morphine B) Hold the medication and wait 30 minutes C) Call the physician to check the order D) Document the client's pain rating on a scale of 0 to 10
A) Give the prn morphine Explanation: Pain is what the client says it is, and it exists whenever the client says it does. It would not be appropriate to hold the medication for 30 minutes, call the physician to check the order, or just document the client's pain. Ref: (ch.9 pg.
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? A) Anxiety related to prolonged pain B) Impaired physical mobility related stiff neck C) Risk for deficient fluid volume related to fever D) Acute pain related to sore throat
Acute pain related to sore throat Explanation: The client describes pain of 2 days' duration, which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, or sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for deficient fluid volume.
During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following? A) Analgesics B) Surgery C) Relaxation techniques D) Cutaneous stimulation
Analgesics Explanation: Analgesics are most often the primary treatment measure for pain, although a growing trend involves the integration of complementary, nonpharmacologic measures with conventional medicine.
How may a nurse demonstrate cultural competence when responding to clients in pain? A) Treat every client exactly the same, regardless of culture B) Be knowledgeable and skilled in medication administration C) Know the action and side effects of all pain medications D) Avoid stereotyping responses to pain by clients
Avoid stereotyping responses to pain by clients Explanation: Culture influences an individual's response to pain. It is particularly important to avoid stereotyping responses to pain because the nurse frequently encounters clients who are in pain or anticipating it will develop. A form of pain expression that is frowned on in one culture may be desirable in another cultural group. Ref: (ch.9 pg.148)
When assessing the client for pain, the nurse should A) Doubt the client when he or she describes the pain B) Assess for underlying causes of pain, then believe the client C) Believe the client when he or she claims to be in pain D) Assess for the presence of physiologic indicators (such as diaphoresis, tachycardia, etc.), then believe the client
Believe the client when he or she claims to be in pain Explanation: "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain. Ref: (ch.9 pg.154)
A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action? A) Alert the healthcare provider to the client's somatic pain complaints B) Administer an antacid and apply a topical anesthetic for the arm pain C) Check the client's vital signs and connect her to a cardiac monitor D) 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 Explanation: Pain nociception has various locations. Visceral pain originates from abdominal organs; clients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; clients usually describe somatic pain as sharp (D'Arcy, 2014). Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. It is often burning or sharp, such as with a partial-thickness burn. Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve. An example is cardiac pain that a person experiences as indigestion, neck pain, or arm pain. Phantom pain is pain in an extremity or body part that is no longer there (e.g., a client who experiences pain in a leg with an amputation). The client is presenting with atypical chest pain and should be assessed for pain of a cardiac origin.
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? A) Constipation B) Diarrhea C) Impaired urinary elimination D) Bowel incontinence
Constipation Explanation: The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use. Ref: (ch.9 pg.158)
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? A) Face, Legs, Activity, Cry, Consolability Scale B) Visual Analog Scale C) FACES Pain Scale D) Numeric Pain Intensity Scale
FACES Pain Scale Explanation: Children 2 years and older can identify pain and point to its location. You can use a facial expression scale for children starting at approximately 3 years. The FACES scale uses six faces ranging from happy with a wide smile to sad with tears on the face. Ref: (ch.9 pg.150)
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? A) Measure heart rate B) FLACC scale C) Count respirations D) BPIQ tool
FLACC scale Explanation: The FLACC (Face, Legs, Activity, Cry, Consolability) scale was originally designed to measure acute postoperative pain in children 2 months to 7 years old. Heart rate and respirations are part of an infant pain assessment; however the FLACC scale is the most comprehensive tool. The BPIQ (brief pain impact questionnaire) is used mainly to assess chronic pain in adults. Ref: (ch.9 pg.152)
The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the: A) Face, Legs, Activity, Cry, Consolability Scale B) FACES Pain Scale C) Numeric Pain Intensity Scale D) Combined Thermometer Scale
Face, Legs, Activity, Cry, Consolability Scale Explanation: The Face, Legs, Activity, Cry, Consolability Scale is the appropriate pain assessment tool for a 4-week-old postoperative client. This tool measures pain using observable behaviors as pain indicators. The FACES Pain Scale is appropriate for children age 3 and older, using six faces ranging from happy with a wide smile to sad with tears on the face. The other two scales are appropriate for use with older children and adults. The Numeric Pain Intensity Scale is a one-dimensional pain scale using an 11-poing Likert-type scale ranging from 0 to 10, where 0 means "no pain" and 10 means "worst possible pain." The Combined Thermometer Scale looks like a thermometer and has both numbers that increase from the bottom up and descriptor words to measure pain intensity. Ref: (ch.9 pg.152)
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? A) Verbal Descriptor Scale B) Numeric Rating Scale C) Faces Pain Scale D) Visual Analog Scale
Faces Pain Scale Explanation: The nurse should use the Faces Pain Scale (FPS) to rate the pain felt by the client. The FPS shows different facial expressions; the client is asked to choose the face that best describes the intensity or level of pain being experienced. This tool is best suited for cognitively impaired adults. A Verbal Descriptor Scale (VDS) ranges pain on a scale between mild, moderate, and severe. The Numeric Rating Scale (NRS) rates pain on a scale from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. It has been shown to be best for older adults with no cognitive impairment. The Visual Analog Scale (VAS) rates pain on a 10-cm continuum numbered from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.
A client complains of pain in several areas of the body. How should the nurse assess this client's pain? A) Ask the client to rate the area with the highest pain level B) Mark each site on the client's body with a marker C) If pain does not radiate, there is no need to rate that area D) Have the client rate each location separately
Have the client rate each location separately. Explanation: When assessing pain location, ask the client to point to the painful area. If more than one area is painful, have the client rate each one separately, and note which area is the most painful. Marking each site is not necessary practice for assessing pain. Pain is a subjective sensation for the client. Radiating pain is notable, because such radiation may affect treatment choices.
A client 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? A) Intractable B) Chronic C) Visceral D) Referred
Intractable Explanation: Intractable pain is pain that is highly resistant to pain relief, which appears to be the case in this situation. Referred pain is perceived in body areas away from the pain source; because the pain this client is experiencing is due to an injury to the back, this does not seem to be referred pain. Chronic pain is pain that persists longer than 6 months. Visceral pain is pain experienced in a deep organ, typically in the abdominal cavity, thorax, or cranium.
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: A) Visceral B) Neuropathic C) Somatic D) Referred
Neuropathic Explanation: Visceral pain originates from abdominal organs and is often described as crampy or gnawing. Somatic pain originates from the skin, muscles, bones, and joints. Referred pain originates from a specific site, but the client experiencing the pain feels it at another site along the innervating spinal nerve. Neuropathic pain is described as burning, painful numbness, or tingling.
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? A) Cutaneous pain B) Visceral pain C) Chronic pain D) Neuropathic pain
Neuropathic pain Explanation: The client is experiencing neuropathic pain or functional pain. Neuropathic pain is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client is not experiencing cutaneous, visceral, or chronic pain. In cutaneous pain, the discomfort originates at the skin level. In visceral pain, the discomfort arises from internal organs caused from a disease or injury. In chronic pain the discomfort lasts longer than 6 months. Ref: (ch.9 pg.145)
Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric clients? A) Pain assessment may require multiple methods in order to ensure accurate pain data B) The developing neurological system children transmits less pain than in older clients C) Pharmacologic pain relief should be used only as an intervention of last resort D) A numeric scale should be used to assess pain if the child is older than 5 years of age
Pain assessment may require multiple methods in order to ensure accurate pain data. Explanation: It is often necessary to use more than one technique for pain assessment in children. Though their neurological system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all clients above a certain age; the assessment tool should reflect the client's specific circumstances, abilities, and development.
Which would the nurse recognize as an example of visceral pain? Select all that apply. A) Liver pain B) Gallbladder pain C) Pancreatic pain D) Burn pain E) Muscular pain
Pancreatic pain Gallbladder pain Liver pain Explanation: Examples of visceral pain include pain associated with the liver, gallbladder, and pancreas. Pain associated with a burn is an example of cutaneous pain. Muscular pain is a type of somatic pain. Ref: (ch.9 pg.145)
A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain? A) Referred pain B) Phantom pain C) Visceral pain D) Cutaneous pain
Phantom pain Explanation: The nurse should document the pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client perceives that the amputated limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed. The client is not experiencing referred pain, visceral pain, or cutaneous pain. Visceral pain is associated with disease or injury. Referred pain is not experienced in the exact site where an organ is located. Cutaneous pain originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Ref: (ch.9 pg. 145)
Why is it important for a nurse to gather information about a client's past experiences with pain? A) Identify factors that increase or decrease the pain B) Provides insight into positive or negative expectations for relief C) Assess how much the pain impacts the client's lifestyle D) Understand the course of the pain for clues to patterns
Provides insight into positive or negative expectations for relief Explanation: Past experiences with pain may shed light on the previous history of the client in addition to possible positive or negative expectations of pain therapies. Identifying factors that increase or decrease pain, assessing how much it impacts the client's lifestyle, and understanding the course of the pain are questions that assist the nurse to elicit important information about the pain itself. Ref: (ch.9 pg.154)
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? A) Provoking and alleviating factors B) Availability of medication C) Financial resources to obtain medication D) Medications taken in the past
Provoking and alleviating factors Explanation: The nurse is conducting a focused pain assessment of a hospitalized client. Some burses prefer to use mnemonics to remember the elements of pain assessment. One of these is OPQRST : O: Onset P: Provocative or palliative Q: Quality R: Region and radiation S: Severity T: Timing The availability of medication, past medications, and client's financial resources are not the most pertinent questions to include at this time. Ref: (ch.9 pg.154)
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? A) Visceral pain B) Referred pain C) Cutaneous pain D) Somatic pain
Referred pain Explanation: Referred pain originates from a specific site, but the person feels the pain at another site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigestion. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints. Ref: (ch.9 pg.145)
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? a) Utilize the FLACC scale b) Speak to the client face to face c) Suggest client purchase a hearing aid d) Ask client to numerically rate pain in a high-pitched voice
Speak to the client face to face Explanation: When assessing the older client for pain, determine whether the client has any auditory impairment. If so, position your face in the client's view, speak in a slow, normal tone of voice, reduce extraneous noises, and provide written instructions. The FLACC scale is used primarily for infants. Hearing aids are expensive and suggesting to purchased one does not aid in the pain assessment at present. Ref: (ch.9 pg.148)
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? A) Cognitive dimension B) Sociocultural dimension C) Affective dimension D) Spiritual dimension
Spiritual dimension Explanation: The spiritual dimension refers to the meaning and purpose that the person "attributes to the pain, self, others, and the divine." In this case, it seems that the man is interpreting his accident and subsequent pain as divine retribution for his past wrongdoings. The cognitive dimension concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management." The sociocultural dimension concerns the influences of the client's social context and cultural background on the client's pain experience. The affective dimension concerns feelings, sentiments, and emotions related to the pain experience.
A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client experiencing? A) Visceral pain B) Cutaneous pain C) Somatic pain D) Neuropathic pain
Visceral pain Explanation: The client is experiencing visceral pain, which is associated with disease or injury. It is sometimes referred or poorly localized as it is not experienced in the exact site where an organ is located. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved. Ref: (ch. 9 pg.145)
Mark is a 20-year-old college student who has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is Mark most likely experiencing? A) Visceral pain B) Referred pain C) Cutaneous pain D) Somatic pain
Visceral pain Explanation: Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial and somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix.