Chapter 6: Pain Assessment

The community health nurse is caring for an older client 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?

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

Avoid stereotyping responses to pain by clients.

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:

neuropathic

A nurse enters a client's room to conduct an assessment. The client is crying and states they have so much pain. What is the best response of the nurse?

"Could you tell me more about your pain?"

Which statement by the client would the nurse consider to be a functional goal? Select all that apply.

"I want to walk without a walker at my daughter's wedding" "I want to play tennis w/ my friends by May."

A nursing instructor is teaching students how to assess a client'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."

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

Vocalization

The nursing instructor is teaching a class about how to assess pain in older adults. The teachers tells the students that problems can arise in certain circumstances. The instructor realizes the need for more teaching about pain in the elderly when one of the students replies:

"Pain is a natural part of aging."

A nurse is interviewing a 65-year-old client with a history of atrial fibrillation, type 2 diabetes, obesity, and congestive heart failure. The nurse determines the client is experiencing chronic neuropathic pain when the client makes which of the following statements?

"The burning sensation in my feet has gotten worse over the past year."

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 started?"

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 and C fibers

A client presents to the health care clinic with reports of two-day history of sore throat pain, ear pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?

Acute Pain related to sore throat

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.

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

Bracing

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?

Burning, tingling

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?

FACES Pain Scale

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.

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 nurse assesses a client with small bowel obstruction who reports intermittent pain. Which questions are appropriate for the nurse to ask when assessing the client's pain? Select all that apply.

Describe the pain Where is the pain located? When did the pain start?

A client is experiencing acute pain and has asked the nurse for medication. The client rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the client that the nurse can expect is:

Diaphoresis

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?

FLACC scale.

The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the:

Face, Legs, Activity, Cry, Consolability Scale

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 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?

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 & ensure confidentiality

Which would the nurse recognize as an example of visceral pain? Select all that apply.

Liver pain Gallbladder pain Pancreatic pain

The nurse understands the importance of performing an accurate pain assessment. In addition to having the client rate the pain on a pain scale, other things to assess are the following: (Check all that apply.)

Location & duration Quality & description Alleviating & aggravating factors

After describing the pathophysiology of pain, an instructor determines that the students have understood the teaching when they identify which of the following as being responsible for transmitting the sensations to the central nervous system?

Nociceptors

During assessment, the nurse is using a pain scale with the client, who tells the nurse that his pain is at 7 on a scale of 1 to 10. This type of one-dimensional pain scale is also called a:

Numeric pain intensity scale

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

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

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

Physiological classification

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?

Referred pain

The client with a cognitive impairment sometimes cannot rate pain on a scale of 0 to 10. In such a case, the nurse is aware of other cues to assess the client's pain. Which of the following is correct?

Restlessness, guarding

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?

Spiritual dimension

A nurse is collecting subjective data from a client who is reporting pain. Which of the following actions should the nurse take to determine the severity of the pain?

Use a pain scale to measure the pain.

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

A client presents to the emergency department after falling off a ladder and reports pain in the right shoulder. He says that he has not taken anything for the pain yet. The nurse recognizes this as what type of pain?

acute

A nurse performs a focused assessment on a client reporting back pain after helping someone move into a new home. The nurse uses COLDSPA to further assess the client's pain. Character: sharp; onset: yesterday; location: lower back; duration: persistent since yesterday; severity: 8 out of 10 (on a scale 0-10, 10 being the worst); pattern: continuous; associated factors: movement. The nurse determines the client is experiencing which of the following classifications of pain?

acute inflammatory pain

The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis?

appendicitis

When assessing the client for pain, the nurse should

believe the client when he or she claims to be in pain.

Who is the authority on the presence and extent of pain experienced by a client?

client

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?

constipation

The nursing student asks the nurse what would be an example of visceral pain. What would be the correct response by the nurse?

gallbladder pain

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

A client reports pain in the knee. The knee is warm, swollen, and red and the client describes the pain as aching and gnawing. The nurse determines the client is experiencing which of the following types of nociceptive 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 client is admitted with right lower abdominal pain with rebound tenderness. The nurse suspects appendicitis and documents this type of pain as which of the following?

visceral