Health Assessment PrepU Chp. 06
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 principles should guide the nurse's assessment of a client's pain? a. It is likely that the client's pain rating will be influences by his emotional state. b. The client is likely experiencing less pain than he is reporting. c. The client's depression exists independently of the level of pain. d. The degree of surgery will be the key indicator for level of pain experienced.
a Although pain perception is poorly understood, studies have shown that the emotional status of a client, such as depression or anxiety, directly affects the level of pain perceived and thus reported by clients. The nurse needs to be conscious of and able to react to the possibility that a client with depression is experiencing more pain, or less pain, than he or she is reporting.
A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain? a. Neuropathic b. Somatic c. Nociceptive d. Idiopathic
a Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.
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? a. Emotional b. Verbalization c. Vocalization d. Behavioral
c Moaning is a vocalization pain indicator; other examples include groaning, gasping, and screaming. Verbalization would include the expression specific words, such as counting, praying, and swearing. Emotional pain indicators include excessive sleeping, anxiety, fear, and depression. Behavioral pain indicators include massaging, guarding, and immobilizing body parts.
When assessing the client for pain, the nurse should a. believe the client when he or she claims to be in pain. b. assess for underlying causes of pain, then believe the client. c. assess for the presence of physiologic indicators (such as diaphoresis, tachycardia, etc.), then believe the client. d. doubt the client when he or she describes the pain.
a "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain.
The nurse recognizes that a barrier to successful pain management for the client with opioid tolerance is: a. The client does not experience pain relief with usual doses of opioids. b. The repeated use of opioids causes their bodies to become less sensitive to pain. c. The client has the normal physiologic response to painful stimuli. d. Appropriate pain assessment tools are unavailable for this type of client.
a A barrier to successful pain management for the client with opioid tolerance is that the client does not experience pain relief with usual doses of opioids. The client with opioid tolerance has an altered physiologic response to painful stimuli, and repeated use of opioids causes their bodies to become more sensitive to pain. Pain assessment tools appropriate for use with the client with opioid tolerance exist.
A client is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what? a. Assess the site and intensity of the pain. b. Check the client's record for allergies. c. Check the physician's orders to see what pain medication to administer. d. Call the physician.
a When a client reports pain, the nurse must do an immediate pain assessment. Such an assessment is the first step of the nursing process. The complete pain assessment will cover different characteristics of the pain; however, the very first aspect is to ask about the location and intensity of the pain. Checking for the client's allergies and what medication is ordered will follow after the assessment. The nurse would not call the physician at this point.
Pain affects clients in different ways, with no boundaries. Which of the following are possible causes of pain? (Check all that apply.) a. No identifiable cause b. Injury c. Surgery d. Chronic illnesses e. Gender
a, b, c, d Pain is one of the most common reasons clients seek medical care. It can affect everything about the client, including quality of life and sense of well-being. Pain has many causes such as the result of injury, surgery, and chronic illnesses. In some cases, pain has no identifiable cause. Gender does not cause pain.
The nursing class is learning about pain assessment. Which of the following is a manifestation of pain? a. Pressured speech b. Bracing c. Confusion d. Apathy
b Six pain behaviors indicate pain in clients who cannot verbalize: (1) vocalizations, (2) facial grimacing, (3) bracing, (4) rubbing painful areas, (5) restlessness, and (6) vocal complaints.
A client is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to describe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers? a. C fibers b. AC fibers c. A-delta fibers d. P fibers
c A-delta fibers are myelinated and conduct impulses rapidly, resulting in pain being described as sharp or stabbing. C fibers are unmyelinated and cause pain that is achy and ongoing. There are no known AC or P fibers related to pain.
One of the body's normal physiologic responses to pain is a. pulse rate below 50 beats/minute. b. hypoglycemia. c. diaphoresis. d. hypotension.
c Diaphoresis is associated with acute pain.
A client complains of pain in several areas of the body. How should the nurse assess this client's pain? a. If pain does not radiate, there is no need to rate that area. b. Ask the client to rate the area with the highest pain level. c. Have the client rate each location separately. d. Mark each site on the client's body with a marker.
c 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.
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. Numeric Pain Intensity Scale b. Visual Analog Scale c. Face, Legs, Activity, Cry, Consolability Scale d. FACES Pain Scale
d 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.
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? a. "What were you doing when the pain first started?" b. "When did you first notice the pain?" c. "Do concurrent symptoms accompany the pain?" d. "Is the pain continuous or intermittent?"
a Asking what the client was doing when the pain started might identify a precipitating factor. Asking about concurrent symptoms provides information about the possible source of the pain. Asking when the pain started provides information about the onset and duration of the pain. Asking if the pain is continuous or intermittent helps to identify the nature of the pain.
A nurse educator is presenting an in-service program to a group of oncology nurses. Which of the following characteristics of cancer pain should the nurse describe? a. It is typically caused by compressed peripheral nerves. b. It usually appears in the first month after cancer develops. c. It is most often caused by a specific recent trauma. d. Its basis is usually chronic neuropathy.
a Cancer pain is often due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration. It is not considered a chronic neuropathy. In addition, it does not necessarily occur in the first month after cancer develops. Acute pain is most commonly associated with a specific recent trauma.
A nurse is caring for a 4-year-old client who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the client to point to the one that best represents the pain he is experiencing. This is an example of which of the following: a. FACES scale b. FLACC scale c. Numeric scale d. VISUAL analog scale
a The FACES scale is used for children who are 3 years or older. This tool allows the client to point to the picture of the face that best represents the pain he or she is feeling. The FLACC scale uses face, legs, activity, cry, and consolability to assess the pain. The visual analog scale uses a 100-mm line with "no pain" at one end and "worst pain" at the other. The numeric scale is the most commonly used scale--an example is an 11-point Likert scale with 0 meaning no pain and 10 meaning the worst pain ever.
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. 1630. b. 1930. c. By end of shift. d. 2130.
a 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.
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.) a. Quality and description b. Diet and allergies c. Urine output and pulse oximetry value d. Alleviating and aggravating factors e. Location and duration
a, d, e In a pain assessment. the nurse asks the client to use a pain scale to rate the intensity of the pain. Other areas to assess are location and duration, quality and description, and any alleviating or aggravating factors. Although the nurse would want to assess the client's allergies before giving pain medications, diet is not included, nor is urinary output or oxygenation.
The nursing student asks the nurse what would be an example of visceral pain. What would be the correct response by the nurse? a. Burn pain b. Gallbladder pain c. Arthritic pain d. Cardiac pain
b Visceral pain originates from abdominal organs, such as the gallbladder. Burns cause cutaneous pain, which is derived from the dermis, epidermis, and subcutaneous tissues. Referred pain originates from a specific site, but is experienced in another site along the innervating spinal nerve, such as occurs with cardiac pain. Somatic pain originates from skin, muscles, bones, and joints, such as arthritic pain.
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. Somatic c. Neuropathic d. Referred
c 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.
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. Ask client to numerically rate pain in a high-pitched voice. b. Utilize the FLACC scale. c. Speak to the client face to face. d. Suggest client purchase a hearing aid.
c 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.
A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain? a. Idiopathic b. Somatic c. Nociceptive d. Neuropathic
d Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.
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. Count respirations. c. BPIQ tool. d. FLACC scale.
d 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.
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. Where is the pain located? b. What medical conditions do you have? c. What is the highest level of education you've completed? d. How does the pain influence your overall mood?
d 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.
The nurse is using the Verbal Descriptor Scale to assess a client's pain. What data will the nurse prioritize? a. Ranges from no pain to worst possible pain b. 0 to 10 numeric scale c. Facial expressions d. 0 to 10 visual analog scale
a The Verbal Descriptor Scale rates pain from no pain up to the worst possible pain with mild, moderate, severe, and very severe in between the two end-points. The Faces Pain Scale uses facial expressions to rate pain. A numeric pain intensity scale rates pain using a 0 to 10 number scale. A visual analog scale rates pain along a 10 cm line from no pain to pain as bad as it could possibly be.
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? a. Acute Pain related to sore throat b. Risk for Fluid Volume Deficit related to fever c. Anxiety related to prolonged pain d. Impaired Mobility related stiff neck
a The client describes pain on two-day 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, 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 fluid volume deficit.
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. A-delta and C fibers b. L-beta fibers c. neuronal plasticity d. K-fibers
a The nurse is experiencing nociceptive or somatic pain. A-delta fibers are large nerve fibers covered with myelin that conduct pain impulses rapidly. The sharp or stabbing pain the nurse feels as the finger is pinched involves these fibers. C fibers are smaller, unmyelinated nerve fibers that conduct pain impulses more diffusely and slowly. The achy pain that lingers after the nurse has withdrawn the finger—that the nurse might "shake off"—involves these fibers. Neuronal plasticity refers to changes in pain signal processing due to a prolonged stimulus; the result is chronic sensation of pain after the original stimulus is removed. There are no "K-fibers" or "L-beta fibers."
A nurse is creating a concept map of the pathophysiology of pain. The nurse should identify which of the following as being responsible for transmitting pain sensations to the central nervous system? a. Nociceptors b. Transduction c. Cytokines d. Modulation
a The source of pain stimulates peripheral nerve endings or nociceptors, which transmit the sensations to the central nervous system. Transduction begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage, stimulating the nociceptors. Modulation inhibits the pain message and involves the body's own endogenous neurotransmitters in the course of processing the pain stimuli. Cytokines are released due to an inflammatory process resulting from the painful stimulus.
When performing a pain assessment the client should be asked to provide all the following information except: a. Physiological classification b. Treatment expectations c. Effectiveness of treatment d. Effects of pain on activities of daily living
a While the effects of pain on activities of daily living and past experiences and future expectations for treatment should be elicited from the client, he or she would not be expected to classify pain according to physiology.
The nurse is caring for a client following left hip replacement. Which response by the client is appropriate when the nurse asks the client to identify a pain management goal related to the client's left hip pain? a. "I want to be able to sleep on my left side." b. "I want my pain to be 3 or less." c. "My pain is a 5 all the time." d. "Climbing stairs makes my pain worse."
b A desire to have a pain rating of 3 or less is a pain management goal. A functional goal reflects a specific activity or task the client would like to be able to accomplish. The client wanting to be able to sleep on their left side is an example of a functional goal. A pain rating of 7 describes the intensity of the client's pain. Climbing stairs is an aggravating factor.
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: a. Hypotension b. Diaphoresis c. Decreased pulse d. Flaccid muscles
b Diaphoresis is an expected physiological response to pain resulting from sympathetic nerve stimulation. Decreases in pulse, blood pressure, and muscle tension are not expected findings when a client is experiencing pain.
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? a. Ask the primary care provider to validate the assessment data. b. Validate the assessment data with the client. c. Compare the findings to the most recent previous pain assessment. d. Compare the findings to the client's preinjury level of health.
b It is important to validate pain assessment data that are collected with the client. Comparisons to previous assessments and consultation with other members of the care team do not determine the reliability and accuracy of data obtained during a pain assessment.
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: a. "Acute pain can be as intense as chronic pain." b. "Nurses are the best authority on pain." c. "Patients with chronic illnesses can have chronic pain." d. "Chronic pain can be referred to as persistent pain."
b Pain is what the client says it is, and it exists whenever the client says it does. The client is the best authority on pain, and self-report is the gold standard. Therefore, nurses are not authorities on pain. It is true that clients with chronic illnesses can and often do have chronic pain. It also is true that acute pain can be intense. Chronic pain is sometimes known as persistent pain.
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? a. Visual Analog Scale b. McGill Pain Questionnaire c. Numeric Pain Intensity Scale d. Combined Thermometer Scale
b The MPQ was developed to measure pain in experimentally induced circumstances, following procedures, and with several medical-surgical conditions. It consists of a set of verbal descriptors used to capture the sensory aspect of pain, a VAS scale, and a present pain intensity rating made up of words and numbers. The tool has been found reliable and valid, and has been translated into several languages.
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? a. Verbal Descriptor Scale b. Faces Pain Scale-Revised (FPS-R) c. Graphic Rating Scale d. Numeric Rating Scale (NRS)
b The NRS has been shown to be best for older adults with no cognitive impairment, and the Faces Pain Scale-Revised (FPS-R) for cognitively impaired adults. Because of this client's Alzheimer disease, the FPS-R would be most appropriate.
A nursing instructor is teaching students about the pain experience. The instructor informs the students that a client experiencing pain will have a stress response. The students are aware that this stress response causes the following: a. Decrease in blood glucose and lactate levels b. Release of epinephrine, cortisol, and norepinephrine c. Decrease in oxygen and energy consumption d. Decrease in muscle tension and stress
b The nurse must assess objective data as well as subjective data when assessing the client for pain. Pain will induce a stress response that causes the release of epinephrine, cortisol, and norepinephrine. These hormones will have a metabolic and neuroendocrine response. Some of these effects are increased oxygen demand and consumption, as well as increased blood glucose and lactate levels and ketones. Muscle tension may also increase from the stress response.
The nurse is assessing the client's perception of pain and its intensity and quality. Which dimension is the nurse evaluating? a. Physical b. Sensory c. Behavioral d. Cognitive
b The sensory dimension concerns the quality of the pain and how severe the pain is perceived to be. This dimension includes the client's perception of the pain's location, intensity, and quality. The physical dimension refers to the physiologic effects just described. This dimension includes the client's perception of the pain and the body's reaction to the stimulus. The behavioral dimension refers to the verbal and nonverbal behaviors that the client demonstrates in response to the pain. The cognitive dimension concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management."
The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis? a. Bone fracture b. Appendicitis c. Myocardial infarction d. Shingles
b Visceral pain originates from abdominal organs; clients often describe this pain as crampy or gnawing.
A nurse is assessing a young woman for injuries who appears to be a victim of domestic violence. The nurse observes from the client's health record that her baseline vital signs are within normal limits. Which of the following objective findings would most tend to indicate pain? Select all that apply. a. Heart rate of 90 beats per minute b. Slumped shoulders c. Respiratory rate of 20 breaths per minute d. Edema at the elbow joint e. Blood pressure of 140/90 mm Hg
b, d, e Slumped shoulders, an elevated blood pressure (less than 120/80 mm Hg is normal), and edema at the elbow point are all indicators of pain. A heart rate of 90 beats per minute (60 to 100 is normal) and a respiratory rate of 20 breaths per minute (12-20 is normal) are not indicators of pain.
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. Administer an antacid and apply a topical anesthetic for the arm pain. b. Request a strong narcotic analgesic for the client's visceral pain complaints. c. Check the client's vital signs and connect her to a cardiac monitor. d. Alert the healthcare provider to the client's somatic pain complaints.
c 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.
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. Impaired physical mobility related stiff neck b. Anxiety related to prolonged pain c. Acute pain related to sore throat d. Risk for deficient fluid volume related to fever
c 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.
A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. Which of the following scales should the nurse use to assess the client's pain? a. Word scale b. Numeric scale c. FACES scale d. Linear scale
c The nurse should use the Wong-Baker FACES scale, which is best for children and clients who are culturally diverse or mentally challenged. Nurses generally use a numeric scale, a word scale, or a linear scale to quantify the pain intensity of adult clients who can express their pain intensity in words, numbers, or linear fashion with the help of the respective scales.
The nurse prepares to update the care plan of a client recovering from abdominal surgery. Which diagnosis should the nurse select that most appropriately addresses the client's pain? a. Ineffective breathing pattern related to abdominal pain b. Impaired physical mobility related to abdominal pain c. Chronic pain related to surgical procedure d. Acute pain related to abdominal wound
d Since the client is recovering from abdominal surgery, the most appropriate diagnosis at this time would be Acute pain related to abdominal wound. A period of at least 6 months needs to transpire before identifying the client's pain as being chronic. The client may have impaired physical mobility or an ineffective breathing pattern related to the abdominal pain however these diagnoses may need to be added later once the client is permitted out of bed and engaging in more activity.
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? a. Ineffective coping related to knee pain b. Ineffective role performance related to osteoarthritis c. Situational low self-esteem related to osteoarthritis d. Activity intolerance related to knee pain
d The client's limitation on moving around her house is suggestive of activity intolerance. The client is clearly emotional about this development, but this is not synonymous with ineffective coping. Role performance and self-esteem may be affected, but there is no direct evidence to support these diagnoses.
