nclex/ end of chapter questions: Pain Assessment and Management chapter 30

The client taking an opioid is experiencing pruritus. Which medication should the nurse expect the physician to prescribe? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline

3

The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache; however, the client has been vomiting all day. Which route should be used to administer the medication? 1. Oral 2. Vaginal 3. Rectal 4. Intravenous

3

Which objective assessment data should the nurse obtain before administering a prescribed opioid medication to a client? 1. Pain level as stated by client 2. Any nausea the client may be feeling 3. Respiratory rate 4. Color of skin

3

) A client is receiving opioid-sparing pain management. Which should the nurse consider to enhance the effectiveness for the client? 1. Massage 2. Turning and repositioning 3. Range-of-motion exercises 4. Deep breathing and coughing

1

) A client with pain has had previous episodes of uncontrolled pain in the past and is worried about the current pain pattern. Which diagnosis would be appropriate for the nurse to include for this client? 1. Anxiety 2. Ineffective Coping 3. Deficient Knowledge 4. Hopelessness

1

A client experiencing pain after surgery believes something is wrong because the pain is so severe. What is the best response for the nurse to make to the client? 1. "The amount of tissue disrupted from the surgery is not related to the degree of pain you feel." 2. "That could be so." 3. "Taking pain medication for many years has made the medication ineffective now." 4. "Are you sure the pain is as bad as you are saying it is?"

1

A client experiencing pain has been prescribed aspirin. The nurse realizes that this medication will affect which pain process? 1. Transduction 2. Transmission 3. Perception 4. Modulation

1

A client recoverin g from abdominal surgery refuses analgesia, saying that he is "fine", as long as he doesn't move. which nursing diagnosis should be a priority? 1. lack of Knowledge (pain control measures) 2. fear of drug addiction 3. difficulty maintaining a clear airway 4. Altered physical mobility

1

A client recovering from a left below-the-knee amputation is experiencing left foot pain. The nurse realizes the client is experiencing which type of pain? 1. Phantom limb pain 2. Acute pain 3. Chronic pain 4. Narcotic-induced pain

1

A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment. The nurse realizes the client's pain was influenced by which type of distraction? 1. Visual 2. Tactile 3. Intellectual 4. Behavioral

1

A client who is on postoperative day 1 after abdominal surgery is requesting a back rub. Who should provide this massage? 1. The Registered nurse 2. Assistive personnel (AP) 3. No one, because the client cannot assume the prone position 4. The Physician

1

An opiod-naive client had abdominal surgery 4 hours ago and has received prn IV dose of morphine. which of the following observations indicates the nurse should monitor the client closely? 1. drowsy: drifts off to sleep before completing a sentence 2. respirations 18 per/min 3. drowsy: easily aroused 4. pain rating 1-2/10

1

The client scheduled to undergo minor surgery states, "The physician will not give me pain medication after surgery because my surgery is only minor." What is the best response by the nurse? 1. "You can experience pain after minor surgery, so you can have pain medication." 2. "You are correct. The physician will not order any pain medication." 3. "You are correct. I will need to teach you nonpharmacologic pain relief measures." 4. "You can only have about half the dose because your surgery is minor." Answer: 1

1

The nurse is caring for a client who is using morphine through patient-controlled analgesia. What medication should the nurse have readily available? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline

1

A client reports pain as being a 2 on a scale from 0 to 10. Which pain medications should the nurse consider for the client at this time? (Select all that apply.) 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Naproxen (Naprosyn) 4. Hydrocodone (Vicodin) 5. Methadone (Dolophine)

1, 2, 3

The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions should the nurse use to help this client? (Select all that apply.) 1. Talk with the client about pain. 2. Provide privacy. 3. Present choices for dealing with pain. 4. Encourage distraction with music or television. 5. Allay fears and anxiety.

1, 2, 3, 4

The nurse is preparing to conduct a pain assessment. What should the nurse include in this assessment? (Select all that apply.) 1. Duration 2. Location 3. Intensity 4. Etiology 5. Neurology

1, 2, 3, 4

The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body for pain control. What should the nurse include in these instructions? (Select all that apply.) 1. Massage 2. Acupressure 3. Self-hypnosis 4. Exercise 5. Nutritional supplements

1, 2, 4, 5

The healthcare provider is writing medication orders for a client recovering from spinal fusion surgery. When the client reports pain as a 9 on a scale from 0 to 10, which medications should the nurse consider providing to the client? (Select all that apply.) 1. Oxymorphone (Opana) 2. Hydrocodone (Vicodin) 3. Oxycodone (OxyContin) 4. Morphine sulfate (morphine) 5. Hydromorphone hydrochloride (Dilaudid)

1, 3, 4, 5

The nurse wants to assign back rubs to assistive personnel (AP). Which should the nurse determine before making the assignments? (Select all that apply.) 1. Whether unlicensed assistive personnel know how to perform a back rub 2. Whether there any clients who have intravenous fluids infusing 3. Whether there any clients who should not have a back rub performed 4. Whether there any clients who are prescribed to take nothing by mouth 5. Whether there any clients who do not want a back rub done by unlicensed assistive personnel

1, 3, 5

A client with arthritis has been taking OTC NSAID's for the past year. Which questions would the nurse ask during a heath history? Select all that apply 1. how often do you take this drug? 2. how often do you get your b/p checked 3. have you noticed any problems with your breathing? 4. do you take this drug with food. 5. have you ever vomited blood or had very dark stools?

1, 4, 5

) A client is surprised to learn of the diagnosis of a heart attack when there was no chest pain experienced but only some left shoulder pain. The nurse should explain that the client experienced which type of pain? 1. Phantom pain 2. Referred pain 3. Visceral pain 4. Chronic pain

2

A client experiencing chronic pain is not getting relief with pain medication. What should the nurse do to help this client? 1. Ask the physician to change the prescribed pain medication. 2. Reassess the pain and consider another pain relief measure. 3. Limit interaction with the client. 4. Stop using alternative pain relief measures, if not effective.

2

A client has been taking medication for back pain for several months and has seen several different healthcare providers in efforts to receive pain medication. Which should the nurse suspect the client is exhibiting? 1. Tolerance 2. Addiction 3. Physical dependence 4. Pseudoaddiction

2

A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client? 1. Apply ice to the knee over the cast. 2. Rub the knee of the noncasted leg. 3. Apply heat to the knee over the cast. 4. Rub the foot of the casted extremity.

2

The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician? 1. Pulse rate: 80 2. Respiratory rate: 8 3. Blood pressure: 120/80 4. Pain rating of 4 on scale of 1 to 10

2

The nurse is providing discharge instructions to a client prescribed an opioid medication. What should the nurse suggest to decrease the risk of constipation with this medication? 1. Take an antihistamine three times per day. 2. Drink six to eight glasses of water per day. 3. Assess respiratory rate before taking medication. 4. Assess heart rate before taking medication.

2

Which statement best reflects a nurses assessment of pain? 1. do you have any complaints? 2. are you experiencing any discomfort? 3. is there anything I can do for you now? 4. do you have any complaints of pain?

2

when a client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following? 1. pain tolerance 2. pain intensity 3. location of pain 4. pain history

2

An older client who refuses medication for pain is irritable and unable to sleep. What should the nurse explain to the client to encourage the use of pain medication? (Select all that apply.) 1. There are high-dose medications that will eradicate the pain. 2. The lack of pain control is causing the inability to sleep. 3. The lack of pain control is causing irritability. 4. The risks of taking pain medication are low in the older population. 5. The lack of pain control will affect mobility and activity tolerance.

2, 3, 5

) The nurse is caring for a client receiving pain medication through an epidural catheter. What should the nurse include to ensure safety when caring for this client? (Select all that apply.) 1. Secure all tubing connections with gauze. 2. Apply tape over all injection ports on the tubing. 3. Cleanse the insertion site with alcohol swabs once a day. 4. Label the tubing, infusion bag, and pump with the word "epidural." 5. Post a sign above the client's bed indicating that an epidural is being used.

2, 4, 5

The nurse has completed a back massage for a client. What should the nurse document about this procedure? (Select all that apply.) 1. Effectiveness of pain medication using a rating scale from 0 to 10 2. Position to perform the massage 3. Content of communication that occurred during the back massage 4. Amount of lotion used during the back massage 5. Client response

2, 5

After receiving medication for mild pain, the client states that the pain is getting worse. What should the nurse plan to do for this client? 1. Administer another dose of a nonopioid medication. 2. Administer an opioid for severe pain. 3. Administer an opioid for moderate pain. 4. Administer two doses of an opioid for moderate pain.

3

) A client is experiencing pain after spraining an ankle. The nurse realizes that the client is most likely experiencing which type of pain? 1. Mild pain 2. Severe pain 3. Somatic pain 4. Visceral pain

3

A client is complaining of having the same type of pain prior to being diagnosed with cancer. The nurse realizes that which process will influence this client's perception of pain? 1. Transmission 2. Modulation 3. Perception 4. Transduction

3

A client rates pain as being 7 on a scale from 0 to 10. What should the nurse document as this client's pain intensity? 1. Mild pain 2. Moderate pain 3. Severe pain 4. Physiological pain

3

A client recovering from back surgery is refusing pain medication for fear of becoming addicted. What should the nurse say to the client? 1. "I understand." 2. "There are ways to treat addictions to pain medications." 3. "If the medication is taken to treat pain, you will not become addicted to it." 4. "All pain medication causes addiction. There is nothing that can be done to prevent it."

3

A client seeks medical attention for severe abdominal pain. What is the nurse's first action? 1. Administer IV pain medication as ordered. 2. Start an IV line of lactated Ringer's. 3. Assess pain using a scale of 1 to 10. 4. Place a Foley catheter to bedside drainage.

3

A client tells the nurse that at home, the dog helps distract the client from chronic hip pain. The nurse realizes that the client is utilizing which form of nonpharmacologic pain control? 1. Body 2. Mind 3. Social interactions 4. Spirit

3

A client with severe pain is prescribed two medications from different classes to be given orally and topically. Which is an advantage of this approach to pain management? 1. Lostess costly to the client 2. Less time-consuming to provide 3. Eliminating the need for opioids 4. Reduces the development of chronic pain

3

During the transduction phase of nociception, which method of pain control is most effective? 1. Tricyclic antidepressants 2. Opiods 3. ibuprophen 4. distraction

3

) From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time? (Select all that apply.) 1. Anxiety 2. Hopelessness 3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility

3, 4, 5

when planning care for pain control of older clients, which principals should the nurse apply? Select all that apply 1. pain is a natural occurrence of the aging process 2. pain perception increases with age 3. the client may deny pain 4. the nurse should avoid use of Opioids 5. the client may describe pain as an "ache" or " discomfort"

3, 5

) The nurse is assigning tasks for evening care. Which client should the nurse assign assistive personnel (AP) to provide a back massage? 1. Client with spontaneous fractures 2. Client receiving high-dose heparin 3. Client recovering from back surgery 4. Client with moderate pain asking for help

4

) The nurse provides a client with a back massage. Which information should the nurse omit when documenting the care provided to this client? 1. Client fell asleep 2. Client reports feeling relaxed 3. Client reports pain level 3 on a scale from 1 to 10 4. Client talked with family on the telephone during the massage

4

A client had an order of morphine 2.5 to 5.0 mg IV every 4 hours. He received 2.5 mg IV 4 hrs. ago for pain rating 3/10. he is now watching TV& visiting with family members. when asked about his pain, he rates it as a 6. his vs are stable. what nursing intervention is most appropriate? 1. give morphine 3.5 mg IV and inform him to continue watching tv because it is a distraction from the pain 2. give 2.5 mg IV morphine to avoid the client from becoming addicted 3. give nothing at this time d/t he is not exhibiting any signs of pain 4. give morphine 5.0 mg IV and reassess in 20 minutes.

4

A client states that a cramping pain started 2 hours ago and is not accompanied by any nausea or vomiting. Which type of pain is this client most likely experiencing? 1. Chronic pain 2. Phantom pain 3. Visceral pain 4. Acute pain

4

A client's pain level is assessed as being severe. Which intervention would be the most applicable for the client at this time? 1. Provide NSAID medication as prescribed. 2. Coach the client with guided imagery. 3. Suggest the client read or watch television until the pain subsides. 4. Provide opioid analgesic as prescribed.

4

a client who describes his pain as a 7 out of a 10 is classified as having which of the following? 1. no pain 2. mild pain 3. moderate pain 4 severe pain

4

during an admission nursing assessment, a client with Diabetes describes his leg pain as a "dull", burning sensation." The nurse recognizes this description to be characteristic of which type of pain? 1. Physiologic 2. somatic 3. visceral 4. Neuropathic

4

The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage? (Select all that apply.) 1. Supine 2. Fowler 3. Trendelenburg 4. Prone 5. Side-lying

4, 5

The nurse is preparing to massage a client's back. Place in order the steps the nurse will follow, after conducting hand hygiene and preparing the client, to perform the back massage. 1. Move the hands down the sides of the back. 2. Pour lotion into the palms of the hands to warm the lotion. 3. Massage the areas over the right and left iliac crests. 4. Move the hands up the center of the back. 5. With the palms, massage the sacral area with smooth, circular strokes. 6. Move the hands to the scapulae and massage this region using circular strokes.

: 2, 5, 4, 6, 1, 3

) The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this infant? 1. FLACC scale 2. Wong-Baker FACES 3. Visual analog scale 4. Numeric rating scale

answer: 1

The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication? 1. Gastrointestinal (GI) distress 2. Shakiness 3. Tremors 4. Rash

answer: 1