NUR 201 - Craven Ch. 6

A middle-aged client is complaining of acute joint pain to a nurse who is assessing the client's pain in a clinic. Which of the following questions related to pain assessment should the nurse ask the client?

"Does your pain level change after taking medications?"

The nurse is assessing the client's perception of pain and the client's description of its intensity and quality. Which dimension of pain is the nurse evaluating?

Sensory

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

The patient

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?

FACES scale

A client recently recovering from shingles states that he suffers from pain and burning along his back and sides where the lesions are dried and crusted and requests pain medication. What is the nurse's best response?

"Rate your pain on a 0-10 scale; 0 being no pain and 10 the worst."

The nurse is caring for a patient following left hip replacement. Which response by the patient is appropriate when the nurse asks the patient to identify a pain management goal related to the patient's left hip pain?

"I want my pain to be 3 or less."

A client has questioned why the nurse asked him how his family members usually treat their pain. Which response, by the nurse, would be the most appropriate?

"It helps me to determine how the family understands and perceives pain."

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:

"Nurses are the best authority on pain."

A mother calls the nurse practitioner to say, "I don't know what is wrong with my baby. He cried all night and kept pulling at his ear." How would the nurse respond?

"That means his ear hurts. Bring him in to be checked."

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?

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

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 stated?"

A client who is cringing says that the pain is the worse that it has ever been. If using the numeric pain intensity scale, which number is the client describing?

10

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?

1630.

A client is diagnosed with chronic non-malignant pain. The nurse understands that this client has experienced this pain for at least how many months?

6

A client recovering from total knee replacement is experiencing severe pain. Where should the nurse expect the client to rate this pain on the following scale?

7 - 10

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?

Acute pain related to sore throat

A carpenter has been admitted to the hospital after suffering a heart attack. He explains to the nurse that he felt chest pains for the past 3 days while working, but did not want to go to the doctor because he was afraid that the other workers would tease him about it. The nurse recognizes that which of the following was most likely a barrier to pain assessment in this client?

A belief that acknowledging pain is a sign of weakness

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?

Activity intolerance related to knee 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. The nurse recognizes this as what 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

The patient arrives to the emergency room reporting severe abdominal pain that started 3 hours ago. He rates the pain as an 8 on a scale of 1 to 10. After tests are performed, the patient is diagnosed with appendicitis. This is an example of which of the following types of pain?

Acute

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

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?

Acute pain related to abdominal wound

A patient has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain?

Endorphins

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

Appendicitis

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?

A patient reports pain and rates it as a 9 on a scale of 0 to 10. The nurse administers medication as ordered and returns 20 minutes later to assess the severity of the patient's pain. To assess the severity, the nurse would:

Ask the patient to rate the pain on a scale of 0 to 10.

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 using a mnemonic device. Assess the client's pain by gathering subjective data from the client.

A patient is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what?

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 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?

FACES Pain Scale

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

A nurse is caring for a 4-year-old patient 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 patient to point to the one that best represents the pain he is experiencing. This is an example of which of the following:

FACES scale

A nurse is caring for an elderly client who is unable to walk without a support due to knee pain. During his initial assessment, however, the client does not mention pain. Which of the following beliefs common in elderly clients may cause them to underreport their pain?

FACES scale

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?

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?

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

A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain?

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

All the following are signs or symptoms reported by clients with chronic pain except:

Confusion

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?

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.

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 patient. The most appropriate pain assessment tool would be the:

Face, Legs, Activity, Cry, Consolability Scale

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?

Faces Pain 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)

The nurse is assessing a client whose chronic pain is poorly controlled. The nurse would expect which assessment finding for this client?

Decreased gastric motility

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?

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:

Diaphoresis

Which of the following is not released during the stress response?

Dopamine

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 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?

Give the prn morphine

A client complains of pain in several areas of the body. How should the nurse assess this client's pain?

Have the client rate each location separately.

A client complains of aching all over her body. The client's health record indicates that she is otherwise healthy, with her baseline vital signs all well within normal limits. The nurse is assessing her for pain. Which of the following objective findings would most tend to indicate pain?

Heart rate of 110 beats per minute

The nurse collects vital signs on a hospital client who has recently been experiencing pain. Which finding would indicate the client is currently experiencing pain?

Heart rate of 110 beats per minute

The nurse collects vital signs on a client with pain. Which of the following would indicate to the nurse that the client is experiencing pain?

Heart rate of 110 bpm

A hospital's protocols for assessment have been modified in light of standards established by the Joint Commission. What change would bring practice into alignment with these standards?

Identifying pain as the fifth vital sign and assessing clients accordingly

The nurse is teaching the patient about the importance of treating pain and informs the patient that if pain is not treated adequately, it can lead to many different complications. Which of the following are some examples? (Check all that apply.)

Impaired pulmonary function Decreased immune response Longer hospital stays Chronic regional pain syndrome

A nurse is assessing the vital signs of a patient who is moaning with pain. What would be the expected findings?

Increased pulse and blood pressure

A client rates his pain as "9" on a scale of 1 to 10. The nurse would expect to assess which of the following?

Increased serum glucose

Beliefs of health care providers can serve as barriers to an accurate assessment of a client's pain. Which of the following beliefs will not be likely to impair the assessment of pain?

Infants can feel pain and may respond with crying or agitation.

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?

It is likely that the client's pain rating will be influences by his emotional state.

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

Based on analysis of assessment data from a client with pain, the nurse writes a wellness diagnosis. Which diagnosis would be most appropriate?

Readiness for enhanced spiritual well-being related to coping with prolonged physical pain

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 patient rate the pain on a pain scale, other things to assess are the following: (Check all that apply.)

Location and duration Quality and description Alleviating and aggravating factors

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

Neuropathic

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?

Neuropathic pain

When providing information to a client concerning the client's osteoarthritic, nociceptive pain, the nurse should include which statements about this type of pain? Select all that apply.

Neurotransmitters like endorphins and histamines regulate this pain. The pain is associated with the inflammatory process. This form of pain can be either chronic or acute in nature.

Health care providers often rate pain scores lower in patients of racial and ethnic minority groups than they do in Caucasian patients. Studies have shown that this disparity may be the result of which of the following variables? (Check all that apply.)

Nociceptive differences Communication processes Pain behaviors

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?

Nociceptors

When assessing pain in an older adult client who is alert and oriented, which assessment tool would be most appropriate to use?

Numerical rating scale

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.

A nurse is assessing a client with arthritis. Which of the following should the nurse consider in the initial assessment of the client?

Pain level

A client just underwent a left below-the-knee amputation (BKA). The client now reports pain in the missing left foot. What type of pain is the client describing?

Phantom

A client who recently had his lower leg amputated due to a complication associated with diabetes complains of feeling pain in the area of the foot that was amputated. The nurse recognizes this pain as which of the following?

Phantom

Pain that is felt in a part of the body that has been removed is called:

Phantom pain.

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

Physiological classification

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?

Provoking and alleviating factors

In addition to pain intensity, what is another basic element of a pain assessment?

Quality

A patient in the Emergency Department is diagnosed with a myocardial infarction (heart attack). The patient describes pain in his left arm and shoulder. What name is given to this type of pain?

Referred pain

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?

Referred pain

A nursing instructor is teaching students about the pain experience. The instructor informs the students that a patient experiencing pain will have a stress repsonse. The students are aware that this stress repsonse causes the following:

Release of epinephrine, cortisol, and norepinephrine

Which assessment finding is consistent with the presence of pain?

Restlessness

The patient 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 patient's pain. Which of the following is correct?

Restlessness, guarding

The nurse prepares to complete a pain assessment with a client who recently experienced a stroke. In which order should the nurse use the hierarchy of pain assessment techniques with this client? Drag statements into the proper order.

Self-report Search for potential causes Observe behaviors Surrogate reporting Attempt an analgesic trial

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 nurse is admitting a client to the postsurgical unit following breast reconstruction surgery. What would the nurse use as the primary assessment for the client's pain?

The client's report of her pain

The nurse recognizes that a barrier to successful pain management for the patient with opioid tolerance is:

The patient does not experience pain relief with usual doses of opioids.

The nurse is evaluating the effectiveness of the patient's pain medication and notes the patient is hard to arouse. The nurse interprets this as:

The patient may be over-sedated.

Of the following individuals, who can best determine the experience of pain?

The person who has the pain

A patient reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?

The release of endorphins

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?

Tolerance

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?

Validate the assessment data with the client.

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?

Vocalization

A nurse assesses a non-English-speaking 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?

Wong-Baker Faces

Acute pain can be differentiated from chronic pain because

acute pain is associated with a recent onset of illness or injury with a duration of less than 6 months, whereas chronic pain persists longer than 6 months.

When assessing the client for pain, the nurse should

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

One of the body's normal physiologic responses to pain is

diaphoresis.

After assessing a client in pain, the nurse

documents the exact description given by the client