Nurs 224 Chapter 6 CoursePoint

Diaphoresis

Sweating, especially to an unusual degree as a symptom of disease or a side effect of a drug.

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 my pain to be 3 or less." b) "I want to be able to sleep on my left side." c) "Climbing stairs makes my pain worse." d) "My pain is a 5 all the time."

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

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 stated?" b) "Do concurrent symptoms accompany the pain?" c) "When did you first notice the pain?" d) "Is the pain continuous or intermittent?"

a) "What were you doing when the pain first stated?"

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 fibers b) C-fibers c) K-fibers d) L-beta fibers

a) A-delta fibers

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? a) Consult with the healthcare provider about increasing the dose of medication. b) Inform the client that the next dose of medication is due in one more hour. c) Request a psychiatric evaluation for drug seeking behavior. d) Tell the client to take his own prescription medication.

a) 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. a) Depressive symptoms b) Lack of appetite c) Increased restorative sleep d) Increased levels of play e) Disruption of family functioning

a) Depressive symptoms b) Lack of appetite e) Disruption of family functioning

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

a) Face, Legs, Activity, Cry, Consolability Scale

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.

The U.S. government has created guidelines for health care providers caring for clients in pain. Which of the following reflect these guidelines? a) Joint Commission Standards for Pain Management. b) National Institutes of Health Standards for Pain Treatment. c) American Cancer Society Guidelines for Pain Management. d) American Pain Society Guidelines for Pain Management.

a) Joint Commission Standards for Pain Management.

Which would the nurse recognize as an example of visceral pain? Select all that apply. a) Liver pain b) Burn pain c) Gallbladder pain d) Muscular pain e) Pancreatic pain

a) Liver pain c) Gallbladder pain e) Pancreatic pain

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.

a) Provoking and alleviating factors.

Which of these clinical manifestations are physiologic responses to pain? Select all that apply. a) Sleeplessness b) Increased intestinal motility c) Perspiration d) Increased heart rate e) Increased insulin

a) Sleeplessness c) Perspiration d) Increased heart rate

The nursing class is learning about pain assessment. Which of the following is a manifestation of pain? a) Confusion b) Bracing c) Pressured speech d) Apathy

b) Bracing

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) "Patients with chronic illnesses can have chronic pain." b) "Nurses are the best authority on pain." c) "Acute pain can be as intense as chronic pain." d) "Chronic pain can be referred to as persistent pain."

b) "Nurses are the best authority on pain."

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? a) Ask the client to briefly explain his cultural background. b) Assess the client's pain by gathering subjective data from the client. c) Assess the client's self-management skills. d) Assess the client's pain by obtaining a set of vital signs.

b) Assess the client's pain by gathering subjective data from the client.

Mrs. D. has presented to the clinic six times over the past 8 weeks with complaints of leg pain that is taking a toll on her activities of daily living and mental health. Some clinic staff members have begun rolling their eyes when they see Mrs. D enter the clinic; there is a consensus that her complaints of pain are an attention-getting strategy. The nurse can find no objective indications for the client's pain, which the client claims is worsening over time. Which of the following actions should the nurse choose? a) Order diagnostics to confirm or rule out the existence of the pain. b) Implement treatment that is based on the fact that the pain is real and debilitating. c) Implement an analgesic regimen that is especially conservative to gauge the client's response. d) Tactfully inquire whether Mrs. D. is using her complaints of pain to avoid acknowledging other physical or psychosocial problems.

b) Implement treatment that is based on the fact that the pain is real and debilitating.

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

b) Increased pulse and blood pressure

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

b) Neuropathic

When performing a pain assessment the client should be asked to provide all the following information except: a) Effects of pain on activities of daily living b) Physiological classification c) Treatment expectations d) Effectiveness of treatment

b) 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? a) Visceral pain b) Referred pain c) Cutaneous pain d) Somatic pain

b) Referred pain

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.

b) Speak to the client face to face.

A nurse is performing a detailed pain assessment of a client who has sought care for debilitating migraines. When assessing for precipitating factors, what question should the nurse ask? a) "Is there anything that's given you relief in the past?" b) "Have your migraines gotten more severe in the last few months?" c) "What were you doing immediately before your last migraine?" d) "How long does a typical migraine last?"

c) "What were you doing immediately before your last migraine?"

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) Anxiety related to prolonged pain. b) Impaired Mobility related stiff neck. c) Acute Pain related to sore throat. d) Risk for Fluid Volume Deficit related to fever.

c) Acute Pain related to sore throat.

A client is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what? a) Check the client's record for allergies. b) Check the physician's orders to see what pain medication to administer. c) Assess the site and intensity of the pain. d) Call the physician.

c) Assess the site and intensity of the pain.

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.

c) Believe the client when he or she claims to be in pain.

A female client with bone cancer is experiencing pain that has become more severe over the past several days. When modifying the client's plan of care, the nurse identifies a need to assess the affective dimension of the client's pain. How can the nurse best accomplish this goal? a) Document the ways that the client's pain affects her activities of daily living. b) Determine whether the client is able to independently treat her pain. c) Closely monitor the effects of the client's pain on her emotions. d) Ask the client to rate her pain during every physiological assessment.

c) Closely monitor the effects of the client's pain on her emotions.

One of the body's normal physiologic responses to pain is a) Hypotension b) Pulse rate below 50 beats/minute c) Diaphoresis d) Hypoglycemia

c) Diaphoresis

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) Have the client rate each location separately. d) If pain does not radiate, there is no need to rate that area.

c) Have the client rate each location separately.

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) The client is likely experiencing less pain than he is reporting. b) The client's depression exists independently of the level of pain. c) It is likely that the client's pain rating will be influences by his emotional state. d) The degree of surgery will be the key indicator for level of pain experienced.

c) 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? a) Transduction b) Modulation c) Nociceptors d) Cytokines

c) Nociceptors

A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing? a) Somatic b) Referred c) Visceral d) Neuropathic

d) Neuropathic

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

d) Spiritual dimension

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? a) "Even when he becomes addicted, we can take comfort knowing that his pain is controlled." b) "It's actually a myth that clients can become addicted to hospital narcotics." c) "If he ends up needing higher doses to resolve the pain, we will discontinue the drug." d) "There's a very minimal risk of addiction, and controlling his pain is our first concern."

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

The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis? a) Shingles b) Bone fracture c) Myocardial infarction d) Appendicitis

d) Appendicitis

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.

d) Avoid stereotyping responses to pain by clients.

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) Numeric scale b) Word scale c) Linear scale d) FACES scale

d) FACES 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? a) Graphic Rating Scale b) Numeric Rating Scale (NRS) c) Verbal Descriptor Scale d) Faces Pain Scale-Revised (FPS-R)

d) 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? 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?

d) How does the pain influence your overall mood?

A nurse is meeting for the first time a 42-year-old client whose visit to the clinic has been prompted by her chief complaint of ongoing lower back pain. Which of the following approaches to pain assessment should the nurse use when assessing the client's pain? a) The nurse should implement a pain assessment tool that is as detailed as possible. b) The nurse should allow the client to guide the direction and character of assessment to identify her priorities. c) The nurse should prioritize objective data to quantify and validate the client's pain. d) The nurse should use a pain assessment tool that is simple but still addresses the major parameters of pain.

d) The nurse should use a pain assessment tool that is simple but still addresses the major parameters of pain.