PrepU Chapter 6 - Pain Assessment

An emergency department nurse is assessing a client's complaint of upper abdominal pain. To assess the character of the pain, the nurse would begin with what assessment question?

"Can you describe to me how your pain feels?"

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

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

The nurse is assessing a client who is experiencing a great deal of pain. Which assessment data would be considered normal under those circumstances?

Decreased gastric motility

Which statement by the patient would the nurse consider to be an alleviating factor? Select all that apply.

"Elevating my leg makes the swelling go down in my foot." "I picture myself on the beach listening to the waves." "Listening to music makes my pain much more tolerable."

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."

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."

The patient asks the nurse about possible causes of neuropathic pain. Which is the best response by the nurse?

"Patients with diabetes often develop neuropathic."

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?

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

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

The nurse is caring for a client diagnosed with chronic nonmalignant pain. The nurse should understand that this client has experienced this pain for at least how many months?

6

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 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.

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

Confusion

Nurses use the FLACC scale to assess pain in children ages 2 months to 7 years. This scale uses which of the following indicators? (Select all that apply.)

Facial expression Leg movements Activity Cry Ability to console patient

A client who has fractured her arm is describing her pain as "excruciating." The nurse determines that the client is experiencing what type of pain?

Deep somatic

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 acute small-bowel obstruction who reports intermittent pain. He only noticed symptoms of this condition earlier today. 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 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?

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

Dopamine

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?

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

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 patient who was in an automobile accident a week ago is at home recovering from her injuries. She contacts her primary care provider's office to report that she still has severe pain in her back, resulting from an injury to that region, that has not been lessened by two different pain relievers that the physician had prescribed for her. The nurse recognizes this as which type of pain?

Intractable

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 would the nurse need to keep in mind when assessing the client's pain?

It is likely that the client's pain rating will be less than what he is feeling.

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?

McGill Pain Questionnaire

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.

A patient with a history of opioid tolerance will have an altered physiologic response to the pain stimulus. The repeated use of opioids will cause the body to become more sensitive to pain. This sensitivity is known as which of the following?

Opioid hyperalgesia

What is the main issue that a nurse should consider when choosing a pain assessment tool to collect objective data?

Produce accurate results each time it is used

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

The nurse is using the Verbal Descriptor Scale to assess a client's pain. What data will the nurse prioritize?

Ranges from no pain to worst possible pain

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

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

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

Sensory

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

Which of these clinical manifestations are physiologic responses to pain? Select all that apply.

Sleeplessness Perspiration Increased heart rate

The nurse is observing a client's posture and facial expression for evidence of pain. Which of the following would most likely lead the nurse to suspect that the client may be experiencing pain?

Slumped poster

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

The nurse is explaining the difference between acute pain and chronic pain to the patient. Which should the nurse include in the explanation?

The cause of acute pain can be identified.

The nurse is using the Verbal Descriptor Scale to assess a client's pain. What data will the nurse prioritize?

The client's explanation of how her pain feels

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?

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

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.

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 enorphins

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

A client injures his thumb by accidently slamming the car door shut on it. He arrives at the emergency department in intense pain. Which of the following processes is associated with the transduction process of this pain?

Tissue injury leading to inflammation

A nursing instructor is teaching the class about different theories of pain. The instructor informs the students that the most common clinical interpretation of pain transmission is called "nociception." The instructor includes the following components in nociception: (Check all that apply.)

Transduction Modulation Perception Transmission

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.