Chapter 9: Assessing Pain: The 5th Vital Sign PrepU

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? Explanation: 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.

A patient recovering from abdominal surgery is complaining of pain. The nurse realizes that the patient is most likely experiencing which type of pain?

Somatic Explanation: Somatic pain is caused by tissue damage, which would occur after abdominal surgery. Psychogenic pain relates to factors that influence the patient's report of pain such as anxiety and depression. Idiopathic pain does not have an identified cause. Neuropathic pain results from direct injury to the peripheral or central nervous system.

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." Explanation: Concerns about addiction are normally unfounded. Nonetheless, it is inaccurate to characterize the possibility of addiction as a myth, on one hand, or a very real risk, on the other. Tolerance would not necessitate discontinuation.

Which would the nurse recognize as an example of visceral pain? Select all that apply.

-Liver pain -Gallbladder pain -Pancreatic pain Explanation: Examples of visceral pain include pain associated with the liver, gallbladder, and pancreas. Pain associated with a burn is an example of cutaneous pain. Muscular pain is a type of somatic pain.

A client enters the emergency department moaning and complaining of severe pain in his lower back. Which of the following clinical manifestations should the nurse expect to see in this client as a physiologic response to pain? Select all that apply.

-Perspiration -Increased heart rate -Sleeplessness Explanation: Sleeplessness, perspiration, and increased heart rate are physiologic responses to pain. Pain elicits a stress response in the human body that triggers the sympathetic nervous system. Hyperglycemia, not hypoglycemia, and decreased, not increased, intestinal motility are physiologic responses to 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?

Check the client's vital signs and connect her to a cardiac monitor. Explanation: Pain nociception has various locations. Visceral pain originates from abdominal organs; patients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; patients 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 patient 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.

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 Explanation: The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use.

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 Explanation: 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.

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 Explanation: The FACES scale is used for children who are 3 years or older. This tool allows the patient 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.

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. Explanation: 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.

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 Explanation: The Face, Legs, Activity, Cry, Consolability Scale is the appropriate pain assessment tool for a 4-week-old postoperative patient. This tool measures pain using observable behaviors as pain indicators. The FACES Pain Scale is appropriate for children age 3 and older, using six faces ranging from happy with a wide smile to sad with tears on the face. The other two scales are appropriate for use with older children and adults. The Numeric Pain Intensity Scale is a one-dimensional pain scale using an 11-poing Likert-type scale ranging from 0 to 10, where 0 means "no pain" and 10 means "worst possible pain." The Combined Thermometer Scale looks like a thermometer and has both numbers that increase from the bottom up and descriptor words to measure pain intensity.

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 Explanation: The nurse should use the Faces Pain Scale (FPS) to rate the pain felt by the client. The FPS shows different facial expressions; the client is asked to choose the face that best describes the intensity or level of pain being experienced. This tool is best suited for cognitively impaired adults. A Verbal Descriptor Scale (VDS) ranges pain on a scale between mild, moderate, and severe. The Numeric Rating Scale (NRS) rates pain on a scale from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. It has been shown to be best for older adults with no cognitive impairment. The Visual Analog Scale (VAS) rates pain on a 10-cm continuum numbered from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.

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 Explanation: 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.

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 Explanation: Pain is what the client says it is, and it exists whenever the client says it does. It would not be appropriate to hold the medication for 30 minutes, call the physician to check the order, or just document the client's pain.

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. Explanation: When assessing pain location, ask the patient to point to the painful area. If more than one area is painful, have the patient 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 radation may affect treatment choices.

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 Explanation: The client is experiencing neuropathic pain or functional pain. Neuropathic pain is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client is not experiencing cutaneous, visceral, or chronic pain. In cutaneous pain, the discomfort originates at the skin level. In visceral pain, the discomfort arises from internal organs caused from a disease or injury. In chronic pain the discomfort lasts longer than 6 months.

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. Explanation: It is often necessary to use more than one technique for pain assessment in children. Though their neurological system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all patients above a certain age; the assessment tool should reflect the patient's specific circumstances, abilities, and development.

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 Explanation: Referred pain originates from a specific site, but the person feels the pain at another site site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigeston. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints.

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following?

Somatic pain Explanation: Somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissues. Visceral pain is poorly localized and originates in body organs. Phantom pain occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the patient

When assessing the client for pain, the nurse should

believe the client when he or she claims to be in pain. Explanation: "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain.