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

The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level?

1630

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 dopamine -The release of endorphins -The release of melatonin -The release of insulin

The release of endorphins

A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client experiencing?

Visceral pain

Mark is a 20-year-old college student who has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is Mark most likely experiencing?

Visceral pain

How may a nurse demonstrate cultural competence when responding to patients in pain? -Avoid stereotyping responses to pain by patients. -Treat every patient exactly the same, regardless of culture. -Be knowledgeable and skilled in medication administration. -Know the action and side effects of all pain medications.

Avoid stereotyping responses to pain by patients.

A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client? -Kicking -Occasional grimace or frown -Lying quietly -Whimpering

Kicking

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

Neuropathic

A patient who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return? -"Oh, that is all in your mind. Just forget it." -"Well, that is really strange. I will notify the doctor." - "I think it might be good to refer you to a psychiatrist." -"That is called phantom pain, and it is not unusual."

"That is called phantom pain, and it is not unusual."

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."

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. He says that he has not taken anything for the pain yet. The nurse recognizes this as what type of pain?

Acute

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? -Impaired physical mobility related stiff neck -Anxiety related to prolonged pain -Acute pain related to sore throat -Risk for deficient fluid volume related to fever

Acute pain related to sore throat

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

Appendicitis

The nurse is assessing a female client diagnosed with fibromyalgia. The nurse should assess for which physiological indicators of pain? (Select all that apply.)

Blood pressure 180/75. Heart rate 115 beats/minute.

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 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 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 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? -Hold the medication and wait 30 minutes -Give the prn morphine -Document the client's pain rating on a scale of 0 to 10 -Call the physician to check the order

Give the prn morphine

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?

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 Alleviating and aggravating factors Quality and description

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

Identify the steps in nociception. (Number 1 is the first step and number 4 is the last step.)

Noxious stimuli cause a nerve impulse perceived by free nerve endings. The neuronal signal moves from the periphery to the spinal cord and up to the brain. The impulses being transmitted to the higher areas of the brain are identified as pain. Inhibitory and facilitating input from the brain influences the sensory transmission at the level of the spinal cord.

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.

Which of the following cultural expressions of pain would be likely to be found in a person of Hispanic culture? -Pain is honorable and should be endured. -Pain must be endured to perform gender role duties, but response to it is very expressive. -Pain is part of the preparation for the next life in the cycle of reincarnation. -Pain may be caused by past transgressions and helps to atone and achieve higher spirituality.

Pain must be endured to perform gender role duties, but response to it is very expressive.

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

Pancreatic pain Gallbladder pain Liver 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 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 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.

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 caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?

Transduction

When assessing the client for pain, the nurse should -doubt the client when he or she describes the pain. -assess for the presence of physiologic indicators (such as diaphoresis, tachycardia, etc.), then believe the client. -assess for underlying causes of pain, then believe the client. -believe the client when he or she claims to be in pain.

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