ATI RN Pain Assessment 2.0

A nurse is discussing the FLACC scale with a neewly licensed nurse. Which of the following categories should the nurse include?

Face Legs Consolability

A nurse is discussing end of life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end of life pain managment?

Fear of addiction. Belief that pain is an expected part of their illness is correct. Inadequate pain assessment is correct.

A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter R?

R-region. This question evaluates the region of the client's pain.

A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include?

Transcutaneous electronic stimulating unit massage acupuncture cold therapy

A nurse is discussing transcutaneous electrical nerve stimulation TENS treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include?

You can be taught how to use TENS therapy at home. The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas. We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy..

A nurse is providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family?

Your family member has the right to receive effective pain management.

A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression?

A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN.

A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take?

Administer 1mg IM

A nurse is caring for an older adult client who has cognitive impairment and is postoperative. Which of the following actions should the nurse take?

Evaluate the client for pain by observing their behaivor.

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort?

Grimacing Restlessness Increased diaphoresis

A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make?

Justice allows the client the opportunity to be treated fairly.

a nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions?

Muscular pain backache menstrual discomfort

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose the client reports to the nurse their pain is still a 7 and has not changed.Which of the following actions should the nurse take?

Offer to assist the client with nonpharmacological relief strategies.

A nurse is monitoring a client who is 2 hr postoperative and is receiving morphone via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment(OIVI)?

Respiratory Rate Capnography Oxygen saturation

A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of the clients pain?

The client is diaphoretic.

A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include?

You should write down the pain interventions you use and your pain rating before and after.

A nurse is evaluation a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain?

A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury.

A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the clients's pain and administer prescribed pain medication. Which of the following can the nurse be charged with?

Negligence Rationale: Negligence means failure to perform in a manner that a reasonable person would have. By failing to assess the client's pain and administer the client's pain medication, the nurse was negligent.

A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy?

A nurse provides the client with the opportunity to take an intramuscular injection or oral medication for pain relief.

A nurse is caring for a client who report muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. Which way should the nurse categorize this client's pain.

Chronic pain Rationale: chronic pain is paint that has present usually for 3 to 6 months or longer after the injury or damage has healed. Examples of chronic pain are arthritis pain or pain from a back injury. Chronic pain can physically and emotionally debilitate a client.

A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions?

I will keep the morphine bottle in a locked cabinet in my kitchen.

A nurse is caring for a client who has prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client's knee for how long?

20 minutes

A group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC pain scale to assess their pain level?

A 3 year old toddler who has a fractured femur A 14 year old client who has severe cognitive and developmental delays. A 5 year old preschooler who is experiencing during a sickle cell crisis. Rationale: FLACC is used for patients who is 6 months to 7 years old.

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information?

A client's religious beliefs might affect the way they respond to pain A client's past pain experiences are not related to their current pain and pain management. Pain control might be harder to achieve if the nurse and the client speak different languages.

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control?

Consider each client's cultural preferences Determine the effectiveness of nonpharmalogical strategies. Use a pain scale specific to each client's cognitive abilities.

A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression?

Naloxone Rationale: Naloxone is a reversal agent for respiratory depression caused by opiods.

The nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include?

Stress culture social support disease severity