Chapter 4: Pain Assessment

Which term is used to describe pain quality?

Cramping

Which condition places the patient at highest risk for undertreatment of pain?

Delirium

What does the nurse infer if a patient scores a 2 on the Wong-Baker FACES pain rating scale?

Hurts a little bit

Which strategy represents correct use of behavioral signs as part of pain assessment?

Identifying specific pain behaviors that are unique to the patient

Which term describes pain produced by inflammation of the trigeminal nerve (trigeminal neuralgia) that is diffuse in nature, extending across the various nerves that innervate the face?

Projected

Use of the term "scalding" applies to which component of pain assessment?

Quality

Which component of a comprehensive pain assessment is most helpful for differentiating between nociceptive and neuropathic pain?

Quality

Which component of pain assessment is addressed by the patient describing his pain as "searing"?

Quality

Which term describes pain that originates at the location of a spinal nerve injury and then extends down that nerve into both of the patient's legs?

Radiating

The nurse is performing a comprehensive pain assessment. Which statement by the nurse will be most useful in helping to differentiate between nociceptive and neuropathic pain?

"Please describe what your pain feels like."

The nurse preceptor is educating the novice nurse about the use of McCaffery and Pasero's Hierarchy of Pain Measures. Which statement by the nurse preceptor accurately describes this tool?

"The Hierarchy of Pain Measures includes behavioral pain assessment."

A patient with metastasized breast cancer reports pain in the back. What statements by the patient best describe it as a chronic pain? Select all that apply.

"The pain does not allow me to get out of bed." "The pain began gradually and has become persistent." "The pain tires me and makes me feel sad and depressed."

The nurse is preparing to assess pain in a patient with peripheral vascular disease. Which open-ended question is appropriate for this assessment?

"How does your pain affect your job?"

Which question is most effective for assessing the psychosocial impact of chronic pain?

"How has chronic pain affected your professional life?"

During assessment of the psychosocial impact of chronic pain, which question will the nurse ask the patient?

"How has your daily routine changed because of your pain?"

The nurse believes a patient with cancer is attaching spiritual significance to the lingering pain. What nursing question assesses the spiritual beliefs of the patient?

"How has your pain affected your role as a parent?"

Which patient statement indicates localized pain?

"My shoulder blade hurts a lot."

Pain duration may be described using which term?

Brief

A patient rates their pain at a 2 or 3 on a pain rating scale on a calibrated 0-to-10. How does the nurse interpret this finding?

The patient has mild pain.

The emergency department nurse is caring for a patient who sustained a 1-inch laceration on her thumb. Treatment by the primary health care provider includes application of antibiotic ointment and a small dressing; no sutures were needed. As the nurse prepares to review the patient's discharge instructions, the patient states, "My thumb really hurts! I need something for pain now!" Which response by the nurse is most appropriate?

"I will tell your primary health care provider that you are having a lot of pain."

A postoperative patient is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the patient before administering the medication?

"Is your pain controlled between doses?"

A nurse is caring for a patient with a history of dementia and chronic pain. In which order would the nurse follow the recommendations for the Hierarchy of Pain Measures as given by the primary health care provider?

1. "Obtain a self-report." 2. "Consider underlying painful pathology, conditions, and procedures." 3. "Observe the behaviors." 4. "Evaluate physiologic indicators" 5. "Conduct an analgesic trial."

A patient on opioid therapy is in a deep sleep and unresponsive to verbal and physical stimuli. Which Pasero Opioid-Induced Sedation Scale (POSS) score does the nurse document?

4

Which patients are at greatest risk for undertreatment of pain? Select all that apply.

A patient who is sedated following general anesthesia A patient who is intubated after a motor vehicle collision A patient who is unresponsive after sustaining a head injury A cognitively impaired patient who is diagnosed with bronchitis

The nurse is attending to a 75-year-old patient with dementia. How does the nurse measure the intensity of pain due to rheumatoid arthritis in this patient? Select all that apply.

Ask the family about the patient's pain. Observe vocalizations and verbalizations. Observe facial expression and body movements.

The nurse is performing a pain assessment on an alert, mechanically ventilated patient. Which patient behavior has the potential to provide the most useful assessment data for determining pain intensity?

Blinking

Which objectives are accomplished by conducting an analgesic trial for a cognitively impaired patient? Select all that apply.

Confirming the presence of pain Establishing a basis for a pain treatment plan

A patient reports sharp, shock-like, burning, shooting pain in the feet and legs that is associated with numbness. The nurse suspects that the patient is experiencing what condition?

Diabetic neuropathy

Which nursing action reflects correct use of the Wong-Baker FACES® Pain Rating Scale?

Encouraging the patient to choose a cartoon face that best represents the pain

A patient is brought to the hospital in a state of delirium. Which indicators on the Checklist of Nonverbal Pain Indicators (CNPI) does the nurse use to assess this patient's level of pain? Select all that apply.

Facial expression Mental status changes Changes in interpersonal interactions

The registered nurse is working with a student nurse who is trying to help gauge the level of pain in a patient who is unable to use other tools of communication. Which action by the student nurse needs correction?

Misinterpreting lip-reading by eye contact

Which is a risk factor for opioid-induced respiratory depression?

Obstructive sleep apnea

Which intervention facilitates nursing assessment of the severity of the patient's pain?

Obtaining a self-report

Which statement is true about assessing pain in an older adult patient?

Older adults are at great risk for undertreated pain.

Effective pain assessment requires the nurse to understand which principles related to pain perception among older adults? Select all that apply.

Older adults may be reluctant to report pain. The incidence of pain is higher in older adults.

Which information will the nurse prioritize when analyzing data obtained during a pain assessment to determine the amount of pain the patient is experiencing?

Pain rating of 6 on a scale of 0 to 10

Which term describes pain that originates at the site of a herniated cervical disk and extends into the arm, hand, and fingers?

Radiating

Which term describes right shoulder pain caused by gallstones?

Referred

Which pain rating scale requires the patient to select the phrase that best corresponds with the pain intensity?

The Verbal Descriptor Scale (VDS)

Which strategy is most useful for pain assessment in the alert patient who is mechanically ventilated?

Using a communication board

The nurse is attending to an Asian-American patient who cannot communicate in English. What tool does the nurse use when assessing the pain of the patient?

Wong-Baker FACES Pain Rating Scale