Chapter 9: Assessing Pain
A nurse enters a client's room to conduct an assessment. The client is crying and states they have so much pain. What is the best response of the nurse? "When did it start?" "I am sorry to hear that." "Could you tell me more about your pain?" "Do you want some pain medication?"
"Could you tell me more about your pain?" Chapter 9: Assessing Pain - Page 150
A nurse is interviewing a 65-year-old client with a history of atrial fibrillation, type 2 diabetes, obesity, and congestive heart failure. The nurse determines the client is experiencing chronic neuropathic pain when the client makes which of the following statements? "My shoulder has been hurting off and on for the year." "The burning sensation in my feet has gotten worse over the past year." "I have had this aching pain in the right side of my stomach for a few months now." "I have been so depressed since my husband died that I ache all over."
"The burning sensation in my feet has gotten worse over the past year." Chapter 9: Assessing Pain - Page 140
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? "Even when he becomes addicted, we can take comfort knowing that his pain is controlled." "It's actually a myth that clients can become addicted to hospital narcotics." "If he ends up needing higher doses to resolve the pain, we will discontinue the drug." "There's a very minimal risk of addiction, and controlling his pain is our first concern."
"There's a very minimal risk of addiction, and controlling his pain is our first concern." Chapter 9: Assessing Pain - Page 137
As a nurse is adjusting a client's hospital bed, the nurse accidently pinches a finger between the bed and the wall. Which of the following components is involved in the transduction of the pain the nurse feels? neuronal plasticity K-fibers L-beta fibers A-delta and C fibers
A-delta and C fibers Chapter 9: Assessing Pain - Page 138
A pathophysiology instructor is discussing pain and its treatment across cultures. The instructor points out that clients from racial and ethnic minorities often receive less pain medication compared to Caucasians for what specific conditions? Acute pain in the ED Chronic pain from fibromyalgia Broken limbs Head injuries
Acute pain in the ED Chapter 9: Assessing Pain - Page 142
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? Anxiety related to prolonged pain Impaired physical mobility related stiff neck Risk for deficient fluid volume related to fever Acute pain related to sore throat
Acute pain related to sore throat Chapter 9: Assessing Pain - Page 141
During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following? Analgesics Surgery Relaxation techniques Cutaneous stimulation
Analgesics Chapter 9: Assessing Pain - Page 155
The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis? Shingles Bone fracture Myocardial infarction Appendicitis
Appendicitis Chapter 9: Assessing Pain - Page 151
How may a nurse demonstrate cultural competence when responding to clients in pain? Treat every client 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 clients.
Avoid stereotyping responses to pain by clients. Chapter 9: Assessing Pain - Page 143
The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus? Sharp, stabbing Aching, gnawing Burning, tingling Pain only on movement
Burning, tingling Chapter 9: Assessing Pain - Page 138-139
A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action? Alert the healthcare provider to the client's somatic pain complaints. Administer an antacid and apply a topical anesthetic for the arm pain. Check the client's vital signs and connect her to a cardiac monitor. Request a strong narcotic analgesic for the client's visceral pain complaints.
Check the client's vital signs and connect her to a cardiac monitor. Chapter 9: Assessing Pain - Page 138
In preparing a care plan for a client receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use? Constipation Diarrhea Impaired urinary elimination Bowel incontinence
Constipation Chapter 9: Assessing Pain - Page 137
Which of the following is not released during the stress response? Epinephrine Norepinephrine Dopamine Cortisol
Dopamine Chapter 9: Assessing Pain - Page 138
A client has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain? Narcotics Sedatives A-delta fibers Endorphins
Endorphins Chapter 9: Assessing Pain - Page 138
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 client's pain, what is the most appropriate pain assessment tool for the nurse to use? Face, Legs, Activity, Cry, Consolability Scale Visual Analog Scale FACES Pain Scale Numeric Pain Intensity Scale
FACES Pain Scale Chapter 9: Assessing Pain - Page 142-144
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? Measure heart rate. FLACC scale. Count respirations. BPIQ tool.
FLACC scale. Chapter 9: Assessing Pain - Page 154
The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the: Face, Legs, Activity, Cry, Consolability Scale FACES Pain Scale Numeric Pain Intensity Scale Combined Thermometer Scale
Face, Legs, Activity, Cry, Consolability Scale Chapter 9: Assessing Pain - Page 154
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? Verbal Descriptor Scale Numeric Rating Scale Faces Pain Scale Visual Analog Scale
Faces Pain Scale Chapter 9: Assessing Pain - Page 144-145
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 Burn pain Cardiac pain Arthritic pain
Gallbladder pain Chapter 9: Assessing Pain - Page 140
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 Hold the medication and wait 30 minutes Call the physician to check the order Document the client's pain rating on a scale of 0 to 10
Give the prn morphine Chapter 9: Assessing Pain - Page 137
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? What medical conditions do you have? Where is the pain located? What is the highest level of education you've completed? How does the pain influence your overall mood?
How does the pain influence your overall mood? Chapter 9: Assessing Pain - Page 145
The nurse understands the importance of performing an accurate pain assessment. In addition to having the client rate the pain on a pain scale, other things to assess are the following: (Check all that apply.) Location and duration Quality and description Diet and allergies Alleviating and aggravating factors Urine output and pulse oximetry value
Location and duration Quality and description Alleviating and aggravating factors Chapter 9: Assessing Pain - Page 139
When clients report pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source is more than likely: Visceral Neuropathic Somatic Referred
Neuropathic Chapter 9: Assessing Pain - Page 140
A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain? Nociceptive Neuropathic Somatic Idiopathic
Neuropathic Chapter 9: Assessing Pain - Page 140--141
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? Cutaneous pain Visceral pain Chronic pain Neuropathic pain
Neuropathic pain Chapter 9: Assessing Pain - Page 140
Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric clients? Pain assessment may require multiple methods in order to ensure accurate pain data. The developing neurological system children transmits less pain than in older clients. Pharmacologic pain relief should be used only as an intervention of last resort. A numeric scale should be used to assess pain if the child is older than 5 years of age.
Pain assessment may require multiple methods in order to ensure accurate pain data. Chapter 9: Assessing Pain - Page 146
The client 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 client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following? Visceral pain Referred pain Cutaneous pain Somatic pain
Referred pain Chapter 9: Assessing Pain - Page 139-140
A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what ty.pe of pain? Visceral Somatic Cutaneous Referred
Somatic Chapter 9: Assessing Pain - Page 140
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 Cutaneous pain Visceral pain Phantom pain
Somatic pain Chapter 9: Assessing Pain - Page 140
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? Cognitive dimension Sociocultural dimension Affective dimension Spiritual dimension
Spiritual dimension Chapter 9: Assessing Pain - Page 152
What are the steps for pain transmission in the gate control theory? (Mark all that apply.) Unrelieved painful stimulus on a peripheral neuron causes the "gate" to open The gate opens through repolarization of the nerve fiber The brain stem recognizes the stimulus as pain The pain stimulus passes down the afferent pathway The pain stimulus crosses the dorsal horn of the spine to the limbic system
Unrelieved painful stimulus on a peripheral neuron causes the "gate" to open The pain stimulus crosses the dorsal horn of the spine to the limbic system Chapter 9: Assessing Pain - Page 138
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 Referred pain Cutaneous pain Somatic pain
Visceral pain Chapter 9: Assessing Pain - Page 140
A nurse performs a focused assessment on a client reporting back pain after helping someone move into a new home. The nurse uses COLDSPA to further assess the client's pain. Character: sharp; onset: yesterday; location: lower back; duration: persistent since yesterday; severity: 8 out of 10 (on a scale 0-10, 10 being the worst); pattern: continuous; associated factors: movement. The nurse determines the client is experiencing which of the following classifications of pain? chronic neuropathic pain acute psychological pain chronic psychogenic pain acute inflammatory pain
acute inflammatory pain Chapter 9: Assessing Pain - Page 141
When assessing the client for pain, the nurse should doubt the client when he or she describes the pain. assess for underlying causes of pain, then believe the client. believe the client when he or she claims to be in pain. assess for the presence of physiologic indicators (such as diaphoresis, tachycardia, etc.), then believe the client.
believe the client when he or she claims to be in pain. Chapter 9: Assessing Pain - Page 144
A client is admitted with right lower abdominal pain with rebound tenderness. The nurse suspects appendicitis and documents this type of pain as which of the following? phantom somatic visceral referred
visceral Chapter 9: Assessing Pain - Page 140
