NUR 120 Pain Questions
Which of the following is not released during the stress response? Cortisol Epinephrine Dopamine Norepinephrine
Dopamine The stress response causes the release of epinephrine, norepinephrine, and cortisol.
The nurse is assessing the pain of an older adult client who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient's pain? Elimination pattern Genetic history Family history Sleep patterns
Sleep patterns When assessing pain in older adults, the nurse should be sure to also review the effects of pain on diet, sleep, and mood. Unrelieved pain may lead to insomnia or depression and seriously affect the client's quality of life. It would not be necessary to assess the family history, genetic history, or elimination pattern to gain insight into the client's pain level.
Who is the authority on the presence and extent of pain experienced by a patient? The patient An anesthesiologist A surgeon A nurse
The patient The only one who can be a real authority on whether, and how, an individual is experiencing pain is that individual.
When reviewing a client's medication administration record, the nurse should plan to administer a medication containing which substance that blocks pain sensations? Substance P Bradykinin Glutamate Gamma-aminobutyric acid
Gamma-aminobutyric acid BOX 6.1 Substances with a Role in Pain Pain-facilitating substances • Substance P • Bradykinin • Glutamate Pain-blocking substances • Serotonin • Opioids (both natural and synthetic) • Gamma-aminobutyric acid: gabapentin (Neurontin) and pregabalin (Lyrica)
A patient is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to decribe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers? C fibers A-delta fibers AC fibers P fibers
A-delta fibers A-delta fibers are myelinated and conduct impulses rapidly, resulting in pain being described as sharp or stabbing. C fibers are unmyelinated and cause pain that is achy and ongoing. There are no known AC or P fibers related to pain.
When providing information to a client concerning the client's osteoarthritic, nociceptive pain, the nurse should include which statements about this type of pain? Select all that apply. The trigger is a direct injury to either the peripheral or central nervous systems. Neurotransmitters like endorphins and histamines regulate this pain. The pain is associated with the inflammatory process. This form of pain can be either chronic or acute in nature. It is a form of idiopathic pain.
Neurotransmitters like endorphins and histamines regulate this pain. The pain is associated with the inflammatory process. This form of pain can be either chronic or acute in nature. Pain related to tissue damage is termed nociceptive somatic. Nociceptive pain can be either acute and remitting or chronic and persistent. This form of pain is mediated by the afferent A-delta and C-fibers of the sensory system that respond to noxious stimuli and is modulated by both neurotransmitters and psychological processes. Modulating neurotransmitters include endorphins, histamines, acetylcholine, and monoamines like serotonin, norepinephrine, and dopamine. These afferent nociceptors can be sensitized by inflammatory mediators. Pain resulting from direct injury to the peripheral or central nervous system is termed neuropathic. Idiopathic pain is not a form of nociceptive pain but rather a specific form of pain that has an unidentifiable cause.
A patient rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment? Patient experiencing a moderate amount of pain. Patient experiencing mild pain. Patient rated pain level as being a 5 using the rating scale. Patient stated "pain level not that bad."
Patient rated pain level as being a 5 using the rating scale. The nurse should document the exact pain assessment finding which would be patient rated pain level as being a 5 using the rating scale. The statement "patient experiencing a moderate amount of pain" is a subjective statement made by the nurse and is inaccurate. The statement "patient experiencing mild pain" is a subjective statement made by the nurse and is inaccurate. The statement "patient stated pain level not that bad" is a subjective statement made by the patient however does not identify that the patient rated the pain level as being a 5 on the Numeric Rating Scale.
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. Hypoglycemia Perspiration Increased heart rate Increased intestinal motility Sleeplessness
Perspiration Increased heart rate Sleeplessness 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.
Which of the following statements most accurately conveys an aspect of the gate-control theory? Specialized cells can decrease pain transmission by exciting inhibitory neurons. The transmission and sensation of pain exist completely within the spinal cord. Pain transmission and emotional state exist independently of each other. Substances such as endorphins are noted to increase pain sensation.
Specialized cells can decrease pain transmission by exciting inhibitory neurons. According to the gate-control theory, the excitation of inhibitory interneurons can inhibit pain. Peripheral receptors, the spinal cord, and the brain are all involved in the process, and endorphins can decrease pain. The gate-control theory identifies the way that pain and emotional state affect each other.
The nurse is explaining the difference between acute pain and chronic pain to the patient. Which should the nurse include in the explanation? Acute pain lasts longer than 3 to 6 months. The duration of chronic pain is short. Chronic pain is caused by damage to nerves. The cause of acute pain can be identified.
The cause of acute pain can be identified. Acute pain is of short duration and has an identifiable cause. Chronic pain lasts beyond the normal healing period of 3 to 6 months. Neuropathic pain results from damage to nerves in the peripheral or central nervous system.
The element of pain transmission that causes nociceptors to perceive a nerve impulse is what? Transmission Perception Modulation Transduction
Transduction In transduction, noxious stimuli create enough of an energy potential to cause nociceptors (free nerve endings) to perceive a nerve impulse. Transmission is when the neuronal signal moves from the periphery to the spinal cord and up to the brain. Perception is when higher areas of the brain perceive the impulse being transmitted as pain. Modulation is the action of inhibitory and facilitating input from the brain modulating or influencing sensory transmission at the level of the spinal cord.
Below are the four physiological processes involved in pain perception. Put them in the correct order. 1 Transduction 2 Modulation 3 Perception 4 Transmission
Transduction Transmission Perception Modulation The correct order of the four physiological processes involved in pain perception is as follows: 1) transduction, 2) transmission, 3) perception, and 4) modulation.
A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing? somatic referred visceral neuropathic
neuropathic Pain resulting from direct injury to the peripheral or central nervous system is termed neuropathic. Over time, neuropathic pain may become independent of the inciting injury and be described as burning. Somatic pain originates from skin, muscles, bones, and joints and is usually described as sharp. Referred pain is pain felt in a body area, away from the pain source. Visceral pain originates from abdominal organs and is usually described as cramping or gnawing.
Nurses use the FLACC scale to assess pain in children ages 2 months to 7 years. This scale uses which of the following indicators? (Select all that apply.) Ability to console patient Facial expression Cry Leg movements Activity Vital signs
Facial expression Leg movements Activity Cry Ability to console patient The FLACC scale is used in children ages 2 months to 7 years. It uses the indicators of facial expression, leg movement, activity, cry, and ability to console. Behaviors include frowning, kicking, arched back, crying, and difficulty consoling. The tool has established reliability and validity.
Which of the following best describes neuropathic pain? Described as sharp, or dull and aching May be labelled as central pain Associated with organs in the thorax, abdomen, and pelvis Labelled as musculoskeletal pain
May be labelled as central pain Neuropathic pain is described as burning, tingling, numbness, stabbing, shooting, or electric, and if the problem is in the central nervous system, the pain may be labelled as central pain. Visceral pain is associated with the organs, and somatic nociceptive pain is labeled as musculoskeletal. Nociceptive pain is more often described as sharp, or dull or aching.
A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain? Nociceptive Neuropathic Somatic Idiopathic
Neuropathic Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.
The charge nurse on a geriatric unit should further educate a new staff nurse who makes which statement? Pain sensation is diminished in older adults. There is little information about the effects of increased age on pain. Transmission of pain along A-delta and C fibers may be altered in older adults. Older adults tend to be undertreated for pain.
Pain sensation is diminished in older adults. Little is known about the effect of increased age on pain perception. No evidence suggests that pain sensation is diminished in older adults, which is a common misperception. Transmission along the A-delta and C fibers may become altered with aging, but it is not clear how this change affects the pain experience. Studies of sensitivity and pain tolerance have indicated that changes in pain perception are probably not clinically significant (American Geriatric Society, 2002; Reyes-Gibby, Aday, Todd, et al., 2007). Because older people are likely to experience more adverse effects from analgesia, especially from opiates, health care providers may undertreat pain in older adults.
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? Suggest client purchase a hearing aid. Ask client to numerically rate pain in a high-pitched voice. Speak to the client face to face. Utilize the FLACC scale.
Speak to the client face to face. When assessing the older patient for pain, determine whether the patient has any auditory impairment. If so, position your face in the patient's view, speak in a slow, normal tone of voice, reduce extraneous noises, and provide written instructions. The FLACC scale is used primarily for infants. Hearing aids are expensive and suggesting to purchased one does not aid in the pain assessment at present.
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? A-delta fibers C-fibers K-fibers L-beta fibers
A-delta fibers Nociceptors are located at the peripheral ends of both myelinated nerve endings of type A fibers and unmyelinated type C fibers, and there are three types that are stimulated by different stimuli: mechanosensitive nociceptors (of A-delta fibers), sensitive to intense mechanical stimulation (e.g., pliers pinching skin); temperature-sensitive (thermosensitive) nociceptors (of A-delta fibers), sensitive to intense heat and cold; and polymodal nociceptors (of C fibers), sensitive to noxious stimuli of a mechanical, thermal, or chemical nature. There are no "K-fibers" or "L-beta fibers."
A post-operative client is observed breathing 24 breaths/minute while complaining of 10/10 abdominal pain. The client's oxygen saturation is 90% on 2 liters nasal cannula. What is the nurse's priority action? Administer prescribed analgesia as ordered. Manually ventilate client with ambu bag at bedside. Teach and encourage incentive spirometry use. Explain why deep breathing and coughing is important.
Administer prescribed analgesia as ordered. The client is complaining of a the highest level of pain at 10/10. Therefore, the increased respirations and low oxygen saturation are likely a result of hypoventilation due to pain. Acute pain that is is not adequatley treated can impair pulmonary function. When the client is suffering from an intense amount of time, the client may not be very receptive to teaching and explanations. The client may have the desire to cough and deep breathe but is unable to due to the intensity of pain. The client can still breathe on his/her own, so an ambu bag is not needed.
The nurse is assessing a client with a history of drug addiction. What will be helpful in determining interventions that will be most beneficial for providing adequate pain relief to this client? Collecting objective data that the client chooses to share Using in-depth questions to collect significant data about the client's pain Collecting subjective data that the nurse notes during assessment Gathering information that the client wants to share about his pain
Using in-depth questions to collect significant data about the client's pain Use of in-depth questions to collect all the significant data from the pain assessment will be the biggest help in determining what types of interventions will be most beneficial for providing adequate pain relief to the client. Objective data are not shared by the client, and subjective data are not what the nurse notes during the assessment—these are what the patient shares about the pain. While assessing a client's pain, the nurse needs to gather more information than is freely shared by the client.
A nurse begins to assess pain in a client admitted to the hospital for new onset of severe nausea and vomiting. What question should the nurse ask the client to assess the pattern of pain? "Where is the pain located?" "When did your pain start?" "What therapies have you tried to control the pain?" "How often do you experience the pain?"
"How often do you experience the pain?" The nurse uses a mnemonic device including but not limited to OLD CART or COLDSPA to elicit information from a client about the pain. The nurse should assess for patterns by asking questions that elicit information about what makes the pain better or worse. Asking the client how often the pain occurs will help the nurse understand the course of the pain and if there is any pattern that may help identify the source of the pain. Asking about onset of the pain is essential to determine the severity of the situation. Therapies alert the nurse to the effect of treatment modalities that have or have not been successful in alleviating the pain. Location helps to identify the underlying cause.
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 The nurse should assess for neuropathic pain associated with diabetic neuropath. Neuropathic pain: Pain that results from damage to nerves in the peripheral or central nervous system (Staats, et al., 2004). Examples of neuropathic pain include diabetic peripheral neuropathy, post herpetic neuralgia, and postmastectomy pain. You should also be alert for the common terms that patients use to report neuropathic pain, such as burning, painful tingling, pins and needles, and painful numbness.
Pain is whatever the patient says it is. Self-report is the gold standard for assessing pain; however, nurses learn when assessing pain to assess the following as well: (Check all that apply.) Rocking Grimacing Decreased urine output Increased blood pressure Increased heart rate Increased urine output
Grimacing Rocking Increased heart rate Increased blood pressure Pain is whatever the patient says it is, and it exists whenever the patient says it does. For verbal patients, self-report is the gold standard. Nurses also, however, should assess for pain behaviors, such as grimacing, rocking, or guarding. Physiological responses to pain include increased heart rate and blood pressure. A change in the urinary output is not necessarily associated with pain.
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? Occasional grimace or frown Whimpering Lying quietly Kicking
Kicking According to the FLACC scale for pediatric pain assessment, kicking or the legs being drawn up is a strong sign indicating pain, as it would receive a 2. An occasional grimace or frown and whimpering are weaker signs of pain, as they would each warrant only a 1. Lying quietly is a normal activity and indicates the absence of pain; thus, it would receive a 0.
A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing? Transduction Transmission Perception Modulation
Modulation The client is in the modulation phase of pain, during which the brain interacts with the spinal nerves in a downward fashion to subsequently alter the pain experience. The client is not in the transduction, transmission, or perception phase of pain. Transduction phase refers to the conversion of chemical information at the cellular level into electrical impulses that move toward the spinal cord. In transmission phase, the stimuli move from the peripheral nervous system toward the brain, and the perception phase occurs when the pain threshold is reached.
When patients report pain, it is important to find the source. When patients describe pain as "burning, painful numbness, or tingling," the source is more than likely: Visceral Neuropathic Somatic Referred
Neuropathic Visceral pain originates from abdominal organs and is often described as crampy or gnawing. Somatic pain originates from the skin, muscles, bones, and joints. Referred pain originates from a specific site, but the patient experiencing the pain feels it at another site along the innervating spinal nerve. Neuropathic pain is described as burning, painful numbness, or tingling.
A 12-year-old boy has reported to the emergency department after having fallen off his bicycle and sustained what appear to be minor injuries. The nurse is assessing him for pain. Which of the following objective findings would most tend to indicate pain? Upright posture while sitting Sustained eye contact with the nurse Nodding up and down in response to questions Maintaining a consistent position and posture
Nodding up and down in response to questions Nodding up and down or saying, "yeah, yeah," may not indicate a client's positive response to questions, but rather may indicate just listening or not wanting to be negative, as responding verbally or in detail would require too much effort while the client is in pain. The other findings listed would all tend to indicate a lack of pain: upright posture, sustained eye contact, and maintaining a consistent position and posture.
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. The developing neurological system children transmits less pain than in older patients. 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. 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 nurse is using the Visual Analog Scale to assess pain of an adult patient. The nurse instructs the patient to: Rate their pain using a 0 to 10 scale where 0 means "no pain" and 10 means "worst possible pain" Select a number with descriptors located on a thermometer that describe their pain Complete a short questionnaire comprised of open-ended questions to describe their pain Place a mark on a 100-mm line with "no pain" at one end and "worst possible pain" at the other
Place a mark on a 100-mm line with "no pain" at one end and "worst possible pain" at the other The Visual Analog Scale is a 100-mm line with "no pain" at one end and "worst possible pain" at the other. 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. The Brief Pain Impact Questionnaire is a short questionnaire comprised of open ended questions to assess pain.
In addition to pain intensity, what is another basic element of a pain assessment? Preferred assessment tool History Focused goal Quality
Quality Some prefer to use mnemonics to remember the elements of pain assessment. One of these is PQRST: O: Onset; P: Provocative or palliative; Q: Quality; R: Region and radiation; S: Severity; T: Timing.
A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain? Visceral Somatic Cutaneous Referred
Somatic 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 specifi c site, but the person experiencing it feels the pain at another site along the innervating spinal nerve (Fig. 6.3).
The nurse should clarify which medication order prescribed for a client with chronic back pain? Narcotic analgesia Tricyclic antidepressant Selective serotonin reuptake inhibitor Angiotensin converting enzyme inhibitor
Angiotensin converting enzyme inhibitor To treat some chronic pain conditions, health care providers may prescribe medications that increase serotonin levels, such as tricyclic antidepressants and selective serotonin reuptake inhibitors, to modulate incoming pain stimuli. Opiates, antidepressants, and calcium channel blockers are pharmacological alternatives in the treatment of chronic pain. ACE inhibitors are not routinely prescribed for chronic pain conditions.
Beliefs of health care providers can serve as barriers to an accurate assessment of a client's pain. Which of the following beliefs will not be likely to impair the assessment of pain? Infants can feel pain and may respond with crying or agitation. Old people have more pain which is to be expected. Persons asking for pain medication but who are showing no other evidence of pain are just addicted to the medication. A sleeping person feels no pain.
Infants can feel pain and may respond with crying or agitation. It is hard to evaluate pain in neonates and infants. Behaviors that indicate pain are used to assess their pain. Crying and not being able to be consoled indicate pain in this population.
A patient who was in an automobile accident a week ago is at home recovering from her injuries. She contacts her primary care provider's office to report that she still has severe pain in her back, resulting from an injury to that region, that has not been lessened by two different pain relievers that the physician had prescribed for her. The nurse recognizes this as which type of pain? Visceral Chronic Intractable Referred
Intractable Intractable pain is pain that is highly resistant to pain relief, which appears to be the case in this situation. Referred pain is perceived in body areas away from the pain source; because the pain this client is experiencing is due to an injury to the back, this does not seem to be referred pain. Chronic pain is pain that persists longer than 6 months. Visceral pain is pain experienced in a deep organ, typically in the abdominal cavity, thorax, or cranium.
A student nurse learns that especially in the very young and very old pain can be inadequately treated. What else would the student learn about inadequate pain treatment in the very young? It can lead to neurodevelopmental problems It can lead to higher patient compliance with medication It can lead to nutritional deficiencies from lack of appetite It can lead to an increase in hormonal disorders
It can lead to neurodevelopmental problems Inadequate pain treatment can lead to a delay in healing and behavioral consequences, such as learning disabilities, psychiatric disorders, and neurodevelopmental problems. It does not increase hormonal disorders, nutritional deficiencies, or patient compliance with medication.
The U.S. government has created guidelines for health care providers caring for clients in pain. Which of the following reflect these guidelines? Joint Commission Standards for Pain Management. National Institutes of Health Standards for Pain Treatment. American Cancer Society Guidelines for Pain Management. American Pain Society Guidelines for Pain Management.
Joint Commission Standards for Pain Management. Joint Commission Standards for Pain Management were revised and published in 2000-2001. The standards require health care providers and organizations to improve pain assessment and management for all patients.
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 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.
A nurse is caring for an athlete who was injured during a practice session. There is visible skin impairment, and the client complains of throbbing pain in the leg. What level of pain does the nurse document for this client? Epidermis level Dermis level Subcutaneous level Muscle level
Subcutaneous level The nurse should document the client's pain as subcutaneous level pain, which is indicated by the throbbing pain. Pain at the epidermis level is a burning sensation. Pain at the dermis level is superficial and localized. Somatic pain develops from injury to muscles, tendons, and joints.
The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what? The research supporting intravenous medications given for pain take half as long to work as oral medications The time it takes a pain medication to block pain in a client The time it takes a pain medication to decrease pain intensity The median half-life of an intravenous pain medication
The time it takes a pain medication to decrease pain intensity Most healthcare facilities have a standard time frame for reassessment, such as 1 hour for oral medication and 30 minutes for pain medication given intravenously. Standards are based on the time it takes a pain medication to provide a noticeable decrease in pain intensity. The mandate from The Joint Commission does not look at the half-life of the pain medication, because the half-life would differ from drug to drug, and no drug is listed in the question. The pain medication does not block pain, but decreases the pain intensity. Research does not support that intravenous medication take half as long to work as oral medication, because this information depends on the individual drug and the chemical makeup of the drug.
A client injures his thumb by accidently slamming the car door shut on it. He arrives at the emergency department in intense pain. Which of the following processes is associated with the transduction process of this pain? Inflammation leading to conduction of an impulse to the spinal cord Tissue injury leading to inflammation Changes or inhibitions to the pain message relay in the spinal cord Emotional response and rational interpretation and response
Tissue injury leading to inflammation Transduction of pain begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage, resulting in an inflammatory process. The transmission process is initiated by this inflammatory process, resulting in the conduction of an impulse in the primary afferent neurons to the dorsal horn of the spinal cord. The process of pain perception involves the hypothalamus and limbic system, which are responsible for the emotional aspect of the pain perception, and the frontal cortex, which is responsible for the rational interpretation and response to pain. Modulation changes or inhibits the pain message relay in the spinal cord.
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? Somatic pain Cutaneous pain Referred pain Visceral pain
Visceral pain Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial and somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this patient's pain is sensed near the location of his appendix.
