NURS 224: Pain Assessment
A client rates his pain as "9" on a scale of 1 to 10. The nurse would expect to assess which of the following? a) Constricted pupils b) Hypotension c) Increased serum glucose d) Flaccid muscles
c) Increased serum glucose
The nurse is caring for a client following left hip replacement. Which response by the client is appropriate when the nurse asks the client to identify a pain management goal related to the client's left hip pain? a) "I want my pain to be 3 or less." b) "I want to be able to sleep on my left side." c) "Climbing stairs makes my pain worse." "d) My pain is a 5 all the time."
a) "I want my pain to be 3 or less."
The nursing instructor is teaching a class about how to assess pain in older adults. The teachers tells the students that problems can arise in certain circumstances. The instructor realizes the need for more teaching about pain in the elderly when one of the students replies: a) "Pain is a natural part of aging." b) "Patients may fear that uncontrolled pain will affect their independence." c) "Older clients may worry that reporting pain will lead to costly tests." d) "Patients are reluctant to report pain because they want to be considered as 'good' clients."
a) "Pain is a natural part of aging."
The community health nurse is caring for an older client who states that she has not been taking the postoperative pain medication that she was prescribed. What question is most likely to be relevant? a) Are you able to afford the prescribed medication? b) Is confusion causing you to refuse your pain medications? c) Are you too busy to take your prescribed pain medication? d) Will you take the medication if you are ordered to do so?
a) Are you able to afford the prescribed medication?
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? a) Constipation b) Diarrhea c) Impaired urinary elimination d) Bowel incontinence
a) Constipation
The nursing student asks the nurse what would be an example of visceral pain. What would be the correct response by the nurse? a) Gallbladder pain b) Burn pain c) Cardiac pain d) Arthritic pain
a) Gallbladder pain
A nursing instructor is teaching students about the pain experience. The instructor informs the students that a client experiencing pain will have a stress response. The students are aware that this stress response causes the following: a) Release of epinephrine, cortisol, and norepinephrine b) Decrease in oxygen and energy consumption c) Decrease in blood glucose and lactate levels d) Decrease in muscle tension and stress
a) Release of epinephrine, cortisol, and norepinephrine
The nurse recognizes that a barrier to successful pain management for the client with opioid tolerance is: a) The client does not experience pain relief with usual doses of opioids. b) The client has the normal physiologic response to painful stimuli. c) The repeated use of opioids causes their bodies to become less sensitive to pain. d) Appropriate pain assessment tools are unavailable for this type of client.
a) The client does not experience pain relief with usual doses of opioids.
A nursing instructor is teaching students how to assess a client's pain. The instructor emphasizes that there are many misconceptions about pain. The instructor realizes that a student needs further direction when the student states: a) "Patients with chronic illnesses can have chronic pain." b) "Nurses are the best authority on pain." c) "Acute pain can be as intense as chronic pain." d) "Chronic pain can be referred to as persistent pain."
b) "Nurses are the best authority on pain."
A client was administered PO pain medications at 1530. By what time should the nurse re-assess and document the effects of the pain medication? a) By end of shift. b) 1630. c) 1930. d) 2130.
b) 1630.
A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What would the nurse do next? a) Ask the client to briefly explain his cultural background. b) Assess the client's pain by gathering subjective data from the client. c) Assess the client's self-management skills. d) Assess the client's pain by obtaining a set of vital signs.
b) Assess the client's pain by gathering subjective data from the client.
A client is experiencing acute pain and has asked the nurse for medication. The client rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the client that the nurse can expect is: a) Decreased pulse b) Diaphoresis c) Hypotension d) Flaccid muscles
b) Diaphoresis
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: a) Visceral b) Neuropathic c) Somatic d) Referred
b) Neuropathic
When attempting to assess a client's pain, what would the nurse do first? a) Observe behaviors in the client. b) Obtain a client self-report. c) Search for possible causes of pain. d) Ask family members about the client's pain.
b) Obtain a client self-report.
When performing a pain assessment the client should be asked to provide all the following information except: a) Effects of pain on activities of daily living b) Physiological classification c) Treatment expectations d) Effectiveness of treatment
b) Physiological classification
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? a) Visceral pain b) Referred pain c) Cutaneous pain d) Somatic pain
b) Referred pain
A nurse is caring for a client who was administered opioid narcotics. The client complains of constipation. Which of the following is another potential side effect of opioid narcotics? a) Anxiety b) Sedation c) Diarrhea d) Insomnia
b) Sedation
The nurse is observing a client for evidence of pain. Which finding would lead the nurse to suspect that the client is experiencing pain? a) Frequent questioning b) Slumped posture c) Eye contact d) Periodic position changes
b) Slumped posture
A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain? a) Visceral b) Somatic c) Cutaneous d) Referred
b) Somatic
A client is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what? a) Check the client's record for allergies. b) Check the physician's orders to see what pain medication to administer. c) Assess the site and intensity of the pain. d) Call the physician.
c) Assess the site and intensity of the pain.
After describing the pathophysiology of pain, an instructor determines that the students have understood the teaching when they identify which of the following as being responsible for transmitting the sensations to the central nervous system? a) Transduction b) Modulation c) Nociceptors d) Cytokines
c) Nociceptors
Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric clients? a) The developing neurological system children transmits less pain than in older clients. b) Pharmacologic pain relief should be used only as an intervention of last resort. c) Pain assessment may require multiple methods in order to ensure accurate pain data. d) A numeric scale should be used to assess pain if the child is older than 5 years of age.
c) Pain assessment may require multiple methods in order to ensure accurate pain data.
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? a) Inflammation leading to conduction of an impulse to the spinal cord b) Emotional response and rational interpretation and response c) Tissue injury leading to inflammation d) Changes or inhibitions to the pain message relay in the spinal cord
c) Tissue injury leading to inflammation
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? a) Anxiety related to prolonged pain b) Impaired physical mobility related stiff neck c) Risk for deficient fluid volume related to fever d) Acute pain related to sore throat
d) Acute pain related to sore throat
Which of the dimensions of pain listed is being assessed by the question "How does the pain treatment you are getting affect your overall mood?" a) Physical. b) Behavioral. c) Cognitive. d) Affective.
d) Affective.
The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis? a) Shingles b) Bone fracture c) Myocardial infarction d) Appendicitis
d) Appendicitis
A client complains of pain in several areas of the body. How should the nurse assess this client's pain? a) Ask the client to rate the area with the highest pain level. b) Mark each site on the client's body with a marker. c) If pain does not radiate, there is no need to rate that area. d) Have the client rate each location separately.
d) Have the client rate each location separately.
A nurse is providing care to a client who has been in a motor vehicle accident and who has facial lacerations and a pelvic fracture. How can the nurse best determine the reliability and accuracy of data obtained during a pain assessment? a) Ask the primary care provider to validate the assessment data. b) Compare the findings to the client's preinjury level of health. c) Compare the findings to the most recent previous pain assessment. d) Validate the assessment data with the client.
d) Validate the assessment data with the client.
