Nursing Assessment Chapter 9
When documenting assessment data, the nurse should avoid which phrases because of their lack of description? Select all that apply.
"Client presented as well developed." "Client appears to be in no apparent physical distress." "Client is of average height and well nourished." Choose vivid and graphic words such as "pale" and "appropriate eye contact." Avoid clichés such as "well developed," "well nourished," or "in no acute distress" because they are nondescript and could apply to any client.
A middle-aged client is complaining of acute joint pain to a nurse who is assessing the client's pain in a clinic. Which of the following questions related to pain assessment should the nurse ask the client?
"Does your pain level change after taking medications?"
A nursing instructor is teaching students how to assess a patient'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:
"Nurses are the best authority on pain."
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:
"Pain is a natural part of aging." Pain is prevalent in older adults; however, some of them mistakenly believe pain to be a normal part of aging. Older patients may be afraid to report pain for many different reasons. They may not want pain to interfere with their independence. They may worry that medical attention to their pain will lead to costly tests. They also may fear that healthcare providers will not see them as "good" patients if they mention pain, and so they try to mask it.
The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level?
1630 Pain should be assessed every 4 hours; reassessments after interventions should be done in 30 minutes after intervention.
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?
1630. The JCAHO has set a standard that states that nurses must assess and reassess pain regularly. Most hospitals have a standard timeframe for reassessment, such as 1 hour for oral medication and 30 minutes for pain medication given intravenously. They base these timeframes on the time it takes a pain medication to provide a noticeable decrease in pain intensity.
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
The patient arrives to the emergency room reporting severe abdominal pain that started 3 hours ago. He rates the pain as an 8 on a scale of 1 to 10. After tests are performed, the patient is diagnosed with appendicitis. This is an example of which of the following types of pain?
Acute
A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?
Acute Acute pain results from tissue damage, whether through injury or surgery. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Phantom pain is pain in an extremity or body part that is no longer there. Cutaneous pain and phantom pain are not described as above. Chronic pain, also known as persistent pain, is a description of a pain that is present for more than six months, and can be described in many different terms, not just as above.
A pathophysiology instructor is discussing pain and its treatment across cultures. The instructor points out that patients from racial and ethnic minorities often receive less pain medication compared to Caucasians for what specific conditions?
Acute pain in the ED
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?
Acute pain related to sore throat The client describes pain of 2 days' duration, which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, or sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for deficient fluid volume.
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. 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.
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
The nurse should clarify which medication order prescribed for a client with chronic back pain?
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.
How may a nurse demonstrate cultural competence when responding to patients in pain?
Avoid stereotyping responses to pain by patients.
The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?
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.
A male client with a history of a back injury 2 months ago has been taking daily doses of narcotic pain medication. He is currently hospitalized with a leg fracture after falling down the stairs. He complains of 10/10 pain in his back and leg after taking pain medication one hour ago. What is the nurse's best action?
Consult with the healthcare provider about increasing the dose of medication. Clients with a history of opioid tolerance pose diffi cult challenges for pain assessment (D'Arcy, 2014). They have an altered physiologic response to the pain stimulus, and the repeated use of opioids causes their bodies to become more sensitive to pain. This sensitivity is called opioid hyperalgesia and can occur as soon as 1 month after opioid use begins. Not only are clients with opioid tolerance more sensitive to pain, they face a high level of bias from health care providers. Because these clients are more sensitive to pain, they often report high levels of pain with little relief from usual doses of opioids. They are often labeled as drug seeking.
Which of the following is not released during the stress response?
Dopamine The stress response causes the release of epinephrine, norepinephrine, and cortisol.
A nurse is caring for a 4-year-old patient who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the patient to point to the one that best represents the pain he is experiencing. This is an example of which of the following:
FACES scale
The nurse is caring for a 4-week-old postoperative patient. The most appropriate pain assessment tool would be the:
Face, Legs, Activity, Cry, Consolability Scale The Face, Legs, Activity, Cry, Consolability Scale is the appropriate pain assessment tool for a 4-week-old postoperative patient. This tool measures pain using observable behaviors as pain indicators. The FACES Pain Scale is appropriate for children age 3 and older, using six faces ranging from happy with a wide smile to sad with tears on the face. The other two scales are appropriate for use with older children and adults. 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 nursing student asks the nurse what would be an example of visceral pain. What would be the correct response by the nurse?
Gallbladder pain
Which would the nurse recognize as an example of visceral pain? Select all that apply.
Gallbladder pain Pancreatic pain Liver pain
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
A client complains of pain in several areas of the body. How should the nurse assess this client's pain?
Have the client rate each location separately.
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. 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 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?
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 patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain?
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.
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:
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.
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.
A nurse is working with an elderly Jewish man who is experiencing excruciating pain from a severe burn that he suffered earlier in the day. Given his cultural background, which expression of pain should the nurse most expect to find in this client?
Pain is expressed openly, with much complaining
Which of the following cultural expressions of pain would be likely to be found in a person of Hispanic culture?
Pain must be endured to perform gender role duties, but response to it is very expressive. In the Hispanic culture pain response is often very expressive, though pain must be endured to perform gender role duties.
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. 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.
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 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 who recently had his lower leg amputated due to a complication associated with diabetes complains of feeling pain in the area of the foot that was amputated. The nurse recognizes this pain as which of the following?
Phantom Phantom pain can be perceived in nerves left by a missing, amputated, or paralyzed body part. Radiating pain is perceived both at the source and extending to other tissues, and referred pain is perceived in body areas away from the pain source. Deep somatic pain is felt in the ligaments, tendons, bones, blood vessels, or nerves.
The nurse is assessing hospitalized post-operative pain and has asked the client to rate his pain, describe it, state the location and onset of when it started. What other question should the nurse include in this pain assessment?
Provoking and alleviating factors The nurse is conducting a focused pain assessment of a hospitalized client. Some burses prefer to use mnemonics to remember the elements of pain assessment. One of these is OPQRST : O: Onset P: Provocative or palliative Q: Quality R: Region and radiation S: Severity T: Timing The availiability of medication, past medications, and client's financial resources are not the most pertinent questions to include at this time.
The patient 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 patient is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?
Referred pain
Which assessment finding is consistent with the presence of pain?
Restlessness Common assessment findings that are present when a patient is in pain include restlessness, grimacing, crying, clenching fists, guarding of the painful area, increased blood pressure and pulse, and reported pain.
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?
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.
A patient recovering from abdominal surgery is complaining of pain. The nurse realizes that the patient is most likely experiencing which type of pain?
Somatic
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 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. Reference:
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?
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.
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.
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?
Spiritual dimension
Who is the authority on the presence and extent of pain experienced by a patient?
The patient
The element of pain transmission that causes nociceptors to perceive a nerve impulse is what?
Transduction
A nurse is caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client
Transduction The client is going through the transduction phase, which is the first phase of pain in which injured cells release chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. The client is not going through the transmission, perception, or modulation phase of pain. Transmission is the phase during which stimuli move from the peripheral nervous system toward the brain. Perception occurs when the pain threshold is reached. Modulation is the last phase of pain impulse transmission, during which the brain interacts with the spinal nerves to alter the pain experience.
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?
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 patient has a severe abdominal injury with damage to the liver and colon from a motorcycle crash. What type of pain will predominate?
Visceral pain
A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client experiencing?
Visceral pain The client is experiencing visceral pain, which is associated with disease or injury. It is sometimes referred or poorly localized as it is not experienced in the exact site where an organ is located. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.
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 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.
A nurse assesses a non-English-speaking 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?
Wong-Baker Faces
When assessing the client for pain, the nurse should
believe the client when he or she claims to be in pain "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain.
After assessing a client in pain, the nurse
documents the exact description given by the client. Validate the pain assessment data you have collected with the client. It is also useful to validate the findings with other caregivers and family members, especially if the client is reluctant to express pain. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.
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?
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.
