Week 3 pain
Which patients would the nurse offer to massage the leg? Select all that apply. Has a hurting leg with a fracture Has an aching leg with a blood clot Has a leg with muscle spasms Has a strained leg with tightness Has a sore leg with muscle tension
Has a hurting leg with a fractureMassage therapy can cause further injury and displace fractures, as well as cause excruciating pain to the patient. Fractured extremities should not be massaged. Has an aching leg with a blood clotMassage is contraindicated (avoided) in a patient with a blood clot in the leg because massage can dislodge the clot, making the situation worse. **Has a leg with muscle spasmsThe nurse would massage this patient's leg because massage aids in relieving muscle spasms by improving circulation and reducing muscle tension. **Has a strained leg with tightnessThe nurse would massage this patient's leg because massage increases flexibility and reduces tension. **Has a sore leg with muscle tensionThe nurse would massage this patient's leg because massage aids in relieving aches by improving circulation and reducing muscle tension.
Which response would the nurse make to a patient who says, "I can't go to sleep"? "I will bring you a sleeping pill." "Is something bothering you or are you hurting?" "I will get your pain medicine." "What do you want me to do to help you sleep?"
"I will bring you a sleeping pill."The nurse needs more facts before making this decision. **"Is something bothering you or are you hurting?"If patients state that they are having a hard time sleeping, the nurse would ask them to explain more. Sometimes the patient can't sleep because of pain, which would require a pain medication rather than sleeping medication. "I will get your pain medicine."The nurse needs to gather more information from the patient before making this decision. "What do you want me to do to help you sleep?"Although the nurse can ask for the patient's input about how to address the sleep issue, it is the nurse's responsibility to provide care, not the patient's. This could also be perceived as uncaring and/or aggressive.
Which principles would the nurse recall about pain signaling when caring for a patient with pain from stepping on a nail? Select all that apply. A nail pricking a foot is changed into an electrical impulse in transduction. Trying to pull the foot away from the nail occurs during transmission. The patient first translates the pain during modulation. When the patient's brain sends inhibitory messages to the spinal cord, this is perception. Release of endogenous opioids causes the pain to decrease.
**A nail pricking a foot is changed into an electrical impulse in transduction.Transduction is changing the painful stimulus (nail pricking foot) into an electrical impulse. **Trying to pull the foot away from the nail occurs during transmission.During transmission, a healthy motor reflex will try to protect the body (pull the foot away from nail). The patient first translates the pain during modulation.When the patient first translates the pain, this is perception, not modulation. When the patient's brain sends inhibitory messages to the spinal cord, this is perception.When the patient's brain sends inhibitory messages to the spinal cord, this is modulation, not perception. **Release of endogenous opioids causes the pain to decrease.During modulation, release of endogenous opioids (natural pain killers) will cause the pain to decrease.
Which hypothesis would the nurse select for a postoperative patient who has increasing abdominal pain, a blood pressure of 142/92, and pulse of 110? Acute Pain Chronic Pain Reduced Pain Arthritis Pain
**Acute PainIncreasing abdominal pain postoperatively, elevated blood pressure, and pulse rate indicate Acute Pain. Chronic PainThe patient has an identifiable cause of the pain (postoperative); Chronic Pain may or may not have an identifiable cause and the pain is continuous or intermittent, lasting for at least 3 to 6 months. The patient's pain has not lasted that long. Reduced PainSince the patient has increasing abdominal pain, Reduced Pain is not the hypothesis for this patient. Arthritis PainArthritis Pain is a type of chronic pain, and the patient's cues do not support a hypothesis of Arthritis Pain.
Which factors would decrease an anxious patient's pain when fatigue is present and the patient's partner rubs the painful area and talks about events happening at home? Select all that apply. Emotional support Distraction Anxiety Fatigue Rubbing the painful area
**Emotional supportEmotional support from the patient's partner being present will decrease the pain. **DistractionDistraction by the partner talking about events happening at home will decrease the pain. Anxiety will increase the pain, not decrease it. Fatigue will increase the pain, not decrease it. **Rubbing the painful areaRubbing the painful area (massage) will decrease the pain.
Which prescribed medications would the nurse administer to a patient whose pain level is 3/10? Select all that apply. Ibuprofen Naproxen Acetaminophen Morphine Oxycodone
**IbuprofenThe nurse would administer ibuprofen. Ibuprofen, a nonopioid, nonsteroidal antiinflammatory drug, is given for mild (1 to 3) to moderate pain (4 to 7). **NaproxenThe nurse would administer naproxen. Naproxen, a nonopioid, nonsteroidal antiinflammatory drug, is given for mild (1 to 3) to moderate pain (4 to 7). **AcetaminophenThe nurse would administer acetaminophen. Acetaminophen, a nonopioid, is given for mild (1 to 3) to moderate pain (4 to 7). Morphine is an opioid and is given for moderate to severe pain, not 3/10. Oxycodone is an opioid and is given for moderate to severe pain, not 3/10.
Which cues would a nurse closely monitor to determine a patient's pain level who is intubated and can have nothing by mouth? Select all that apply. Pulse Blood pressure Eating habits Temperature Restlessness
**PulseA nonverbal patient's pain measurement can be determined by closely monitoring a patient's pulse because it will increase. **Blood pressureA nonverbal patient's pain measurement can be determined by closely monitoring a patient's blood pressure because it will increase. Eating habitsA patient who is intubated does not eat food because the patient can have nothing by mouth. TemperatureA patient's temperature may or may not rise with pain and would not be monitored closely to indicate pain. **RestlessnessA nonverbal patient's pain measurement can be determined by closely monitoring a patient's restlessness because it will increase.
Which nonpharmacologic interventions would the nurse utilize to alleviate a patient's immediate postoperative pain? Select all that apply. Restrict visitors. Close the door. Provide a quiet, dimly lit environment. Encourage the patient to ambulate through the halls. Increase the amount of stimulation the patient is exposed to. Administer prescribed morphine.
**Restrict visitors.Restricting visitors lowers the amount of stimulation a patient is exposed to and may help provide pain relief. **Close the door.Lowering noise by closing the patient's door will help decrease further stimulation and decrease pain. **Provide a quiet, dimly lit environment.Providing a quiet, dimly lit environment for the patient provides nonpharmacologic pain relief to the patient; it reduces further stimulation. Encourage the patient to ambulate through the halls.Encouraging the patient to get out of bed immediately postoperative and ambulate through the halls will increase stimulation and expose the patient to increased light and noise, thus increasing the patient's pain, and the walking itself may increase the pain immediately postoperative. Increase the amount of stimulation the patient is exposed to.Increasing the amount of stimulation and noise that a patient is exposed to will only increase stress and anxiety and promote discomfort. Administer prescribed morphine.Although morphine is administered for pain, it is a pharmacologic intervention, not nonpharmacologic.
Which findings would alert the nurse the patient with an acute pain rating of 7/10 is declining? Select all that apply. States the pain is severe. States the pain is moderate. Pulse increases. Blood pressure decreases. States pain is 7/10.
**States the pain is severe.A patient with a 7/10 (moderate) who states the pain is severe indicates the patient is declining because the pain is increasing. States the pain is moderate.A patient with a 7/10 (moderate) who states the pain is moderate indicates the patient is unchanged or improving if the pain level is a 4, 5, or 6 (all moderate ratings). **Pulse increases.With acute pain, if the pulse increases, the patient is declining because the sympathetic nervous system is being stimulated from an increase in pain. Blood pressure decreases.A decrease in blood pressure would indicate the patient is improving, not declining. States pain is 7/10.Stating that the pain is 7/10 indicates the patient is unchanged, not declining.
Which information to help decrease the pain would the nurse share with a postoperative abdominal patient who states that it is hard to move because the incision hurts? Teach the patient about splinting. Teach the patient about guarding. Teach the patient about transmission. Teach the patient about differences in acute and chronic pain.
**Teach the patient about splinting.Splinting (supporting the painful area with a pillow or blanket) will help decrease the pain when moving. Teach the patient about guarding.Guarding (a cue that indicates the patient is hurting by protecting the area) would not decrease the pain but would alert the nurse the patient is hurting. Teach the patient about transmission.Although transmission is important in pain signaling, it will not help decrease the pain when the patient is moving. Teach the patient about differences in acute and chronic pain.Although differences do exist between acute and chronic pain, this will not help decrease the pain when moving.
Which question would be the most important for the nurse to ask when a postoperative patient says, "I'm hurting"? Where is your pain? When did the pain start? Is it constant or intermittent? Could you rate it on a scale of 1 to 10?
**Where is your pain?If the patient has had surgery, the nurse would not automatically assume the pain is around the incision. The nurse would follow up with "Where are you hurting?" because the patient may be having a headache and not incisional pain. When did the pain start?Although this question is appropriate, it is not the most important because it does not let the nurse know where the pain is occurring. Is it constant or intermittent?Although this question is appropriate, it does not inform the nurse of the location of the pain. Could you rate it on a scale of 1 to 10?Location is more important than severity when the patient tells the nurse pain is occurring.
Match the process to its function for signaling pain. 1-Impulse crosses over in the spinal cord. 2-Inhibitory messages from the brain are sent to the spinal cord. 3-Painful stimulus is changed into an electrical impulse. 4-Impulse signal is received by the cortex. A-Transduction B-Modulation C-Transmission D-Perception
1-C 2-B 3-A 4-D
Match the intervention to its mechanism of action for managing pain. 1-Relieves pressure 2-Applies pressure to pressure points 3-Creates a diversion from pain 4-Blocks pain pathways A-Distraction B-Medication C-Positioning D-Massage
1-C 2-D 3-A 4-B
Which patient would the nurse assess first? A patient with arthritis reporting joint pain A patient with an open airway A patient with a pain rating of 3/10 A recent head injury patient who is reporting head pain
A patient with arthritis reporting joint painA patient with arthritis reporting joint pain is a chronic situation and there is an acute situation that would be assessed first. A patient with an open airwayA patient with an open airway is expected and does not need to be assessed first. A patient with a pain rating of 3/10A patient with a pain rating of 3/10 is an expected finding and would not be assessed first. **A recent head injury patient who is reporting head painA recent head injury with head pain would be assessed first because it is an acute situation. An acute situation is addressed before chronic situations.
Which action would the nurse likely take for a patient with a hip fracture who has advanced dementia, does not answer appropriately, and is disoriented? Ask the patient if the hip hurts. Encourage the patient to rate pain on a scale of 0 to 10. Tell the patient to point to the face on the Wong-Baker FACES scale that best describes the pain. Closely monitor the patient's vital signs, as well as level of agitation, irritation, and restlessness.
Ask the patient if the hip hurts.The patient is disoriented with advanced dementia and would not likely be able to accurately report if the hip hurts. Encourage the patient to rate pain on a scale of 0 to 10.The patient is disoriented with advanced dementia and would not likely be able to accurately rate pain on a scale of 0 to 10. Tell the patient to point to the face on the Wong-Baker FACES scale that best describes the pain.The patient is disoriented with advanced dementia and typically does not answer appropriately, so the patient would not likely be able to point to the face on the Wong-Baker FACES scale that best describes the pain. **Closely monitor the patient's vital signs, as well as level of agitation, irritation, and restlessness.Closely monitoring the patient's vital signs, such as heart rate, respiration, and pulse, as well as behaviors, such as the level of agitation, irritation, and restlessness, would be the most appropriate way to assess the pain for this patient because the patient has advanced dementia.
Which classification would the nurse document the patient is experiencing when reporting the pain at a 7/10? Mild Moderate Severe Maximal
Mild pain is 1 to 3, not a 7. **Moderate pain is ranked as 4 to 7. Severe pain is 8 to 10, not 7. MaximalThere is no ranking of maximal pain.
Which expected outcome would the nurse develop for a patient suffering with acute pain? Patient will report a pain level less than the previous rating. Patient will ambulate up to 2 feet after surgery without pain. Patient will report a pain level of less than 3/10 within 45 minutes of receiving pain medication. Patient will meet with the health care provider to outline a plan for adjusting pain medication dosages within the next 3 days.
Patient will report a pain level less than the previous rating.This is not an appropriate patient expected outcome because there is no time period associated with this outcome. Patient will ambulate up to 2 feet after surgery without pain.This is not an appropriate (2 feet) or realistic (without pain) patient outcome for a patient suffering from pain. **Patient will report a pain level of less than 3/10 within 45 minutes of receiving pain medication.This is an appropriate patient outcome because it provides reasonable outcome criteria within a reasonable amount of time. Patient will meet with the health care provider to outline a plan for adjusting pain medication dosages within the next 3 days.This is not a reasonable or appropriate time period for this outcome because the patient requires immediate help with pain relief, not within the next 3 days.
Which pain assessment tool would the nurse use when assessing a young school-age patient who has a broken arm after falling off the jungle gym? Verbal Descriptor Wong-Baker FACES Activity Tolerance Scale Neonatal Infant Pain Scale
Verbal DescriptorA pediatric patient (young school-aged) may not have the ability to properly explain pain levels. The Verbal Descriptor relies on the patient's self-report as the most reliable indicator of the existence and intensity of pain, so this is not the most appropriate pain assessment tool to use. **Wong-Baker FACESThe popular pediatric FACES scale was originally created to help young children describe their pain. This is the most appropriate pain assessment tool for a pediatric patient. Activity Tolerance ScaleThe Activity Tolerance Scale helps the patient describe systematically the effect of pain on activity level. This is not the most appropriate pain assessment tool for assessing the pain of a young school-age patient. Neonatal Infant Pain ScaleThe patient is school-aged, not a neonate.
Which question would the nurse ask to determine the severity of the patient's back pain? Where do you hurt? Can you describe the type of pain you are having? Is the pain sharp, burning, or stabbing? On a scale of 0 to 10 with 10 being the worst pain in your life, how would you rate the pain?
Where do you hurt?This question determines location, not severity. Can you describe the type of pain you are having?This question determines character, not severity. Is the pain sharp, burning, or stabbing?This question determines character, not severity. **On a scale of 0 to 10 with 10 being the worst pain in your life, how would you rate the pain?This question determines severity by asking the patient to rank the pain.
