Deck 8: Pain Assessment

Question 1

A 45-year-old client continues to request intravenous pain medications 4 days after being placed in skeletal traction due to a complex fracture of the hip.While giving report to the next shift,the nurse who cared for the client during the day states,"I just do not know why he still needs medication 4 days after surgery.The client we had last month with the same type situation did not need any medication after 2 days." Which of the following responses by a nursing peer is the best example of being a client advocate?
1)"I just think this client needs more because of his age."
2)"Have you tried getting the doctor to order oral pain medications to see if they work?"
3)"Wouldn't you want all of the pain medication you could have if you were in traction?"
4)"Everyone does not have the same pain perception or response to a similar injury."

Answer 1

4

Question 2

The nurse is assessing a postoperative client that reports a pain level of 10 on a 1 to 10 scale.The client is grimacing and appears anxious.Which of the following actions should the nurse perform first?
1)Administer pain medication if it has been longer than the ordered interval.
2)Offer to call the pastoral service to provide spiritual counseling.
3)Obtain an order for an anti-anxiety medication.
4)Call the family to come in and stay with the client.

Answer 2

1

Question 3

The nurse is caring for a 3-year-old child who has been hospitalized for internal fixation of a fractured arm.The nurse is considering nonpharmacological pain management techniques to implement.What interventions should be included in the plan of care?
1)Offer a glucose-coated pacifier.
2)Sit with the child and allow her to "blow bubbles."
3)Explain to the child the cause of the pain.
4)Teach the use of guided imagery.
5)Hold the child.

Answer 3

2,5

Question 4

The nurse is working at pain clinic and is preparing an orientation for new staff nurses.Which of the following definitions of pain would the nurse correctly choose to include in this orientation? Pain is:
1)Validated by the nurse determining the cause of the pain.
2)Unpleasant sensations,typically experienced upon movement.
3)Whatever the experiencing person says it is.
4)Very subjective so observations must be used to assess levels and intensity.

Question 5

The nurse is assessing a client admitted with chronic back pain.Which of the following would the nurse associate with this type of pain?
1)Sudden onset
2)Interferes with daily activities
3)Lower intensity
4)Prolonged in duration
5)Sharp elevations in body temperature

Question 6

A client has multiple fractures following a motor vehicle accident.One of the client outcomes of the nurse's plan of care includes reducing the perception of pain.Which of the following nursing interventions would apply to reaching this outcome?
1)Offering a selection of musical CDs
2)Assisting with guided imagery
3)Administering Demerol (Meperidine)intravenously
4)Providing instruction on deep breathing techniques
5)Administering an anti-inflammatory medication

Question 7

The nurse understands amount of pain stimulation that is needed for an individual to feel pain is referred to as:
1)Pain threshold.
2)Pain tolerance.
3)Somatic interval.
4)Cephalgia reporting.

Question 8

The nurse is caring for two clients who both are in pain due to sickle cell anemia.One of the clients rates his pain as a 7 out of 10 (1 is no pain and 10 is the worst pain possible).This client is moving around easily and is eating well,but has asked for pain medicine.The nurse would choose which of the following actions?
1)Wait 30 minutes and see if the client is still requesting the pain medicine.
2)Administer half the ordered does of pain medication.
3)Administer the pain medication if it is has been longer than the ordered interval.
4)Notify the healthcare provider that the client is faking his pain.

Question 9

The nurse is caring for two clients involved in a motor vehicle accident.Both clients required explorative abdominal surgery.Neither has received any pain medication in six hours and both have asked.However,one client is in greater distress than the other.Which pain theory is useful in explaining this phenomenon? The theory of:
1)Pattern.
2)Specificity.
3)Stress.
4)Gate control.

Question 10

The nurse is assessing a client admitted with severe abdominal pain.Which of the following would the nurse include as essential components of the pain assessment?
1)Description of the pain
2)Temperature,pulse,respirations,and blood pressure
3)Pain intensity rating
4)Family medical history
5)Previous pain experience

Question 11

The client is in the triage area of the Emergency Department when a client arrives complaining of chest and arm pain.The client also reports jaw pain,but states that the chest pain hurts more.The nurse observes the client rubbing his left arm.The nurse suspects what type of pain?
1)Phantom pain
2)Radiating pain
3)Intractable pain
4)Cutaneous pain

Question 12

The nurse is caring for a teenager and is assessing pain level with the vital signs.The client is reporting pain but when the nurse asks for a description of the pain the client says,"It just hurts.Why can't I have something?" The nurse would choose to do which of the following next?
1)Leave the room and come back later.
2)Provide questions that require yes or no answers related to pain.
3)Ask the client what they would like to have for pain.
4)Continue with the vital signs assessment.

Question 13

A recently licensed nurse states,"My client keeps saying he is in pain.I don't believe him because I had the same surgery last year and didn't feel nearly as bad as he claims." What response by the more experienced nurse is most appropriate?
1)"It sounds as if your client is a drug seeker."
2)"You should contact the healthcare provider."
3)"I would call the nursing supervisor for this one."
4)"Pain differs from person to person."

Question 14

The nurse is caring for a client who denies having pain.The nurse has noticed the client grimacing and clenching his teeth when moving.The client's spouse has asked the nurse why some people deny obvious pain.What response by the nurse is most appropriate?
1)"You should try to find out why your husband is denying the pain."
2)"Have you talked to the healthcare provider about this?"
3)"Some people feel reporting their pain is a sign of weakness."
4)"Maybe we are wrong and pain is not really bad."

Question 15

The nurse is performing an assessment on a 23-year-old client who is being seen for chronic back pain.During the assessment,which of the following findings can be anticipated?
1)Increased pulse rate
2)Increased respiratory rate
3)Normal pulse rate
4)Normal blood pressure
5)Diaphoresis

Question 16

A nurse working in a healthcare provider's office is interviewing a client that reports experiencing daily migraines.The nurse decides to further assess the impact of the client's pain.An appropriate choice of assessment tools would be which of the following?
1)Psychologic well-being inventory
2)Body Diagram tool
3)Intensity rating scale
4)Brief Pain Inventory

Question 17

The parents of a 13-month-old infant requiring a veinipuncture for laboratory studies ask the nurse what they can do to help with pain during the procedure.Which of the following would be the best action for the nurse to take?
1)Have the parents leave the area during the procedure.
2)Tell the parents to touch and reassure the infant during the procedure.
3)Wait until the infant is asleep to do the procedure.
4)Administer an analgesic 30 minutes before the procedure.

Question 18

The nurse is examining a client is in the Emergency Department.The client has recently been discharged after a right above-the-knee amputation.The client tells the nurse that her right foot hurts.The nurse suspects what type of pain?
1)Phantom pain
2)Radiating pain
3)Intractable pain
4)Cutaneous pain

Question 19

The nurse is caring for a client complaining of a backache and administers ibuprofen.The client asks the nurse how the medication will help the pain.The nurse understands that ibuprofen's effect occurs during which phase of nocioception?
1)Transduction
2)Transmission
3)Perception
4)Modulation

Question 20

A nursing student is reviewing the home medications of a client who has just been admitted with chronic back pain.When asked by the nursing instructor why there is a tricyclic antidepressant on the client's list,which response by the student is most likely the accurate reason?
1)"I would think having chronic pain would make the client depressed."
2)"It may be to prevent depression due to physical limitations."
3)"This type of medication can help inhibit painful stimuli."
4)"The client is at risk for suicidal thoughts related to the chronic pain."

Question 21

A client with a history of cardiac problems is brought to the emergency room by the paramedics with a tentative diagnosis of myocardial infarction (MI,or "heart attack").The paramedic tells the nurse that the client had pain in the jaw area that was not relieved with nitroglycerin.The client asks the nurse how jaw pain is related to having a "heart attack." The nurse's best explanation is:
1)"The doctors would rather treat you as a cardiac client until they find out why the nitroglycerin did not work."
2)"Sometimes cardiac pain is not just in your chest,but in your jaws,arms or back."
3)"You may have been so stressed that you clenched your jaws and not realized if you had any chest pain or not."
4)"It may not be related,but cardiac pain is so serious to investigate and treat."

Question 22

The nurse is preparing to complete the admission assessment for a client who is being admitted to the acute care facility for complaints of severe pain.As the nurse plans actions relating to this task,the following steps will be taken.Organize in order the actions that should be taken by the nurse.
1)Contact the healthcare provider. Choice
2)Discuss the unit routine with the client and family. Choice
3)Ask the client when the pain first began. Choice
4)Ask the client what helps to relieve the pain. Choice
5)Assess the client's past coping methods for pain throughout her life.

Question 23

The nurse is interviewing a 75-year-old client who is in the healthcare provider's office for complaints of joint pain.The client verbalizes that the pain has been present for a few years.When planning interview questions to ask concerning the pain,the nurse recognizes which of the following?
1)Clients start to complain of many types of pain as they age.
2)The joint pain is probably not the real reason the client is in the office.
3)The client is most likely depressed.
4)Older adults frequently avoid seeking treatment for their pain.

Question 24

The nurse has completed a shift assessment on a client who has terminal breast cancer with extensive metastasis.The client tells the nurse,"Nothing helps the pain." What best describes the pain being experienced by the client?
1)The client is experiencing referred pain.
2)The client is experiencing intractable pain.
3)The client is experiencing retractable pain.
4)The client is experiencing radiating pain.

Question 25

A nurse is orienting to a new position in an infant nursery.When the healthcare provider is preparing to perform a circumcision on a 2-day-old newborn who was born 2 weeks early,the nurse asks about the administration of pain medication prior to the procedure.The healthcare provider states: "Newborns do not have pain at this age,so why should we give any medication?" The nurse's best response would be:
1)"I would think it would make the parents feel better to know it had been given."
2)"I am going to have to report you to the ethics board."
3)"Pain transmission has been documented in infants of this age."
4)"What will it hurt to just go ahead and give it?"

Question 26

The nursing student is discussing an assigned client's pain responses with the nursing instructor.The student reports feeling amazed about how the client has continued to avoid taking any analgesics only hours after surgery.What response by the nursing instructor is indicated?
1)"Sometimes clients just don't need any analgesics."
2)"Have you seen any nonverbal cues that might indicate the client is experiencing pain?"
3)"We will need to contact the healthcare provider to report the client's continued refusal of analgesics."
4)"Do the client's vital signs indicate the client is experiencing pain?"

Question 27

Which of the following assessment data will be most reflective of a client's pain response following open-heart surgery?
1)Family report of pain
2)Response from the client based on use of a pain tool
3)Observations of the client's behaviors while asleep
4)Measurement of vital signs

Question 28

A 19-year-old Arab male is in the hospital for a ruptured appendix.His parents are at the bedside the majority of his waking hours.The nurse caring for him during the day observes that he denies any pain during the day shift.The night nurse reported that the client had requested pain medication every 4 hours during the night.The nurse considers the most probable explanation for this to be:
1)The night nurse had more time to spend with the client.
2)The client must be afraid or lonely at night and is trying to get attention.
3)The client may not report pain in the presence of his parents based on their influence or cultural beliefs.
4)The client was asking for medication at night to help him sleep.

Question 29

A 12-year-old client is brought to the emergency room after falling on his arm during a football game.When the nurse tells the client that she is going to administer pain medication through the intravenous line,the client begins to scream and wave his unhurt arm.The parents ask the nurse why their child is behaving this way.The nurse's best response would be:
1)"He is just immature for his age."
2)"I am sure he is just scared."
3)"It looks like he may have hurt his head during the fall."
4)"He may be remembering another time when he got a shot."

Question 30

The nurse is performing a physical assessment on a client with undiagnosed back pain.The client is unable to communicate verbally.Which of the following vital sign values would indicate to the nurse that the client is in acute pain?
1)Temperature of 100.6 degrees:
2)Pulse rate 94
3)Respiratory rate 32
4)Blood pressure 158/92
5)Facial grimacing