Question 1

A young adult male client of Arab descent is admitted to the medical-surgical unit for a ruptured appendix. The client's parents are at the bedside for most of the day. The nurse who is providing care notes that the client denies pain while on day shift, but request medication every four hours during the night. Which explanation for this client behavior is the most probable?

Accepted Answer

The client may not report pain in the presence of parents based on their influence or cultural beliefs. This is a common behavior in some cultures where children are encouraged to endure pain and pain expression is seen as a sign of weakness. The parents may also play a role in discouraging pain expression as a sign of strength and endurance. Therefore, the client may feel more comfortable asking for pain medication when alone or with a nurse who is not perceived as a parental figure.

Question 2

The nurse conducts a pain assessment on a client who has terminal breast cancer with extensive metastasis. The client tells the nurse, "Nothing helps the pain." Which documentation regarding this client's pain is the most appropriate?

Accepted Answer

Intractable pain refers to pain that cannot be controlled or relieved by medication or treatment. This is an appropriate documentation for the client with terminal breast cancer with extensive metastasis who reports that nothing helps the pain. The other options are not appropriate as they do not accurately describe the type or nature of the client's pain.

Question 3

The nurse is talking to the spouse of a client who is not requiring pain medication a few hours after surgery. The spouse states that she is amazed that her husband is able to endure such pain without medication. Which response by the nurse is the most appropriate in this situation?

Accepted Answer

It is important to assess for nonverbal cues of pain, even if the client is not verbalizing their pain. This will help the nurse determine if the client truly does not require pain medication or if they may need further assessment and treatment. Option A could be interpreted as dismissive, option C is not appropriate as the client has a right to refuse treatment, and option D only addresses physiological indicators of pain, not nonverbal cues.

Question 4

A newborn nursery nurse is caring for a newborn who will be circumcised and asks the health care provider to prescribe a pain medication. The healthcare provider states: "Newborns do not have pain at this age, so why should we give any medication?" Which response by the nurse is the most appropriate?

Accepted Answer

Pain transmission has been documented in all age groups, including newborns. It is important to provide pain relief to newborns, including during circumcisions, to promote their comfort and well-being. The nurse should educate the healthcare provider about the importance of pain management in newborns and advocate for the use of appropriate pain medication. It is not appropriate to make false statements or threaten to report the healthcare provider without first attempting to educate and collaborate with them.

Question 5

A school-age client is brought to the emergency department after an arm injury during a football game. When the nurse tells the client that pain medication will be administered through the intravenous line the client begins to scream and wave the unaffected arm. The client's parents ask the nurse why their child is behaving this way. Which response by the nurse is the most appropriate?

Accepted Answer

The client's reaction to the suggestion of receiving medication through an intravenous line suggests that the child may have had a previous painful injection or procedure. Acknowledging this possibility and addressing it can help alleviate the child's fear and distress. Option A ("Your child is just immature") and option B ("Your child is just scared") do not provide an explanation for the child's behavior and may come across as dismissive. Option C ("It looks like your child may have experienced a head injury as well") is an unfounded assumption that is not supported by the information provided in the scenario.

Question 6

The nurse is preparing to complete the admission assessment for a client who is being admitted for pain management due to severe pain. The nurse is preparing to plan care for this client. Organize the nursing actions in the order in which they should occur. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.
Response
A) Contact the healthcare provider. Response
B) Discuss the unit routine with the client and family. Response
C) Ask the client when the pain first began. Response
D) Ask the client what helps to relieve the pain. Response
E) Assess the client's past coping methods for pain throughout her life.

Accepted Answer

The answer of The nurse is preparing to complete the...

Question 7

The nurse is assessing a client who is recovering from open-heart surgery. Which assessment data is most reflective of a client's pain response?

Accepted Answer

The most reliable indicator of a client's pain response is their self-report using a pain tool. Family report of pain may not accurately reflect the client's pain experience, while observations while asleep or vital signs may not be specific to pain and may also be influenced by other factors.

Question 8

The nurse is interviewing an older adult client who is complaining of joint pain. The client verbalizes that the pain has been present for a few years. Prior to continuing the client interview, which should the nurse recognize?

Accepted Answer

Research shows that older adults often avoid seeking treatment for their chronic pain conditions, which can lead to exacerbation of symptoms and decreased quality of life. Therefore, it is important for the nurse to validate the client's concerns and encourage them to seek appropriate medical attention for their joint pain.

Question 9

A client with a history of cardiac issues is admitted to the emergency department with suspected myocardial infarction (MI, or "heart attack"). The client's spouse tells the nurse that the client had pain in the jaw area that was not relieved with nitroglycerin. The client's spouse asks the nurse how jaw pain is related to having a "heart attack." Which explanation by the nurse is the most appropriate?

Accepted Answer

Sometimes when a person is experiencing cardiac pain, it may also manifest in other areas such as the jaw, arms, or back. It is important to consider all possible symptoms and investigate accordingly.

Quiz 11: Pain Assessment

The nurse conducts a pain assessment on a client who has terminal breast cancer with extensive metastasis. The client tells the nurse, "Nothing helps the pain." Which documentation regarding this client's pain is the most appropriate?

The nurse is talking to the spouse of a client who is not requiring pain medication a few hours after surgery. The spouse states that she is amazed that her husband is able to endure such pain without medication. Which response by the nurse is the most appropriate in this situation?

The nurse is assessing a client who is recovering from open-heart surgery. Which assessment data is most reflective of a client's pain response?

The nurse is interviewing an older adult client who is complaining of joint pain. The client verbalizes that the pain has been present for a few years. Prior to continuing the client interview, which should the nurse recognize?