Question 1

Which term describes the amount of pain stimulation that is needed for an individual to feel pain?

Accepted Answer

Pain threshold refers to the amount of painful stimulation required for an individual to feel pain. It is the point at which a sensation is experienced as painful.

Question 2

The nurse 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 which type of pain?

Accepted Answer

The symptoms presented by the client suggest radiating pain, which is felt in an area away from the actual site of injury or problem, in this case, the chest pain is radiating to the arm and jaw.

Question 3

The spouse of a client who is being treated for chronic pain asks the nurse why an antidepressant has been prescribed and states, "My husband is not depressed." Which response by the nurse is the most appropriate?

Accepted Answer

Antidepressants can be used in the management of chronic pain because they help modulate pain pathways and inhibit the perception of pain, which is not solely related to their effects on mood.

Question 4

The parents of a young toddler who requires a venipuncture for laboratory studies ask the nurse what they can do to help with pain during the procedure. Which response by the nurse is the most appropriate?

Accepted Answer

Having the parents touch and reassure the toddler during the procedure will provide comfort and distraction, which can help to reduce the perception of pain. Parental presence has been shown to decrease fear and anxiety in children undergoing painful procedures. The other options are not the best choices. Having the parents leave the area may increase the toddler's anxiety and make the procedure more difficult. Waiting until the toddler is asleep may not be practical, and administering an analgesic 30 minutes before the procedure may not be safe or effective for a toddler.

Question 5

The nurse is performing an assessment on a young adult client who is experiencing chronic back pain. During the assessment, which findings does the nurse anticipate?

Accepted Answer

Normal pulse rate and normal blood pressure are expected findings during an assessment of a young adult client experiencing chronic back pain.

Question 6

The nurse is assessing a client admitted with severe abdominal pain. Which are essential components of a pain assessment?

Accepted Answer

The answer of The nurse is assessing a client admitted...

Question 7

The nurse is assessing a client admitted with chronic back pain. Which assessment data related to pain does the nurse anticipate for this client?

Accepted Answer

Chronic pain is defined as pain that lasts for longer than three months. It is typically persistent and can interfere with a person's daily activities. Additionally, chronic pain can have a prolonged duration, lasting for months or even years. Sudden onset of pain or pain that causes a sharp elevation in body temperature is not typically associated with chronic pain. Pain intensity can range from low to high, so this is not a specific assessment data that can be anticipated for this client.

Question 8

The nurse is assessing pain level with vital signs for an adolescent client. 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?" Which action by the nurse is the most appropriate?

Accepted Answer

Providing questions that require yes or no answers related to pain can help the adolescent to better describe their pain and assist the nurse in assessing the severity and location of the pain. Leaving the room, asking about pain medications, or continuing with the vital signs assessment would not address the adolescent's need to describe their pain more fully.

Question 9

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 bases the response on ibuprofen's effect during which phase of nociception?

Accepted Answer

Ibuprofen works during the transduction phase of nociception by inhibiting the production of prostaglandins, which are chemicals that promote inflammation, pain, and fever.

Question 10

The nurse is caring for a preschool age client who is hospitalized for internal fixation of a fractured arm. The nurse is considering nonpharmacological pain management techniques to implement. Which interventions are appropriate for the nurse to include in the plan of care?

Accepted Answer

Non-pharmacological pain management techniques for preschool age children include holding the child, allowing them to blow bubbles, and using guided imagery.

Question 11

The nurse is assessing a client who presents to the emergency department after recently being discharged from the hospital after a right above-the-knee amputation. The client tells the nurse that her right foot hurts. Which type of pain does the nurse suspect that this client is experiencing?

Accepted Answer

Phantom pain is a type of pain that is perceived in a body part that is no longer present. In this case, the client is reporting pain in her foot which has been amputated, suggesting that she could be experiencing phantom pain. Radiating pain occurs when pain spreads from one area to another, intractable pain is severe pain that is difficult to manage, and cutaneous pain is pain that is felt on the skin. None of these options accurately describe the client's reported symptoms.

Question 12

A nurse working in a healthcare provider's office is interviewing a client who reports experiencing daily migraines. The nurse decides to further assess the impact of the client's pain. Which assessment tool is most appropriate to use for this client?

Accepted Answer

The Brief Pain Inventory is the most appropriate assessment tool for this client, as it specifically focuses on the impact of pain on the client's daily life, including the intensity of pain, and how it affects their ability to carry out activities of daily living. The other options listed are not specifically designed for assessing the impact of pain.

Question 13

The nurse is assessing a postoperative client who reports a pain level of 10 on a 0 to 10 scale. The client is grimacing and appears anxious. Which is the priority action by the nurse?

Accepted Answer

The priority action in this scenario is to address the client's pain level. Administering pain medication if it has been longer than the ordered interval is the most appropriate action to take in order to alleviate the client's pain and anxiety. The other options, such as offering spiritual counseling or calling the family, may be appropriate actions, but addressing the client's pain should take precedence in this situation. Obtaining an order for an anti-anxiety medication may also be appropriate, but pain relief should be the priority.

Question 14

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." Which response by the more experienced nurse is most appropriate?

Accepted Answer

Pain is a subjective experience and can differ greatly from person to person, which is why it is important to validate and assess the client's pain rather than dismissing it based on personal experience or assumptions. Choice A assumes the client is seeking drugs without any evidence, Choice B may be appropriate but does not directly address the issue of the nurse's disbelief in the client's pain, and Choice C does not provide any guidance or resolution for the situation.

Question 15

The nurse is working at a 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?

Accepted Answer

The definition that the nurse correctly choose to include in the orientation is "Pain is whatever the experiencing person says it is." This definition emphasizes the subjective nature of pain and the importance of listening to and believing the patient's report of pain.

Question 16

The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the clients rates the pain as a 7 out of 10 (0 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. Which action by the nurse is the most appropriate?

Accepted Answer

It is appropriate to administer the pain medication if the ordered interval has passed and the client is still requesting it. Sickle cell pain can be severe and although the client is able to move around and eat, it does not mean that the pain is not present. It is not appropriate to assume that the client is faking their pain without first assessing and evaluating their condition. Waiting 30 minutes or giving half of the dose may not provide adequate relief for the client's pain.

Question 17

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?

Accepted Answer

The Gate control theory is useful in explaining why one client is in greater pain than the other. This theory suggests that pain signals can be blocked or allowed to pass through a neurological "gate" in the spinal cord. Factors such as stress and other sensory input can influence whether the gate is open or closed. In this case, the client in greater pain may have a more "open" gate due to factors such as higher stress levels or other sensory input, allowing more pain signals to pass through. Providing pain medication can help to close the gate and reduce the client's pain.

Question 18

The nurse is providing care to a client who has multiple fractures after a motor vehicle accident. The nurse includes reduction of the perception of pain as a client outcome. Which nursing interventions would apply to reaching this outcome?

Accepted Answer

Options A (Offering a selection of musical CDs), B (Assisting with guided imagery) and D (Providing instruction on deep breathing techniques) are non-pharmacological interventions that can reduce pain perception. Option C (Administering Demerol intravenously) is a pharmacological intervention that can reduce pain perception, but it may have potential side effects and risks. Option E (Administering an anti-inflammatory medication) may be appropriate for treating the underlying cause of the pain, but it may not directly reduce pain perception.

Question 19

An adult 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 response by a nursing peer is the best example of being a client advocate?

Accepted Answer

This response acknowledges the individuality of pain perception and response to injury, emphasizing the need to assess and manage pain based on the client's specific needs. It is an example of being a client advocate by advocating for individualized pain management. Choices A and C make assumptions about the client and are not based on individualized assessment. Choice B suggests an appropriate intervention but does not address the underlying issue of individualized pain management.

Question 20

The nurse is caring for a client who denies having pain. The nurse notices the client grimacing and clenching his teeth when moving. The client's spouse has asked the nurse why some people deny obvious pain. Which response by the nurse is most appropriate?

Accepted Answer

Some people associate pain with weakness, and they may feel embarrassed or ashamed to admit that they are in pain. It is important for the healthcare provider to assess and address any pain the client may be experiencing, as uncontrolled pain can lead to negative outcomes in the client's recovery. Simply telling the spouse to "find out why" the client is denying the pain or suggesting that pain may not be bad is not helpful in addressing the client's needs. Asking if the healthcare provider has been informed is a good suggestion, but it does not directly address the spouse's question about why people deny pain.

Quiz 11: Pain Assessment