Deck 20: Assessing Pain

Question 1

The nurse is providing care to an older adult patient who has had knee replacement surgery. Which will the nurse monitor the patient for in response to unrelieved pain?

A) Diarrhea
B) Weight gain
C) Insomnia
D) Hypotension

Answer 1

Insomnia

Question 2

The nurse is assessing a 4-week-old infant who had cardiovascular surgery to repair a patent ductus arteriosus (PDA). The infant is currently inconsolable. Using the CRIES scale, which score for crying is appropriate?

A) 0
B) 1
C) 2
D) 3

Answer 2

2

Question 3

Which question would best assess the quality of a patient's pain?

A) "Can you tell me what the pain feels like?"
B) "Is the pain continuous?"
C) "Does anything make the pain better?"
D) "Is the pain stabbing?"

Answer 3

"Can you tell me what the pain feels like?"

Question 4

The nurse is assessing an infant for pain. Which integumentary assessment finding indicates that the infant may be experiencing pain?

A) Palmar sweating
B) Increased heart rate
C) Rapid respirations
D) Increased muscle tone

Question 5

Which question is best for assessing the severity of pain?

A) "Does the pain really hurt?"
B) "Does anything make the pain worse?"
C) "On a scale of 0 to 10 with 0 being no pain, what would you rate your pain?"
D) "How long have you had the pain?"

Question 6

Which action by the nurse is most appropriate when conducting a pain assessment for a preschool-age child who has been in a bike accident?

A) Assessing the child's pain with a numeric scale
B) Monitoring the child's heart rate
C) Asking the child to point on a doll where the pain is located
D) Evaluating the child's blood pressure

Question 7

The nurse is using the acronym QUESTT to assess the pain in a preschool-age child. Which action is appropriate for the "S" in this acronym?

A) Sedating the child
B) Securing parental involvement
C) Sitting next to the child
D) Secluding the parents from the child

Question 8

The nurse wants to provide the most culturally appropriate care to a Chinese American patient who is admitted to the medical-surgical unit after a knee replacement surgery. Which question is most appropriate do determine appropriate interventions to treat pain?

A) "Do you have a history of substance abuse that will affect which pain medication you take?"
B) "Will having a family member at the bedside help you deal with your pain more effectively?"
C) "Do you believe that prayer is one way of treating your pain?"
D) "Will the use of oils help with your pain?"

Question 9

The nurse is using the FACES Pain Scale to assess the pain for a preschool-age child after a tonsillectomy. The patient points to the face that indicates hurting "a whole lot." Which numeric value is associated with this?

A) 2
B) 3
C) 4
D) 5

Question 10

Your patient has had an exploratory laparotomy and bowel resection. She is complaining of severe incisional pain. What is the most accurate means of assessing your patient's pain?

A) Assess her incision.
B) Assess her vital signs.
C) Assess for abdominal tenderness.
D) Ask the patient about her pain.

Question 11

The nurse is assigned several patients on a pediatric postsurgical unit. For which patient would the nurse use the FLACC Postoperative Pain Tool when assessing pain?

A) A 1-month-old infant admitted for hernia repair
B) A 6-year-old patient admitted for tonsillectomy
C) A 10-year-old patient admitted for an appendectomy
D) A 13-year-old patient admitted for scoliosis surgery

Question 12

The nurse is providing care to several patients on a medical-surgical unit who are experiencing pain after surgery. Which patient may request herbal medications for the treatment of pain?

A) African American male patient
B) Appalachian female patient
C) Arab American male patient
D) Native American female patient

Question 13

Which is an infant behavior that is associated with pain?

A) Loss of appetite
B) Increased muscle tone
C) Increased blood glucose
D) Dilated pupils

Question 14

The nurse is conducting a pain assessment for a patient who experiences chronic pain. Which scale is most appropriate when initially assessing the effect of the pain on activities of daily living (ADLs)?

A) Numerical Rating Scale
B) Initial Pain Assessment Inventory
C) Brief Pain Inventory
D) Neuropathic Pain Scale

Question 15

The nurse is providing care to a patient who is experiencing acute, unrelieved pain. Which will the nurse monitor the patient for based on this data?

A) Bronchitis
B) Emphysema
C) Atelectasis
D) Wheezes

Question 16

The nurse is conducting an assessment for a patient on a medical-surgical unit. Which finding is indicative of pain?

A) Constricted pupils
B) Decreased heart rate
C) Decreased blood pressure
D) Abnormal posture

Question 17

The clinic nurse is assessing a patient who presents with ear pain. Which question is most appropriate to determine the precipitating factor for the current pain?

A) "What does the pain feel like?"
B) "How often are you experiencing this pain?"
C) "What were you doing when the pain started?"
D) "Does the pain spread anywhere else?"

Question 18

The nurse is using a pain scale that allows the patient to choose descriptors when describing the current level of pain. Which pain scale is the nurse using?

A) Numerical Rating Scale
B) Visual Analogue Scale
C) Faces Scale
D) Categorical Scale

Question 19

Which pain scale is appropriate for children ages 3 to 13 years?

A) Color Tool
B) FACES Pain Rating Scale
C) Oucher
D) Poker Chip Tool

Question 20

The nurse is providing care to a patient who is experiencing acute pain with nausea and vomiting. Which term will the nurse use when documenting this patient's pain in the medical record?

A) Referred pain
B) Visceral pain
C) Neuropathic pain
D) Complex regional pain

Question 21

The nurse is assessing an infant who is experiencing pain. Which finding is caused by an increase in glucagon secretion?

A) Increased blood glucose
B) Decreased pH
C) Increased hemoglobin
D) Decreased fatty acids

Question 22

The nurse is providing care to a patient who is in labor. Which type of pain is this patient experiencing?

A) Acute
B) Chronic
C) Malignant
D) Chronic pain syndrome

Question 23

The nurse is assessing an older adult patient with dementia for pain. Which scale is most appropriate for the nurse to use?

A) Numerical Pain Scale
B) FACES Scale
C) FLACC Postoperative Pain Tool
D) PAINAD Scale

Question 24

The nurse is assessing an older adult patient diagnosed with dementia for pain. Which behavioral manifestations would indicate the patient is experiencing pain? Select all that apply.

A) Increased heart rate
B) Increased blood pressure
C) Increased agitation
D) Increased restlessness
E) Increased moaning

Question 25

The nurse is assessing an infant for pain. Which facial expression is unexpected for an infant experiencing pain?

A) Eye squeeze
B) Brow bulge
C) Chin quiver
D) Occasional smile

Question 26

The nurse reassesses a patient's pain 1 hour after administering a pain medication. Which route did the nurse use to administer the pain medication?

A) Intravenous
B) Intramuscular
C) Rectal
D) Oral

Question 27

The nurse is assessing an older adult patient with dementia for pain using the Pain Assessment in Advanced Dementia Scale (PAINAD). The patient is experiencing short periods of hyperventilation, occasionally moans, is frowning, and is tense, but is reassured by the nurse's touch. Which score will the nurse document for this patient?

A) 5
B) 6
C) 7
D) 8

Question 28

The nurse is providing care to an adolescent patient who is experiencing pain. Which is a behavioral change that often occurs when an adolescent is experiencing pain? Select all that apply.

A) Crying
B) Clenched fists
C) White knuckles
D) Verbalization of pain
E) Muscle tension

Question 29

Which signs are seen in response to acute pain? Select all that apply.

A) Constricted pupils
B) Increased blood pressure
C) Increased heart rate
D) Decreased respiratory rate
E) Rapid speech

Question 30

The nurse is conducting a health history assessment for a preschool-age child who is in pain. Which actions by the nurse are appropriate? Select all that apply.

A) Using a numerical pain scale
B) Using age-appropriate language, such as "wound"
C) Using a doll to assess the location of the pain
D) Having the child draw a picture of the pain
E) Asking the parents to leave the room

Question 31

The nurse administers a parenteral dose of pain medication to a patient. When will the nurse reassess the patient's level of pain?

A) After 15 minutes
B) After 30 minutes
C) After 45 minutes
D) After 60 minutes

Question 32

Which nursing actions are appropriate after the nurse treats a child's pain? Select all that apply.

A) Developing a plan of care
B) Reassessing for pain
C) Revising the plan of care
D) Administering another dose of medication
E) Considering the pathophysiology of the pain

Question 33

The nurse is using the Pain Assessment in Advanced Dementia Scale (PAINAD) to assess an older adult patient with dementia. Which finding would score a 1 for this patient?

A) Loud moaning and groaning
B) Facial grimacing
C) Occasional labored breathing
D) Rigid, clenched fists

Question 34

The nurse is conducting a pain assessment for a pediatric patient diagnosed with cerebral palsy (CP). Which behavioral pain assessment scale is most appropriate for this patient?

A) Behavioral Pain Score (BPS)
B) Nurses Assessment of Pain Inventory (NAPI)
C) Objective Pain Score (OPS)
D) Riley Infant Pain Scale (RIPS)

Question 35

The nurse is providing care to a Mexican American patient after an appendectomy. Which should the nurse expect based on the patient's culture regarding pain? Select all that apply.

A) The patient may feel obligated to endure pain in the performance of daily activities.
B) The patient may believe that pain is a consequence of immoral behavior.
C) The patient may believe that methods used to relieve pain maintain balance.
D) The patient may believe that denial of pain may delay treatment.
E) The patient may believe that the use of medication represents weakness.

Question 36

The nurse is conducting a pain assessment for a nonverbal child. Which physiological changes indicate the child is experiencing pain? Select all that apply.

A) Increased blood pressure
B) Sweating
C) Constricted pupils
D) Crying
E) Clenched fists

Question 37

The nurse is conducting a pain assessment for a preschool-age child. Which questions should the nurse ask the child's parents? Select all that apply.

A) "Why did you give your child aspirin for the pain?"
B) "What is your child's past experience with pain?"
C) "How does your child typically respond to pain?"
D) "How do you know your child is in pain?"
E) "What relieves your child's pain?"