Deck 54: Comfort

Question 1

A nurse assesses a client who is experiencing acute pain. Which aspects of the pain assessment are gathered first before the detailed assessment? Select all that apply.

A)Location
B)Provocation
C)Intensity
D)Quality
E)Radiation

Answer 1

Location
Intensity
Quality

Question 2

The nurse prepares to apply dry heat to a client's extremity in an effect to reduce pain. Which variables does the nurse recognize affects physiological tolerance to heat and cold? Select all that apply.

A)Body part location
B)Size of the exposed body part
C)Individual tolerance
D)Intactness of skin
E)Gender

Answer 2

Body part location
Size of the exposed body part
Individual tolerance
Intactness of skin

Question 3

The nurse is caring for a client in acute pain and plans to use a pain scale tool for assessment. What is the major advantage in using this tool?

A)It allows organization in the assessment process.
B)It works with the same efficacy among the entire population.
C)It allows for variation among various cultures.
D)It can always be performed quickly.

Answer 3

It allows organization in the assessment process.

Question 4

The nurse is caring for a client in acute pain. When assessing the client's quality of pain, which statement will the nurse use?

A)"How long have you been having pain?"
B)"Is the pain better or worse at certain times of the day or night?"
C)"What words would you use to describe your pain?"
D)"Have you noticed any time during the day or night that the pain is better or worse?"

Question 5

The nurse assesses a toddler for pain using the FLACC scale. The nurse notes the client is crying steadily with a quivering chin, is kicking, is shifting back and forth, and is difficult to console. What number does the nurse document for the client's pain, based on the FLACC scale?

A)8
B)9
C)10
D)11

Question 6

The nurse cares for a client who requires a PCA for pain control. The health care provider has ordered a loading dose for the client. Place the steps in order for the nurse to provide the loading dose by PCA pump.

A)Set the safety parameters.
B)Press the loading dose control button.
C)Set the volume to be delivered.
D)Set the pump for a lockout time of zero minutes.

Question 7

A nurse cares for a 13-year-old adolescent with a terminal illness. Which client statement does the nurse expect to hear from this client regarding death and dying?

A)"I will go to sleep for a long time and then wake up."
B)"I know that people die with my disease but I won't die."
C)"I wonder what happens to people after death."
D)"I know people die but I will defy my own death."

Question 8

The nurse cares for a client who needs a PCA pump for control of postoperative pain. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

A)Pushing the client button if the client is unable.
B)Silencing the pump alarm while waiting for the nurse.
C)Reporting specific client observations.
D)Asking the client about level of pain.

Question 9

The nurse is caring for a client with acute pain and uses the FLACC pain assessment. Which clinical scenario does the nurse recognize as least appropriate for use of the FLACC pain assessment?

A)Situations where clients self-report pain.
B)Situations requiring rapid pain assessment.
C)Clients who are asleep.
D)Clients who are children.

Question 10

The nurse cares for a client with chronic pain who asks the nurse about using acupressure for pain relief. Which statements will the nurse include in the teaching regarding how this treatment works for pain relief. Select all that apply.

A)"The pressure compresses and splints irritated nerve endings."
B)"It redirects energy flow through pressure on meridian points."
C)"The therapy restores structural integrity and balance."
D)"The therapy reduces pain and increases endorphins."
E)"It manipulates muscles and realigns spinal column nerve function."

Question 11

The nurse prepares to perform a pain assessment and chooses to use a standardized pain assessment tool. Place the steps in order for the use of the standardized pain assessment tool.

A)Assess the client's physiological response to pain.
B)Assess the client's perception of pain.
C)Perform a focused assessment.
D)Document the findings.

Question 12

The nurse is caring for a client who is dying. When prioritizing care, which intervention will the nurse provide to meet the client's physiological needs?

A)Encourage frequent ambulation and deep breathing.
B)Initiate total nutrition intravenously.
C)Administer curative medications.
D)Encourage favorite foods as tolerated.

Question 13

The nurse cares for a client who wants to try biofeedback for relief of chronic pain. What advantages to this therapy does the nurse recognize? Select all that apply.

A)Increases circulation and endorphins.
B)Completely controlled by the client.
C)Rapid pain relief.
D)Redirects energy flow through pressure on meridian points.
E)Promotes stress reduction as well as pain relief.

Question 14

The nurse is caring for five clients with acute pain. When considering the use of heat and cold therapy, which medical conditions will the nurse determine require special precautions? Select all that apply.

A)Diabetes
B)Venous insufficiency
C)Asthma
D)Congestive heart failure
E)Arterial disease

Question 15

The nurse is preparing to use a disposable hot pack on the client for pain relief. Which action will the nurse prioritize as an appropriate task for the UAP?

A)Observing the site of application and reporting abnormal findings.
B)Assessing the client's level of pain.
C)Determining if the client requires additional therapy.
D)Documenting the client's response to therapy.

Question 16

The nurse prepares to apply a TENS unit on a client who is experiencing pain. Place the steps of this procedure in the correct order.

A)With the unit off, plug the lead wires into the unit.
B)Insert the battery and test for functioning.
C)Turn the unit on and ensure the amplitude is set to zero.
D)Apply the electrodes to the client.
E)Increase the amplitude until the client notes discomfort.
F)Slowly decrease the amplitude until the client notes a pleasant sensation.

Question 17

The nurse cares for a neonate who appears in pain. The neonate has tight facial muscles, loud and shrill cry, rapid breathing, tense extremities and is thrashing about. Using the NIPS pain scale, which number will the nurse give the neonate?

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

Question 18

The nurse is caring for a client who is using a TENS unit for pain management. Which statements will the nurse use when teaching the client about this therapy? Select all that apply.

A)"Make sure and cover the unit while showering or bathing."
B)"When turning the unit on, make sure the amplitude control is set to 5."
C)"With the unit off, plug the lead wires into the battery-operated unit at one end, leaving the electrodes at the other end."
D)"Increase the amplitude until you feel discomfort and then decrease the amplitude until you feel comfortable."
E)"Wash, rinse, and dry the area where you would like to apply the electrodes."

Question 19

The nurse sets up a PCA pump for a postoperative client. Which safety parameters will the nurse use? Select all that apply.

A)Dose volume limits.
B)Partial dose settings.
C)Dosage limits.
D)Lockout interval.
E)Re-programming alarm settings.

Question 20

The nurse cares for an older adult client who will have heat and cold therapy to assist with pain. Which lifespan considerations does the nurse consider when using this treatment for the client? Select all that apply.

A)Skin cells proliferate quicker as one ages.
B)Sensitivity to pain decreases as one ages.
C)Skin becomes thinner as one ages.
D)Moisture in the skin decreases as one ages.
E)Skin burns easier as one ages.