Deck 11: Pain Assessment

Question 1

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

A) Pain threshold.
B) Pain tolerance.
C) Somatic interval.
D) Cephalgia reporting.

Answer 1

Pain threshold.

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?

A) Phantom pain.
B) Radiating pain.
C) Intractable pain.
D) Cutaneous pain.

Answer 2

Radiating pain.

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?

A) "I would think having chronic pain would make your husband depressed."
B) "It may be to prevent depression due to physical limitations."
C) "This type of medication can help inhibit painful stimuli."
D) "Your husband is at risk for suicidal thoughts related to the chronic pain."

Answer 3

"This type of medication can help inhibit painful stimuli."

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?

A) Have the parents leave the area during the procedure.
B) Tell the parents to touch and reassure the toddler during the procedure.
C) Wait until the toddler is asleep to do the procedure.
D) Administer an analgesic 30 minutes before the procedure.

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?

A) Increased pulse rate.
B) Increased respiratory rate.
C) Normal pulse rate.
D) Normal blood pressure.
E) Diaphoresis.

Question 6

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

A) Description of the pain.
B) Temperature, pulse, respirations, and blood pressure.
C) Pain intensity rating.
D) Family medical history.
E) Previous pain experience.

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?

A) Sudden onset of pain.
B) Pain that interferes with daily activities.
C) Pain described as being low intensity.
D) Prolonged pain duration.
E) Pain causing a sharp elevation in body temperature.

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?

A) Leave the room and come back later.
B) Provide questions that require yes or no answers related to pain.
C) Ask the client what they would like to have for pain.
D) Continue with the vital signs assessment.

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?

A) Transduction.
B) Transmission.
C) Perception.
D) Modulation.

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?

A) Offer a glucose-coated pacifier.
B) Sit with the child and allow her to "blow bubbles."
C) Explain to the child the cause of the pain.
D) Teach the use of guided imagery.
E) Hold the child.

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?

A) Phantom pain.
B) Radiating pain.
C) Intractable pain.
D) Cutaneous pain.

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?

A) Psychologic well-being inventory.
B) Body Diagram tool.
C) Intensity rating scale.
D) Brief Pain Inventory.

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?

A) Administer pain medication if it has been longer than the ordered interval.
B) Offer to call the pastoral service to provide spiritual counseling.
C) Obtain an order for an anti-anxiety medication.
D) Call the family to come in and stay with the client.

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?

A) "It sounds as if your client is a drug seeker."
B) "You should contact the healthcare provider."
C) "I would call the nursing supervisor for this one."
D) "Pain differs from person to person."

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?

A) Pain is validated by the nurse determining the cause of the pain.
B) Pain is an unpleasant sensation, typically experienced upon movement.
C) Pain is whatever the experiencing person says it is.
D) Pain is very subjective, so observations must be used to assess levels and intensity.

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?

A) Wait 30 minutes and see if the client is still requesting the pain medicine.
B) Administer half the ordered does of pain medication.
C) Administer the pain medication if it is has been longer than the ordered interval.
D) Notify the healthcare provider that the client is faking his 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?

A) Pattern.
B) Specificity.
C) Stress.
D) Gate control.

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?

A) Offering a selection of musical CDs.
B) Assisting with guided imagery.
C) Administering Demerol (Meperidine) intravenously.
D) Providing instruction on deep breathing techniques.
E) Administering an anti-inflammatory medication.

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?

A) "I just think this client needs more because of his age."
B) "Have you tried getting the doctor to order oral pain medications to see if they work?"
C) "Wouldn't you want all of the pain medication you could have if you were in traction?"
D) "Everyone does not have the same pain perception or response to a similar injury."

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?

A) "You should try to find out why your husband is denying the pain."
B) "Have you talked to the healthcare provider about this?"
C) "Some people feel reporting their pain is a sign of weakness."
D) "Maybe we are wrong and pain is not really bad."

Question 21

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?

A) The night nurse had more time to spend with the client.
B) The client must be afraid or lonely at night and is trying to get attention.
C) The client may not report pain in the presence of parents based on their influence or cultural beliefs.
D) The client was asking for medication at night to facilitate sleep.

Question 22

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?

A) The client is experiencing referred pain.
B) The client is experiencing intractable pain.
C) The client is experiencing retractable pain.
D) The client is experiencing radiating pain.

Question 23

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?

A) "Some people just don't need any analgesics."
B) "Have you seen any nonverbal cues that might indicate your husband is experiencing pain?"
C) "We will need to contact the healthcare provider to report your husband is refusing analgesics."
D) "Have you noticed your husband's monitor alarming?"

Question 24

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?

A) "I would think it would make the parents feel better to know it had been given."
B) "I am going to have to report you to the ethics board."
C) "Pain transmission has been documented in all age groups."
D) "What will it hurt to just go ahead and give it?"

Question 25

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?

A) "Your child is just immature."
B) "Your child is just scared."
C) "It looks like your child may have experienced a head injury as well."
D) "Your child may be remembering a painful injection experience."

Question 26

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.

Question 27

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?

A) Family report of pain.
B) Response from the client based on use of a pain tool.
C) Observations of the client's behaviors while asleep.
D) Measurement of vital signs.

Question 28

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?

A) Clients start to complain of many types of pain as they age.
B) The joint pain is probably not the real reason the client is in the office.
C) The client is most likely depressed.
D) Older adults frequently avoid seeking treatment for their pain.

Question 29

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?

A) "The doctors would rather treat you as a cardiac client until they find out why the nitroglycerin did not work."
B) "Sometimes cardiac pain is not just in your chest, but in your jaws, arms or back."
C) "They may have been so stressed that they clenched their jaws and did not realized if they had any chest pain or not."
D) "It may not be related, but cardiac pain is so serious to investigate and treat."