Chapter 32. Pain My Nursing Test Banks

Chapter 32. Pain

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patients pain?

1)

Acute

2)

Chronic

3)

Intractable

4)

Neuropathic

ANS: 1

Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than 6 months and interferes with daily activities. Intractable pain is chronic and highly resistant to relief. Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves.

PTS:1DIF:EasyREF:p. 1092

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

____ 2. How should the nurse classify pain that a patient with lung cancer is experiencing?

1)

Radiating

2)

Deep somatic

3)

Visceral

4)

Referred

ANS: 3

Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax. Lung cancer produces visceral pain. Radiating pain starts at the source and extends to other locations. Deep somatic pain is typically caused by fracture, sprain, arthritis, and bone cancer. Referred pain occurs in an area distant from the original site.

PTS:1DIF:ModerateREF:p. 1091

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

____ 3. A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain?

1)

Psychogenic

2)

Phantom

3)

Referred

4)

Radiating

ANS: 2

The nurse should document this finding as phantom pain. Phantom pain is pain that is perceived to originate in an area that has been amputated. Psychogenic pain refers to pain experienced by a person which does not match the symptoms or the apparent source of pain. It is thought to arise from psychological factors and is disproportional to the painful stimuli. Referred pain occurs in an area distant from the original site. Radiating pain starts at the source but extends to other locations.

PTS:1DIF:EasyREF:p. 1091

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

____ 4. A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response?

1)

Histamine

2)

Prostaglandin

3)

Bradykinin

4)

Serotonin

ANS: 3

Tissue damage causes the release of the substances histamine, bradykinin, and prostaglandin. Bradykinin triggers the release of inflammatory chemicals that cause the injured area to become red, swollen, and tender. Serotonin is a neurotransmitter and is not involved in the inflammatory response.

PTS:1DIFifficultREF:p. 1092

KEY: Nursing process: NA | Client need: PHSI | Cognitive level: Application

____ 5. In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord?

1)

Transduction

2)

Transmission

3)

Perception

4)

Modulation

ANS: 2

Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during a process known as transmission. In a process called transduction, specialized nociceptors convert potentially damaging mechanical, thermal, and chemical stimuli into electrical activity that leads to the experience of pain. Perception involves the recognition of pain by the frontal cortex of the brain. During modulation, pain signals can be facilitated or inhibited, and the perception of pain can be changed.

PTS:1DIFifficultREF:p. 1092

KEY:Nursing process: NA | Client need: PHSI | Cognitive level: Recall

____ 6. A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process?

1)

Perception

2)

Transduction

3)

Transmission

4)

Modulation

ANS: 4

Music therapy can prompt the release of endogenous opioids during the modulation stage, which is the stage of the pain process where the perception of pain changes. It is not during the perception (recognizing the pain sensation), transmission (relaying the pain message), or transduction (converting potentially damaging stimuli into electrical activity leading to pain sensation).

PTS:1DIF:ModerateREF:pp. 1093, 1100; synthesis of information required

KEY:Nursing process: Planning | Client need: PHSI | Cognitive level: Recall

____ 7. The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain?

1)

Blood pressure 160/82 mm Hg

2)

Temperature 100.6F

3)

Heart rate 80 beats/min

4)

Oxygen saturation 95%

ANS: 1

This patient has an elevation in blood pressure which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is a common response to surgery. Heart rate and oxygen saturation are within normal limits.

PTS: 1 DIF: Moderate REF: pp. 1095-1096

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

____ 8. A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication?

1)

Metabolic alkalosis

2)

Pneumothorax

3)

Pneumonia

4)

Hemothorax

ANS: 3

Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly and avoid deep coughing to expel sputum, which can lead to pneumonia. Rib fractures can also lead to complications such as pneumothorax and hemothorax; however, they do not result from inadequate pain control. Respiratory acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and restricted chest wall movement with splinting.

PTS:1DIF:ModerateREF:p. 1096

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

____ 9. When should the nurse assess pain?

1)

Whenever a full set of vital signs is taken

2)

During the admission interview

3)

Every 4 hours for the first 2 days after surgery

4)

Only when the patient complains of pain

ANS: 1

The nurse should assess pain whenever a full set of vital signs is checked. Moreover, the nurse should assess pain on admission of a patient to the facility, even when pain is not the chief complaint. Patients may have chronic pain that has no association with their reason for seeking care. Pain should be assessed more frequently than every 4 hours in the immediate postoperative period. Pain should be reassessed after any treatment is given to evaluate effectiveness of the treatment. Some patients may not complain of pain unless they are specifically asked whether they are in pain. Pain rating scales help to quantify the intensity of pain for the nurse providing analgesia.

PTS: 1 DIF: Moderate REF: pp. 1096-1098

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

____ 10. Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer?

1)

Acute pain secondary to surgery

2)

Acute pain (abdominal) secondary to surgery for colon cancer

3)

Chronic pain secondary to cancer diagnosis

4)

Chronic pain (abdominal) secondary to abdominal surgery

ANS: 2

The nurse should identify a diagnosis by specifying the location of the pain and any precipitating or etiological factors. This patient is experiencing acute abdominal pain that is related to his surgery for colon cancer; therefore, a nursing diagnosis that specifies the surgery is the most appropriate diagnosis for this patient. In addition, options listing chronic pain are incorrect because the pain is acute, not chronic.

PTS: 1 DIF: Moderate REF: p. 1100

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

____ 11. Which drug might the primary care provider prescribe to help facilitate pain management in a client with chronic pain?

1)

Selective serotonin reuptake inhibitor

2)

Selective norepinephrine reuptake inhibitor

3)

Narcotic analgesic

4)

Anti-emetic

ANS: 1

The control of depression greatly facilitates pain management, especially for patients experiencing chronic pain. Therefore, the physician may prescribe a selective serotonin uptake inhibitor (antidepressant), such as paroxetine (Paxil), as part of the treatment plan. Selective norepinephrine reuptake inhibitors, such as Atomoxetine (Strattera), are commonly used for attention deficit-hyperactivity disorder. If a narcotic, such as oxycodone (OxyContin), is used for a long time, it may become habit forming (causing mental or physical dependence). Physical dependence may lead to withdrawal side effects when you stop taking the medicine. This is not the first-line therapy for chronic pain. An anti-emetic, such as ondansetron (Zofran), is used to control for nausea and vomiting, which can occur with some analgesic medication. However, the prescriber would more likely change the medication to something the patient tolerates better rather than order an anti-emetic to control the side effect.

PTS:1DIFifficultREF:p. 1103; higher-order item, can be inferred from text

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

____ 12. The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient complaining of a severe headache. When should the nurse reassess the patients pain?

1)

15 minutes after administration

2)

60 minutes after administration

3)

90 minutes after administration

4)

Immediately before the next dose is due

ANS: 2

The nurse should reassess pain in the patient who received an oral pain medication 30 to 60 minutes after administration. The nurse should reassess the patient receiving IV medications 10 to 15 minutes after administration. The nurse should not wait until just before the patient can receive another dose. The patient may require additional pain medication before the next dose is due.

PTS:1DIF:ModerateREF:p. 1100

KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

____ 13. After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take?

1)

Use nonpharmacological therapy while waiting 3 more hours before the next dose.

2)

Administer an additional 800 mg oral dose of ibuprofen right away.

3)

Do nothing because the patients facial expression indicates he is comfortable.

4)

Notify the prescriber that the current pain management plan is ineffective.

ANS: 4

The nurse should notify the prescriber that the current pain management plan is ineffective. The nurse should not delay treatment for 3 hours when the next dose of medication is due. The nurse cannot administer an extra dose of ibuprofen without a prescribers order to do so. Ibuprofen 800 mg is a maximum dose for most individuals. The nurse should not assume that the patient is not in pain simply because he appears comfortable; pain is what the patient states it is.

PTS:1DIF:ModerateREF:pp. 1110-1111

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 14. The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan?

1)

Place the cold pack directly on the skin over the ankle.

2)

Apply the cold pack to the ankle for 30 minutes at a time.

3)

Check the skin frequently for extreme redness.

4)

Keep the cold pack in place for at least 24 hours.

ANS: 3

The nurse should instruct the patient to cover the cold pack with a washcloth, towel, or fitted sheet before applying it to the ankle to prevent tissue damage. A cold pack should be applied intermittently for the first 24 hours, leaving it in place for no longer than 15 minutes at a time. The patient should check the skin frequently and discontinue the treatment immediately if redness or other signs of tissue irritation occur.

PTS:1DIF:ModerateREF:p. 1101

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 15. The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using?

1)

Distraction

2)

Guided imagery

3)

Sequential muscle relaxation

4)

Hypnosis

ANS: 1

Music is a form of distraction that has been shown to reduce pain and anxiety by allowing the patient to focus on something other than pain. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out. This relaxation technique has also been effective for relieving pain. Hypnosis involves the induction of a deeply relaxed state.

PTS:1DIF:EasyREF:pp. 1101-1102

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

____ 16. The nurse uses his hands to direct energy fields surrounding the patients body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention?

1)

Tactile distraction was performed and appeared effective in reducing pain.

2)

Guided imagery was effective to relax the patient and reduce the pain.

3)

Therapeutic touch was performed; patient verbalized lessening of pain after treatment.

4)

Sequential muscle relaxation was performed; patient states pain is less.

ANS: 3

Therapeutic touch focuses on the use of hands to direct energy fields surrounding the body. The nurse should document use of therapeutic touch and its effectiveness in the progress notes after performing the procedure. Tactile distraction involves activities such as massage, hugging a favorite toy, holding a loved one, or stroking a pet. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscle while breathing out. This relaxation technique is often effective for relieving pain.

PTS:1DIF:ModerateREF:p. 1102

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

____ 17. A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen (Aleve, Naprosyn), for treatment of arthritis complains of stomach upset. What should the nurse instruct the patient to do?

1)

Notify the prescriber immediately.

2)

Take the medication with food.

3)

Take the medication with 8 ounces of water.

4)

Take the medication before bedtime.

ANS: 2

The nurse should instruct the patient to take the medication with food to lessen gastric irritation. Taking the medication with 8 ounces of water will not decrease gastric irritation. Taking the medication just before bedtime may cause gastric reflux, increasing gastric irritation. Although indigestion is an unwanted side effect of naproxen, it is not an emergency that requires the prescriber to be notified immediately. However, prior to giving naproxen, be sure the patient has not had ulcers, stomach bleeding, or severe kidney or liver problems. If so, the patient is not a candidate for treatment with naproxen.

PTS:1DIF:ModerateREF:p. 1103

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 18. A patient is prescribed morphine sulfate 4 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication?

1)

Monitor the patients respiratory status.

2)

Auscultate the patients heart sounds.

3)

Check blood pressure in supine and sitting positions.

4)

Monitor the patient for psychological drug dependence.

ANS: 1

The nurse should assess the patients respiratory status and level of alertness before administering the medication because respiratory depression can be a life-threatening effect. It is not necessary to auscultate heart sounds or to check blood pressure while the patient lies down (supine position) and sits up. Psychological dependence occurs rarely even after long-term prescribed use of morphine. Therefore, it is not necessary to routinely monitor a patient who is receiving morphine for acute postoperative pain for psychological drug dependence.

PTS:1DIF:ModerateREF:p. 1104

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application

____ 19. A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use?

1)

Caution the patient against combining acetaminophen with alcohol.

2)

Explain that acetaminophen increases the risk for bleeding.

3)

Advise taking acetaminophen with meals to prevent gastric irritation.

4)

Explain that physical dependence may occur with long-term oral use.

ANS: 1

Even in recommended doses, acetaminophen can cause hepatotoxicity in those who consume alcohol. Therefore, the nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases the risk for bleeding because it inhibits platelet aggregation. Nonsteroidal anti-inflammatory drugs (NSAIDs), not acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can cause physical dependence.

PTS:1DIF:ModerateREF:p. 1103

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 20. Which side effects associated with opioid use may improve after taking a few doses of the drug?

1)

Constipation

2)

Drowsiness

3)

Dry mouth

4)

Difficulty with urination

ANS: 2

Drowsiness as well as nausea are side effects of opioid therapy that commonly improve after a few doses are administered. Other side effects include constipation, vomiting, dry mouth, and difficulty with urination. These side effects do not typically lessen with use.

PTS:1DIF:ModerateREF:p. 1104

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

____ 21. A patient develops a respiratory rate 6 breaths/minute after receiving IV hydromorphone (Dilaudid) 2 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect?

1)

Physostigmine (Antilirium)

2)

Flumazenil (Romazicon)

3)

Naloxone (Narcan)

4)

Protamine sulfate

ANS: 3

The nurse should anticipate administering naloxone to reverse the respiratory depression associated with opioid use. Flumazenil reverses the central nervous system depressant effects of benzodiazepines. Physostigmine reverses the effects of anticholinergic drugs. Protamine sulfate is the antidote for heparin.

PTS:1DIF:ModerateREF:p. 1104

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

____ 22. Which pain management task can be safely delegated to nursing assistive personnel?

1)

Assessing the quality and intensity of the patients pain

2)

Evaluating the effectiveness of pain medication

3)

Providing a therapeutic back massage

4)

Administering oral dose of acetaminophen

ANS: 3

The nurse can safely delegate providing a back massage for the patient in pain. However, the nurse should never delegate the responsibility of assessing the patients pain, monitoring the patients response to pain management strategies, administering medications (including over-the-counter preparations), or evaluating the pain management plan.

PTS:1DIF:ModerateREF:p. 1100

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 23. Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia?

1)

The patient will verbalize a reduction in pain after receiving pain medication and repositioning.

2)

The patient will rest quietly when undisturbed.

3)

On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.

4)

The patient will receive pain medication every 2 hours as prescribed.

ANS: 3

A low pain rating is the best expected outcome for the patient with a nursing diagnosis of Acute Pain secondary to surgical resection of a ruptured spleen and possible inadequate analgesia because it is specific and measurable. The patient verbalizing reduced pain is not specific enough. The nurse needs to know how much pain relief is achieved. A numeric score gives a clearer indication of the effectiveness of analgesia. The patient might have experienced a reduction in pain, but his pain level might still be intolerable. Saying the patients pain is relieved because he is resting quietly does not address the pain relief while he is awake. Some patients will sleep in an attempt to cope with pain, so this outcome could lead to inaccurate evaluation. Providing pain medication is a nursing intervention, not an expected outcome.

PTS:1DIFifficultREF:p. 1100

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis

____ 24. A patient had a bowel resection 5 days ago. Which request by the patient might alert the nurse that the patient has a history of substance abuse?

1)

Oral pain medication once every 6 to 8 hours

2)

Patient-controlled analgesic

3)

Oral pain medications instead of the IM form

4)

Only nonpharmacological pain measures

ANS: 2

The patient underwent surgery 5 days ago; if there are no complications, it is unlikely that he would require frequent dosing of analgesic. The nurse should recognize this behavior as a possible indicator of current substance abuse or addiction. Requesting oral pain medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery. Requesting an oral form of the drug does not indicate substance abuse.

PTS:1DIF:EasyREF:pp. 1109-1110

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

____ 25. A patient with Raynauds disease receives no symptomatic relief with diltiazem (Cardizem). Which surgical intervention might be a treatment option for this patient to help provide symptomatic relief?

1)

Cordotomy

2)

Rhizotomy

3)

Neurectomy

4)

Sympathectomy

ANS: 4

Sympathectomy severs the pathways to the sympathetic nervous system. The procedure improves vascular blood supply and eliminates vasospasm. It is effective for treatment of pain associated with vascular disorders, such as Raynauds disease. Cordotomy interrupts pain and temperature sensation below the tract that is severed. This procedure is commonly performed to relieve trunk and leg pain. Rhizotomy interrupts the anterior or posterior nerve route located between the ganglion and the cord. It is commonly used to treat head and neck pain. Neurectomy is used to eliminate intractable localized pain. The pathways of peripheral or cranial nerves are interrupted to block pain transmission.

PTS:1DIF:ModerateREF:p. 1108

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Recall

____ 26. Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale?

1)

Stimulate the patient.

2)

Prepare to administer naloxone (Narcan).

3)

Administer a dose of pain medication.

4)

Notify the physician immediately.

ANS: 1

If the patients score on the sedation rating scale is equal to or greater than 4, the nurse should first stimulate the patient. He should next notify the physician. The nurse should consider administering naloxone, as prescribed, if the patients respiratory rate is less than 8 breaths/minute; if respirations are shallow with marginal or falling oxygen saturation; or if the patient is unresponsive to stimulation. Before the patient receives another dose of pain medication, the dose should most likely be reduced and other potential causes of sedation should be investigated.

PTS:1DIFifficultREF:p. 1106

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 27. A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient?

1)

Anticoagulant therapy

2)

Diabetes mellitus

3)

Hypertension

4)

Embolectomy

ANS: 1

Patients who undergo mitral valve replacement typically require long-term anticoagulant therapy. Anticoagulant therapy is a contraindication for epidural analgesia use because of the risk for spinal hematoma and uncontrolled bleeding. Diabetes and hypertension are not contraindications for epidural analgesia. Epidural analgesia is commonly used after embolectomy because certain anesthetic agents, such as bupivacaine, help prevent vasospasm.

PTS:1DIFifficultREF:p. 1108

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

____ 28. After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviate the patients pain?

1)

Encourage the client to ambulate to promote flow of spinal fluid.

2)

Offer caffeinated beverages to constrict blood vessels in his head.

3)

Encourage coughing and deep breathing to increase CSF pressure.

4)

Restrict oral fluid intake to prevent excess spinal pressure.

ANS: 2

Treatment for a headache that occurs as a result of dural puncture consists of bedrest, analgesics as prescribed, and liberal hydration. Caffeine and a dark, quiet environment may also be helpful. Headaches will be more severe when the patient is sitting upright or ambulating. Fluid volume deficit will also aggravate a spinal headache after epidural anesthesia.

PTS:1DIFifficultREF:p. 1108

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

____ 29. An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client:

1)

Experiences less pain than in earlier stages of cancer.

2)

Cannot communicate the character of his pain effectively.

3)

Recalls pain at a later time than when it occurs.

4)

Relies on caregiver to provide pain relief without asking.

ANS: 2

There is no evidence to suggest that patients with dementia and other forms of cognitive impairment do not experience pain. It is most likely that they cannot effectively communicate the intensity or quality of pain and are therefore at risk for underassessment of pain and inadequate pain relief. Be aware of behavioral cues indicating pain rather than relying on verbal report. Failure to request pain medication is not likely a result of hesitation to ask for it out of habit or reliance on others; rather, it is likely due to inability to effectively express to the caregiver that analgesia is needed.

PTS:1DIF:ModerateREF:p. 1095

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis

____ 30. What is typically the most reliable indicator of pain?

1)

Patients self-report

2)

Past medical history

3)

Description by caregiver(s)

4)

Behavioral cues

ANS: 1

The patients self-report is the most reliable indicator of pain. A patients facial expression, vocalization, posture or position, or other behaviors do not always accurately indicate the intensity or quality of a patients experience of pain. The patient might be trying to hide signs of pain in order to be brave or strong. Sociocultural factors can influence a patients nonverbal expression of pain. Caregivers might not appreciate the extent of pain because pain is an individualized experience. Perception of pain might be heightened if other medical conditions coexist, although this perception is also influenced by other factors, such as past experience with pain and the success or failure of the treatment to produce relief. Emotions, cognitive impairment, developmental stage, communication skills, and mental health disorders, such as depression or anxiety, can influence the perception of pain.

PTS:1DIF:ModerateREF:p. 1096

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scale(s) would be appropriate to use with this patient? Choose all that apply.

1)

Visual analog

2)

Numerical rating

3)

Wong-Baker face rating

4)

Simple descriptor

ANS: 1, 3

The Wong-Baker face-rating scale uses simple illustrations of faces to depict various levels of pain. The scale was developed for children but has proved effective for adults with communication and cognitive impairments. The visual analog requires patients to point to a location on a line that reflects their pain level. Some patients have difficulty with the abstract nature of this scale. When using the numerical rating scale, the patient must choose a number from 0 to 10 to denote his pain level. This scale is sometimes difficult for clients with cognitive impairments, such as expressive aphasia; however, it would be appropriate to try it if the face-rating scale is not available. Patients commonly find the simple descriptor scale difficult to understand. This scale uses a list of adjectives that describe pain intensity.

PTS: 1 DIF: Moderate REF: pp. 1097-1098

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

____ 2. A patient diagnosed with lung cancer who is receiving morphine (MS Contin) complains of constipation. Which instruction(s) by the nurse might help relieve the patients constipation? Choose all that apply.

1)

Be sure the amount of fruit, vegetables, and fiber in your diet is adequate.

2)

Drink at least eight 8-ounce glasses of water each day.

3)

Avoid using stool softeners because they may become habit forming.

4)

Increase your exercise routine to include 1 hour of exercise a day.

ANS: 1, 2

The nurse should instruct the patient to be sure the amount of fruit, vegetables, and fiber in his diet is adequate, and increase fluid intake to eight, 8-ounce glasses of water per day. Stool softeners may also be used. The patient should also be encouraged to increase exercise; even walking a short distance may be helpful. It is not necessary to increase exercise to 1 hour of exercise a day. The patient may be physically able to walk only short distances.

PTS:1DIF:ModerateREF:p. 1105

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

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