Chapter 8 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 8

Question 1

Type: MCSA

The nurse is caring for a teenager and is assessing pain level with the vital signs. The client is reporting pain but when the nurse asks for a description of the pain the client says, It just hurts. Why cant I have something? The nurse would choose to do which of the following next?

1. Leave the room and come back later.

2. Provide questions that require yes or no answers related to pain.

3. Ask the client what they would like to have for pain.

4. Continue with the vital signs assessment.

Correct Answer: 2

Rationale 1: Leaving the room will not provide effective pain management.

Rationale 2: People who are not feeling well or who are in pain may have difficulty with open-ended questions, such as Describe. The nurse may be better able to obtain an accurate description of their pain by having them respond to descriptive words.

Rationale 3: Asking the client what she would like for pain is not appropriate without a complete assessment.

Rationale 4: If the client is in pain, moving on to the vital signs will not yield additional information.

Global Rationale: People who are not feeling well or who are in pain may have difficulty with open-ended questions, such as Describe. The nurse may be better able to obtain an accurate description of their pain by having them respond to descriptive words. Leaving the room will not provide effective pain management. Asking the client what she would like for pain is not appropriate without a complete assessment. If the client is in pain, moving on to the vital signs will not yield additional information.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.

Question 2

Type: MCSA

The nurse is working at 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? Pain is:

1. Validated by the nurse determining the cause of the pain.

2. Unpleasant sensations, typically experienced upon movement.

3. Whatever the experiencing person says it is.

4. Very subjective so observations must be used to assess levels and intensity.

Correct Answer: 3

Rationale 1: At times, the cause of the pain is not determined at the time the client reports it. The nurses role is not to validate the clients report but to assess and assist in alleviating or managing the pain.

Rationale 2: Pain involves unpleasant sensations, though not always limited to movement.

Rationale 3: The most widely accepted definition of pain is the one offered by McCaffery: whatever the experiencing person says it is, existing whenever he or she says it does (McCaffery & Pasero, 1999, p. 5).

Rationale 4: Pain is a subjective experience and the clients report of pain must be trusted in order to effectively manage it.

Global Rationale: The most widely accepted definition of pain is the one offered by McCaffery: whatever the experiencing person says it is, existing whenever he or she says it does (McCaffery & Pasero, 1999, p. 5). It involves unpleasant sensations, though not always limited to movement. At times, the cause of the pain is not determined at the time the client reports it. The nurses role is not to validate the clients report but to assess and assist in alleviating or managing the pain. Pain is a subjective experience and the clients report of pain must be trusted in order to effectively manage it.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 8.1: Provide a definition of pain.

Question 3

Type: MCSA

The client 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 what type of pain?

1. Phantom pain

2. Radiating pain

3. Intractable pain

4. Cutaneous pain

Correct Answer: 2

Rationale 1: Phantom pain is a painful sensation perceived in an absent body part or a body part that is paralyzed.

Rationale 2: The client is describing radiating pain, which has an origin in one part of the body and then spreads to other adjacent body parts.

Rationale 3: Intractable pain does not respond to relief measures.

Rationale 4: Cutaneous pain is pain experienced in the cutaneous tissues.

Global Rationale: The client is describing radiating pain, which has an origin in one part of the body and then spreads to other adjacent body parts. Phantom pain is a painful sensation perceived in an absent body part or a body part that is paralyzed. Cutaneous pain is pain experienced in the cutaneous tissues. Intractable pain does not respond to relief measures.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.1: Provide a definition of pain.

Question 4

Type: MCSA

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? The theory of:

1. Pattern.

2. Specificity.

3. Stress.

4. Gate control.

Correct Answer: 4

Rationale 1: Pattern theory implies that the pattern of the stimulus is more important than the specific stimulus. It does not address the psychosocial component of pain.

Rationale 2: Specificity theory holds that pain neurons are specific and unique and the specific pain neurons transport the sensations directly to the brain.

Rationale 3: Stress does influence a clients perception of pain but is not a specific theory.

Rationale 4: Gate control theory attempts to explain the involvement of the brain as well as nerve fibers in the pain experience. The involvement of the brain helps explain why painful stimuli are interpreted differently by people experiencing pain.

Global Rationale: Gate control theory attempts to explain the involvement of the brain as well as nerve fibers in the pain experience. The involvement of the brain helps explain why painful stimuli are interpreted differently by people experiencing pain. Specificity theory holds that pain neurons are specific and unique and the specific pain neurons transport the sensations directly to the brain. Pattern theory implies that the pattern of the stimulus is more important than the specific stimulus. It does not address the psychosocial component of pain. Stress may impact a clients perception of pain but is not a specific theory.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.2: Identify the physiology of pain.

Question 5

Type: MCSA

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

1. You should try to find out why your husband is denying the pain.

2. Have you talked to the healthcare provider about this?

3. Some people feel reporting their pain is a sign of weakness.

4. Maybe we are wrong and pain is not really bad.

Correct Answer: 3

Rationale 1: The spouse has sought assistance from the nurse. The nurse should attempt to respond to the inquiry.

Rationale 2: The spouse is asking for information that is within the scope of nursing practice. There is no need to refer to the healthcare provider at this time.

Rationale 3: Adult clients may deny the presence of pain. Sometimes the denial is an effort not to appear weak.

Rationale 4: The nonverbal behaviors indicate the presence of pain.

Global Rationale: Adult clients may deny the presence of pain. Sometimes the denial is an effort not to appear weak. The spouse has sought assistance from the nurse. The nurse should attempt to respond to the inquiry. The spouse is asking for information that is within the scope of nursing practice. There is no need to refer to the healthcare provider at this time. The nonverbal behaviors indicate the presence of pain.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.4: Discuss factors that influence pain.

Question 6

Type: MCSA

A client with chronic pain from spinal stenosis has asked the nurse for assistance with pain management. The client is well dressed and composed, with normal vital signs. The nurse observes that the client grimaces when sitting but rates the pain at only a 2. The nurse suspects which of the following? The client:

1. Needs to exercise instead of taking pain medication.

2. Is not in severe pain and does not need treatment.

3. Is getting better.

4. Has adapted to the pain and is able to control behaviors.

Correct Answer: 4

Rationale 1: The plan of care to determine interventions cannot be determined at this point.

Rationale 2: The client has stated that she is there for assistance with pain management, and the nurse has not completed the assessment.

Rationale 3: Determining that the clients condition is improving is beyond the scope of practice for the nurse.

Rationale 4: People with chronic pain develop their individual coping styles to deal with pain, discomfort, or suffering. Also, physiologic responses may be marked in acute pain but because of central nervous system adaptation, physiologic responses are likely to be absent. Therefore, behavioral and physiologic responses are not good indicators of pain.

Global Rationale: People with chronic pain develop their individual coping styles to deal with pain, discomfort, or suffering. Also, physiologic responses may be marked in acute pain but because of central nervous system adaptation, physiologic responses are likely to be absent. Therefore, behavioral and physiologic responses are not good indicators of pain. Determining that the clients condition is improving is beyond the scope of practice for the nurse. The client has stated that she is there for assistance with pain management, and the nurse has not completed the assessment. The plan of care to determine interventions cannot be determined at this point.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.4: Discuss factors that influence pain.

Question 7

Type: MCSA

The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the clients rates his pain as a 7 out of 10 (1 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. The nurse would choose which of the following actions?

1. Wait 30 minutes and see if the client is still requesting the pain medicine.

2. Administer half the ordered does of pain medication.

3. Administer the pain medication if it is has been longer than the ordered interval.

4. Notify the healthcare provider that the client is faking his pain.

Correct Answer: 3

Rationale 1: Waiting to administer the medication is inappropriate and is an action that appears to negate the clients reports.

Rationale 2: Administration of only a portion of the ordered medication places the nurse in a position of prescribing medications and is outside the nurses scope of practice.

Rationale 3: Since pain occurs whenever the experiencing person says it does and is whatever the experiencing person says it is, the nurse should accurately assess and treat the pain with the pain medication if that is what is ordered.

Rationale 4: Notification to the healthcare provider that the patient is faking the pain is inappropriate as there is no evidence of this action.

Global Rationale: Since pain occurs whenever the experiencing person says it does and is whatever the experiencing person says it is, the nurse should accurately assess and treat the pain with the pain medication if that is what is ordered. Waiting to administer the medication is inappropriate and is an action that appears to negate the clients reports. Administration of only a portion of the ordered medication places the nurse in a position of prescribing medications and is outside the nurses scope of practice. Notification to the healthcare provider that the patient is faking the pain is inappropriate as there is no evidence of this action.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.4: Discuss factors that influence pain.

Question 8

Type: MCSA

The nurse is assessing a postoperative client that reports a pain level of 10 on a 1 to 10 scale. The client is grimacing and appears anxious. Which of the following actions should the nurse perform first?

1. Administer pain medication if it has been longer than the ordered interval.

2. Offer to call the pastoral service to provide spiritual counseling.

3. Obtain an order for an anti-anxiety medication.

4. Call the family to come in and stay with the client.

Correct Answer: 1

Rationale 1: Pain needs to be well managed and pain should be assessed with vital signs. Pain is the 5th vital sign. Pain needs to be well managed with pain medications given on a scheduled basis, so that the pain does not get out of control. Once the pain is under control, the nurse can assess other factors influencing the clients pain response.

Rationale 2: Spiritual counseling may not be helpful if the pain is not managed effectively.

Rationale 3: Relieving the anxiety may help in alleviating pain and should be considered with other forms of pain management. However, relieving anxiety will be easier if the pain is managed effectively.

Rationale 4: The presence of family members may provide comfort to the client, but is not the priority intervention.

Global Rationale: Pain needs to be well managed and pain should be assessed with vital signs. Pain is the 5th vital sign. Pain needs to be well managed with pain medications given on a scheduled basis, so that the pain does not get out of control. Once the pain is under control, the nurse can assess other factors influencing the clients pain response. Spiritual counseling may not be helpful if the pain is not managed effectively. Relieving the anxiety may help in alleviating pain and should be considered with other forms of pain management. However, relieving anxiety will be easier if the pain is managed effectively. The presence of family members may provide comfort to the client, but is not the priority intervention.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.

Question 9

Type: MCMA

The nurse is assessing a client admitted with severe abdominal pain. Which of the following would the nurse include as essential components of the pain assessment?

Standard Text: Select all that apply.

1. Description of the pain

2. Temperature, pulse, respirations, and blood pressure

3. Pain intensity rating

4. Family medical history

5. Previous pain experience

Correct Answer: 1,2,3,5

Rationale 1: Description of the pain. The nurse assessing the client will need to determine characteristics of the pain. These characteristics expressed by the client will aid in the management of the condition

Rationale 2: Temperature, pulse, respirations, and blood pressure. The vital signs of the client reporting acute pain will likely provide supportive information concerning the pain being experienced.

Rationale 3: Pain intensity rating. An integral part of the definition of pain is that it is what the individual reports it to be. The degree of intensity will be needed to determine the level of pain being experienced. The degree of pain intensity assessment will be a key component in the interventions being used to manage the pain.

Rationale 4: Family medical history. While the family medical history is a component of a generalized health assessment it is not specific to the assessment of pain.

Rationale 5: Previous pain experience. An individuals past experience with pain is a determining factor in the ability to manage pain. Past experience will also impact reports of pain by the client.

Global Rationale: The nurse assessing the client will need to determine characteristics of the pain. These characteristics expressed by the client will aid in the management of the condition. The vital signs of the client reporting acute pain will likely provide supportive information concerning the pain being experienced. An integral part of the definition of pain is that it is what the individual reports it to be. The degree of intensity will be needed to determine the level of pain being experienced. The degree of pain intensity assessment will be a key component in the interventions being used to manage the pain. While the family medical history is a component of a generalized health assessment it is not specific to the assessment of pain. An individuals past experience with pain is a determining factor in the ability to manage pain. Past experience will also impact reports of pain by the client.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.5: Provide a definition of pain.

Question 10

Type: MCSA

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 understands that ibuprofens effect occurs during which phase of nocioception?

1. Transduction

2. Transmission

3. Perception

4. Modulation

Correct Answer: 1

Rationale 1: Since ibuprofen blocks the production of prostaglandin, it acts during the transduction phase.

Rationale 2: In the transmission phase, the pain impulse travels from peripheral nerve fibers to the spinal cord to the brain stem and thalamus and ultimately, to the somatic sensory cortex.

Rationale 3: Perception occurs when the client becomes aware of the pain.

Rationale 4: Modulation is the process by which neurons in the brain stem send signals back down stimulating the release of neurotransmitters that can inhibit the ascending pain impulses.

Global Rationale: Since ibuprofen blocks the production of prostaglandin, it acts during the transduction phase. In the transmission phase, the pain impulse travels from peripheral nerve fibers to the spinal cord to the brain stem and thalamus and ultimately, to the somatic sensory cortex. Perception occurs when the client becomes aware of the pain. Modulation is the process by which neurons in the brain stem send signals back down stimulating the release of neurotransmitters that can inhibit the ascending pain impulses.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.2: Identify the physiology of pain.

Question 11

Type: MCSA

A nurse working in a healthcare providers office is interviewing a client that reports experiencing daily migraines. The nurse decides to further assess the impact of the clients pain. An appropriate choice of assessment tools would be which of the following?

1. Psychologic well-being inventory

2. Body Diagram tool

3. Intensity rating scale

4. Brief Pain Inventory

Correct Answer: 4

Rationale 1: A psychological well-being inventory may yield information about the impact of pain on the clients sense of well-being but is not designed to specifically assess the elements of pain.

Rationale 2: A unidimensional tool such as the Body Diagram is useful for assessing pain severity at the time the client is experiencing pain.

Rationale 3: A unidimensional tool such as the intensity rating scale is useful for assessing pain severity at the time the client is experiencing pain.

Rationale 4: Migraine pain is chronic in nature and, therefore, a multidimensional tool such as the Brief Pain Inventory is the most useful for assessing two or more elements of the pain and the impact of pain on daily living.

Global Rationale: Migraine pain is chronic in nature and, therefore, a multidimensional tool such as the Brief Pain Inventory is the most useful for assessing two or more elements of the pain and the impact of pain on daily living. A unidimensional tool such as the Body Diagram and intensity rating scale is useful for assessing pain severity at the time the client is experiencing pain. A psychological well-being inventory may yield information about the impact of pain on the clients sense of well-being but is not designed to specifically assess the elements of pain.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.

Question 12

Type: MCSA

The nurse understands amount of pain stimulation that is needed for an individual to feel pain is referred to as:

1. Pain threshold.

2. Pain tolerance.

3. Somatic interval.

4. Cephalgia reporting.

Correct Answer: 1

Rationale 1: The pain threshold is the amount of pain stimulation a person requires in order to feel pain.

Rationale 2: Pain tolerance refers to the ability of an individual to manage differing levels of discomfort.

Rationale 3: Somatic interval is not legitimate pain terminology.

Rationale 4: Cephalgia reporting is not legitimate pain terminology.

Global Rationale: The pain threshold is the amount of pain stimulation a person requires in order to feel pain. Pain tolerance refers to the ability of an individual to manage differing levels of discomfort. Somatic interval and cephalgia reporting are not legitimate pain terminology.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 8.2: Identify the physiology of pain.

Question 13

Type: MCSA

The nurse is examining a client is in the Emergency Department. The client has recently been discharged after a right above-the-knee amputation. The client tells the nurse that her right foot hurts. The nurse suspects what type of pain?

1. Phantom pain

2. Radiating pain

3. Intractable pain

4. Cutaneous pain

Correct Answer: 1

Rationale 1: The client is describing phantom pain, which is a painful sensation perceived in an absent body part or a body part that is paralyzed.

Rationale 2: Radiating pain has an origin in one part of the body and then spreads to other adjacent body parts.

Rationale 3: Intractable pain does not respond to relief measures.

Rationale 4: Cutaneous pain is pain experienced in the cutaneous tissues.

Global Rationale: The client is describing phantom pain, which is a painful sensation perceived in an absent body part or a body part that is paralyzed. Radiating pain has an origin in one part of the body and then spreads to other adjacent body parts. Intractable pain does not respond to relief measures. Cutaneous pain is pain experienced in the cutaneous tissues.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.3: Describe the different types of pain.

Question 14

Type: MCMA

The nurse is assessing a client admitted with chronic back pain. Which of the following would the nurse associate with this type of pain?

Standard Text: Select all that apply.

1. Sudden onset

2. Interferes with daily activities

3. Lower intensity

4. Prolonged in duration

5. Sharp elevations in body temperature

Correct Answer: 2,4

Rationale 1: Sudden onset. Chronic pain is recurring and persists for a period of 6 months or longer.

Rationale 2: Interferes with daily activities. Chronic pain invades the life of a client. The daily activities of the client with chronic pain are impacted.

Rationale 3: Lower intensity. The level of intensity experienced by the client with chronic pain will vary. It is not necessarily low in intensity.

Rationale 4: Prolonged in duration. By definition, chronic pain lasts for a period of 6 months or longer.

Rationale 5: Sharp elevations in body temperature. Sharp elevations in vital signs are not associated with chronic pain.

Global Rationale: Chronic pain is recurring and persists for a period of 6 months or longer. It invades the life of a client, impacting the daily activities of the client. The level of intensity experienced by the client with chronic pain will vary. It is not necessarily low in intensity. Sharp elevations in vital signs are not associated with chronic pain.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.3: Describe the different types of pain.

Question 15

Type: MCSA

The parents of a 13-month-old infant requiring a veinipuncture for laboratory studies ask the nurse what they can do to help with pain during the procedure. Which of the following would be the best action for the nurse to take?

1. Have the parents leave the area during the procedure.

2. Tell the parents to touch and reassure the infant during the procedure.

3. Wait until the infant is asleep to do the procedure.

4. Administer an analgesic 30 minutes before the procedure.

Correct Answer: 2

Rationale 1: Having the parents leave the area may cause the infant to react very strongly to the painful stimulus.

Rationale 2: The nurse understands that the presence of supportive people may affect the infants perception of the severity of the pain, and provide reassurance and security.

Rationale 3: Being awakened from a sound sleep by painful stimuli may cause the infant to react very strongly.

Rationale 4: Administering an analgesic is inappropriate as the infant is not yet experiencing the pain, and after the relatively quick procedure is over, the infant should no longer feel any pain.

Global Rationale: The nurse understands that the presence of supportive people may affect the infants perception of the severity of the pain, and provide reassurance and security. Administering an analgesic is inappropriate as the infant is not yet experiencing the pain, and after the relatively quick procedure is over, the infant should no longer feel any pain. Having the parents leave the area may cause the infant to react very strongly to the painful stimulus, as will being awakened from a sound sleep by painful stimuli.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.4: Discuss factors that influence pain.

Question 16

Type: MCSA

A recently licensed nurse states, My client keeps saying he is in pain. I dont believe him because I had the same surgery last year and didnt feel nearly as bad as he claims. What response by the more experienced nurse is most appropriate?

1. It sounds as if your client is a drug seeker.

2. You should contact the healthcare provider.

3. I would call the nursing supervisor for this one.

4. Pain differs from person to person.

Correct Answer: 4

Rationale 1: There is no evidence that this client is drug seeking.

Rationale 2: Contact with the healthcare provider is premature at this time.

Rationale 3: Contact with the nursing supervisor is premature at this time.

Rationale 4: Pain has been defined as whatever the experiencing person says it is, existing whenever he or she says it does. Pain reports will vary between people.

Global Rationale: Pain has been defined as whatever the experiencing person says it is, existing whenever he or she says it does. Pain reports will vary between people. There is no evidence that this client is drug seeking. Contact with the healthcare provider and nursing supervisor is premature at this time.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.4: Discuss factors that influence pain.

Question 17

Type: MCMA

The nurse is performing an assessment on a 23-year-old client who is being seen for chronic back pain. During the assessment, which of the following findings can be anticipated?

Standard Text: Select all that apply.

1. Increased pulse rate

2. Increased respiratory rate

3. Normal pulse rate

4. Normal blood pressure

5. Diaphoresis

Correct Answer: 3,4

Rationale 1: Increased pulse rate. The heart rate of the client in chronic pain will be within normal limits. The heart rate will more likely be increased in the client with acute pain.

Rationale 2: Increased respiratory rate. The respiratory rate of the client experiencing chronic pain will most likely be within normal levels. The respiratory rate will most likely increase in the client with acute pain.

Rationale 3: Normal pulse rate. The pulse rate of the client experiencing chronic pain will likely be within normal limits. Elevations in pulse rate are seen in clients experiencing acute pain.

Rationale 4: Normal blood pressure. The blood pressure findings in the client experiencing chronic pain will most likely be within normal limits. Elevations are most often seen in clients experiencing acute pain.

Rationale 5: Diaphoresis. Diaphoresis is seen most likely in the client in acute pain, not chronic pain.

Global Rationale: The heart rate, respiratory rate, and blood pressure of the client in chronic pain will likely be within normal limits. The heart rate, respiratory rate, and blood pressure will more likely be increased in the client with acute pain. Diaphoresis is seen most likely in the client in acute pain, not chronic pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.2 Identify the physiology of pain

Question 18

Type: MCMA

The nurse is caring for a 3-year-old child who has been hospitalized for internal fixation of a fractured arm. The nurse is considering nonpharmacological pain management techniques to implement. What interventions should be included in the plan of care?

Standard Text: Select all that apply.

1. Offer a glucose-coated pacifier.

2. Sit with the child and allow her to blow bubbles.

3. Explain to the child the cause of the pain.

4. Teach the use of guided imagery.

5. Hold the child.

Correct Answer: 2,5

Rationale 1: Offer a glucose coated pacifier. The use of a glucose-coated pacifier is most effective with an infant in the management of pain.

Rationale 2: Sit with the child and allow her to blow bubbles. Blowing bubbles is an age-appropriate activity for the preschool-age child. The child can be encouraged to blow the pain away.

Rationale 3: Explain to the child the cause of the pain. A child at the age of 3 is too young to grasp a discussion of the causes of the pain being experienced.

Rationale 4: Teach the use of guided imagery. Age-appropriate guided imagery is not a successful nonpharmacological means to manage pain in a preschool-age child. This may be helpful for the school-age child.

Rationale 5: Hold the child: The preschool-age child will find comfort in being held during the pain.

Global Rationale: The use of a glucose-coated pacifier is most effective with an infant in the management of pain. Blowing bubbles is an age-appropriate activity for the preschool-age child. The child can be encouraged to blow the pain away. A child at the age of 3 is too young to grasp a discussion of the causes of the pain being experienced. Age-appropriate guided imagery is not a successful nonpharmacological means to manage pain in a preschool-age child. This may be helpful for the school-age child. The preschool-age child will find comfort in being held during the pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.

Question 19

Type: MCMA

A client has multiple fractures following a motor vehicle accident. One of the client outcomes of the nurses plan of care includes reducing the perception of pain. Which of the following nursing interventions would apply to reaching this outcome?

Standard Text: Select all that apply.

1. Offering a selection of musical CDs

2. Assisting with guided imagery

3. Administering Demerol (Meperidine) intravenously

4. Providing instruction on deep breathing techniques

5. Administering an anti-inflammatory medication

Correct Answer: 1,2,4

Rationale 1: Offering a selection of musical CDs. The use of music is a means to assist the client to shift the focus from the pain to something else. This will help in reducing the perception of pain.

Rationale 2: Assisting with guided imagery. Guided imagery allows the client to focus on a calmer, more positive place or sensation. This allows the focus to divert from the pain. This is a means to reduce the perception of pain.

Rationale 3: Administering Demerol (Meperidine) intravenously. The administration of narcotic analgesics does not work to diminish the perception. These medications work to reduce the transmission of the pain to the clients nerve sensors.

Rationale 4: Providing instruction on deep breathing techniques. The use of therapeutic techniques will reduce the clients sensation of pain being experienced.

Rationale 5: Administering an anti-inflammatory medication. The medication will reduce discomfort by reducing the inflammation. This method does not reduce the perception of the pain. The medications reduce inflammation, thus reducing the incidence of pain, not the perception of it.

Global Rationale: The use of music, guided imagery, and deep breathing techniques are means to assist the client to shift the focus from the pain to something else. This will help in reducing the perception of pain. The administration of narcotic analgesics does not work to diminish the perception. These medications work to reduce the transmission of the pain to the clients nerve sensors. Anti-inflammatory medication will reduce discomfort by reducing the inflammation. This method does not reduce the perception of the pain. The medications reduce inflammation, thus reducing the incidence of pain, not the perception of it.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.4: Discuss factors that influence pain.

Question 20

Type: MCSA

A 45-year-old 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 of the following responses by a nursing peer is the best example of being a client advocate?

1. I just think this client needs more because of his age.

2. Have you tried getting the doctor to order oral pain medications to see if they work?

3. Wouldnt you want all of the pain medication you could have if you were in traction?

4. Everyone does not have the same pain perception or response to a similar injury.

Correct Answer: 4

Rationale 1: Pain threshold does not appear to change specifically with aging.

Rationale 2: Traditionally oral pain medications are used to manage less severe reports of pain. The client in the scenario has uncontrolled pain. The client in the scenario has uncontrolled pain. The best course of action for the nurse is to educate the colleague about the individuality of the pain experience.

Rationale 3: A nurses personal attitudes or perceptions should not influence the care that is provided to a client.

Rationale 4: Based on the definition by McCaffery & Pasero pain is whatever the experiencing person says it is, existing whenever he or she says it does. This definition supports each clients need for individualized pain management approaches.

Global Rationale: Based on the definition by McCaffery & Pasero, pain is whatever the experiencing person says it is, existing whenever he or she says it does. This definition supports each clients need for individualized pain management approaches. Pain threshold does not appear to change with aging. Traditionally oral pain medications are used to manage less severe reports of pain. The client in the scenario has uncontrolled pain. The client in the scenario has uncontrolled pain. The best course of action for the nurse is to educate the colleague about the individuality of the pain experience. A nurses personal attitudes or perceptions should not influence the care that is provided to a client.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.4: Discuss factors that influence pain

Question 21

Type: MCSA

A nursing student is reviewing the home medications of a client who has just been admitted with chronic back pain. When asked by the nursing instructor why there is a tricyclic antidepressant on the clients list, which response by the student is most likely the accurate reason?

1. I would think having chronic pain would make the client depressed.

2. It may be to prevent depression due to physical limitations.

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

4. The client is at risk for suicidal thoughts related to the chronic pain.

Correct Answer: 3

Rationale 1: This medication is not being used to prevent or manage depression.

Rationale 2: This medication is not being used to prevent or manage depression.

Rationale 3: Tricyclic antidepressants can inhibit the reuptake of norepinephrine and serotonin. This would assist with the modulation phase of pain response by decreasing the pain stimuli response.

Rationale 4: This medication is not being used to reduce the incidence of suicidal thoughts.

Global Rationale: Tricyclic antidepressants can inhibit the reuptake of norepinephrine and serotonin. This would assist with the modulation phase of pain response by decreasing the pain stimuli response. This medication is not being used to prevent depression, manage depression, or reduce the incidence of suicidal thoughts.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.2: Identify the physiology of pain.

Question 22

Type: MCSA

The nursing student is discussing an assigned clients pain responses with the nursing instructor. The student reports feeling amazed about how the client has continued to avoid taking any analgesics only hours after surgery. What response by the nursing instructor is indicated?

1. Sometimes clients just dont need any analgesics.

2. Have you seen any nonverbal cues that might indicate the client is experiencing pain?

3. We will need to contact the healthcare provider to report the clients continued refusal of analgesics.

4. Do the clients vital signs indicate the client is experiencing pain?

Correct Answer: 2

Rationale 1: Sometimes clients just dont need any analgesics. A variety of factors will influence a clients perception of pain and willingness to receive analgesics.

Rationale 2: Have you seen any nonverbal cues that might indicate the client is experiencing pain? The nurse will need to promote a comprehensive assessment of the clients pain experience. Nonverbal behaviors will need to be considered. Some clients may be stoic with the pain experience.

Rationale 3: We will need to contact the healthcare provider to report the clients continued refusal of analgesics. There is no need to contact the healthcare provider at this time.

Rationale 4: Do the clients vital signs indicate the client is experiencing pain? The clients vital signs should be considered in the assessment of pain but they are not the priority consideration

Global Rationale: A variety of factors will influence a clients perception of pain and willingness to receive analgesics. The nurse will need to promote a comprehensive assessment of the clients pain experience. Nonverbal behaviors will need to be considered. Some clients may be stoic with the pain experience. There is no need to contact the healthcare provider at this time. The clients vital signs should be considered in the assessment of pain but they are not the priority consideration.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.4: Discuss factors that influence pain.

Question 23

Type: MCMA

The nurse is performing a physical assessment on a client with undiagnosed back pain. The client is unable to communicate verbally. Which of the following vital sign values would indicate to the nurse that the client is in acute pain?

Standard Text: Select all that apply.

1. Temperature of 100.6 degrees:

2. Pulse rate 94

3. Respiratory rate 32

4. Blood pressure 158/92

5. Facial grimacing

Correct Answer: 2,3,4,5

Rationale 1: Temperature of 100.6 degrees. The client may be diaphoretic with acute pain, but not directly as a result of a low-grade temperature.

Rationale 2: Pulse rate 94. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure.

Rationale 3: Respiratory rate 32. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure.

Rationale 4: Blood pressure 158/92. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure.

Rationale 5: Facial grimacing. Facial grimacing may be noted in the expressions of the client experiencing acute pain.

Global Rationale: The client may be diaphoretic with acute pain, but not directly as a result of a low-grade temperature. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Facial grimacing may be noted in the expressions of the client experiencing acute pain.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8.2: Describe the physiology of pain.

Question 24

Type: MCSA

A client with a history of cardiac problems is brought to the emergency room by the paramedics with a tentative diagnosis of myocardial infarction (MI, or heart attack). The paramedic tells the nurse that the client had pain in the jaw area that was not relieved with nitroglycerin. The client asks the nurse how jaw pain is related to having a heart attack. The nurses best explanation is:

1. The doctors would rather treat you as a cardiac client until they find out why the nitroglycerin did not work.

2. Sometimes cardiac pain is not just in your chest, but in your jaws, arms or back.

3. You may have been so stressed that you clenched your jaws and not realized if you had any chest pain or not.

4. It may not be related, but cardiac pain is so serious to investigate and treat.

Correct Answer: 2

Rationale 1: It is inappropriate for the nurse to indicate the healthcare provider is treating the client in a manner without certainty.

Rationale 2: Referred pain may result when pain is felt in tissues that are not in close proximity to the primary cause or site of the pain. This may be especially true of cardiac pain. It may be exhibited in the jaw, shoulders, arms, or back.

Rationale 3: Clenching teeth would not be linked to chest pain.

Rationale 4: While cardiac pain is serious, this response does not meet the level of client questioning.

Global Rationale: Referred pain may result when pain is felt in tissues that are not in close proximity to the primary cause or site of the pain. This may be especially true of cardiac pain. It may be exhibited in the jaw, shoulders, arms, or back. It is inappropriate for the nurse to indicate the healthcare provider is treating the client in a manner without certainty. Clenching teeth would not be linked to chest pain. While cardiac pain is serious, this response does not meet the level of client questioning.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.2: Identify the physiology of pain.

Question 25

Type: MCSA

A 12-year-old client is brought to the emergency room after falling on his arm during a football game. When the nurse tells the client that she is going to administer pain medication through the intravenous line, the client begins to scream and wave his unhurt arm. The parents ask the nurse why their child is behaving this way. The nurses best response would be:

1. He is just immature for his age.

2. I am sure he is just scared.

3. It looks like he may have hurt his head during the fall.

4. He may be remembering another time when he got a shot.

Correct Answer: 4

Rationale 1: There is no information to indicate that the client is immature for age.

Rationale 2: Assuming the child is just scared is not something the nurse can be sure of, as it is never safe to assume anything as a definite.

Rationale 3: There is no information to indicate the presence of a head injury.

Rationale 4: A clients nervous system responds to pain, but many times there are also behavioral responses. A clients pain reaction may be a behavioral response to a similar or previous situation when pain was experienced. This is a learned response and method of coping with the pain. Many children remember getting a shot for pain, or getting an immunization. Seeing the syringe and/or needle may trigger this pain reaction.

Global Rationale: A clients nervous system responds to pain, but many times there are also behavioral responses. A clients pain reaction may be a behavioral response to a similar or previous situation when pain was experienced. This is a learned response and method of coping with the pain. Many children remember getting a shot for pain, or getting an immunization. Seeing the syringe and/or needle may trigger this pain reaction. Assuming the child is just scared is not something the nurse can be sure of, as it is never safe to assume anything as a definite. There is no information to indicate the presence of a head injury or that the client is immature for age.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 8.4: Describe factors influencing pain.

Question 26

Type: MCSA

A nurse is orienting to a new position in an infant nursery. When the healthcare provider is preparing to perform a circumcision on a 2-day-old newborn who was born 2 weeks early, the nurse asks about the administration of pain medication prior to the procedure. The healthcare provider states: Newborns do not have pain at this age, so why should we give any medication? The nurses best response would be:

1. I would think it would make the parents feel better to know it had been given.

2. I am going to have to report you to the ethics board.

3. Pain transmission has been documented in infants of this age.

4. What will it hurt to just go ahead and give it?

Correct Answer: 3

Rationale 1: The emotional well-being of the parents is of interest but does not address the question being asked.

Rationale 2: Reporting the healthcare provider to the ethics board is not indicated as the healthcare provider has not acted in a manner consistent with a violation of ethics.

Rationale 3: Research has changed the perception that infants do not feel pain. Performing procedures that may induce pain necessitates that pain management interventions should be implemented. An infant may have pain interventions based upon behavioral responses exhibited.

Rationale 4: Asking for the medication to be given does not meet the question being asked.

Global Rationale: Research has changed the perception that infants do not feel pain. Performing procedures that may induce pain necessitates that pain management interventions should be implemented. An infant may have pain interventions based upon behavioral responses exhibited. The emotional well-being of the parents is of interest but does not address the question being asked. Reporting the healthcare provider to the ethics board is not indicated as the healthcare provider has not acted in a manner consistent with a violation of ethics. Asking for the medication to be given does not meet the question being asked.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.2: Identify the physiology of pain

Question 27

Type: MCSA

Which of the following assessment data will be most reflective of a clients pain response following open-heart surgery?

1. Family report of pain

2. Response from the client based on use of a pain tool

3. Observations of the clients behaviors while asleep

4. Measurement of vital signs

Correct Answer: 2

Rationale 1: The family may perceive the client to be in pain when she is not.

Rationale 2: The use of a standardized pain tool that has been discussed with the client preoperatively will provide the most useful data.

Rationale 3: Observations of behavior while the client is asleep may indicate pain, but use of a tool while the client is awake would be more accurate.

Rationale 4: Vital sign changes may be a result of the bodys response to surgery and not just specifically to pain.

Global Rationale: The use of a standardized pain tool that has been discussed with the client preoperatively will provide the most useful data. The family may perceive the client to be in pain when she is not. Observations of behavior while the client is asleep may indicate pain, but use of a tool while the client is awake would be more accurate. Vital sign changes may be a result of the bodys response to surgery and not just specifically to pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.

Question 28

Type: MCSA

The nurse is interviewing a 75-year-old client who is in the healthcare providers office for complaints of joint pain. The client verbalizes that the pain has been present for a few years. When planning interview questions to ask concerning the pain, the nurse recognizes which of the following?

1. Clients start to complain of many types of pain as they age.

2. The joint pain is probably not the real reason the client is in the office.

3. The client is most likely depressed.

4. Older adults frequently avoid seeking treatment for their pain.

Correct Answer: 4

Rationale 1: Older clients typically do not complain of pain. They may fear that the treatment prescribed may limit their independence.

Rationale 2: There is no other information given to suggest that the client has another cause for the visit.

Rationale 3: There is no other information given to suggest that the client is depressed.

Rationale 4: The older adult may perceive pain as part of the aging process. They may fear that the treatment prescribed may limit their independence.

Global Rationale: The older adult may perceive pain as part of the aging process. They typically do not complain of pain. They may fear that the treatment prescribed may limit their independence. There is no other information given to suggest that the client is depressed or has another cause for the visit.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.

Question 29

Type: MCSA

A 19-year-old Arab male is in the hospital for a ruptured appendix. His parents are at the bedside the majority of his waking hours. The nurse caring for him during the day observes that he denies any pain during the day shift. The night nurse reported that the client had requested pain medication every 4 hours during the night. The nurse considers the most probable explanation for this to be:

1. The night nurse had more time to spend with the client.

2. The client must be afraid or lonely at night and is trying to get attention.

3. The client may not report pain in the presence of his parents based on their influence or cultural beliefs.

4. The client was asking for medication at night to help him sleep.

Correct Answer: 3

Rationale 1: There is no information provided to indicate the night nurse spent more time with the client than the day/evening shifts.

Rationale 2: There is no indication the client is afraid or lonely.

Rationale 3: A client may have ethnic or cultural beliefs that influence the response to pain. Some clients may be verbal and open, while some clients may choose to be quiet and suffer with the pain. The presence of family members, especially adult family members in this situation, may influence the reporting of pain. The client may have not wanted to contradict the perceived parental expectations of how an adult Arab male was to respond to pain.

Rationale 4: There is no indication the client is experiencing difficulty sleeping.

Global Rationale: A client may have ethnic or cultural beliefs that influence the response to pain. Some clients may be verbal and open, while some clients may choose to be quiet and suffer with the pain. The presence of family members, especially adult family members in this situation, may influence the reporting of pain. The client may have not wanted to contradict the perceived parental expectations of how an adult Arab male was to respond to pain. There is no information provided to indicate the night nurse spent more time with the client than the day/evening shifts. There is no indication the client is afraid or lonely. Many healthcare providers routinely order hypnotic medications. There is no indication the client is experiencing difficulty sleeping.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.4: Describe factors influencing pain.

Question 30

Type: MCSA

The nurse has completed a shift assessment on a client who has terminal breast cancer with extensive metastasis. The client tells the nurse, Nothing helps the pain. What best describes the pain being experienced by the client?

1. The client is experiencing referred pain.

2. The client is experiencing intractable pain.

3. The client is experiencing retractable pain.

4. The client is experiencing radiating pain.

Correct Answer: 2

Rationale 1: Referred pain refers to pain that is felt in an area that is physically distant to the affected area.

Rationale 2: Intractable pain refers to pain that is not controllable. It is often associated with an advanced malignancy.

Rationale 3: Retractable pain does not exist.

Rationale 4: Radiating pain refers to pain that extends to surrounding areas of the body.

Global Rationale: Intractable pain refers to pain that is not controllable. It is often associated with an advanced malignancy. Referred pain refers to pain that is felt in an area that is physically distant to the affected area. Retractable pain does not exist. Radiating pain refers to pain that extends to surrounding areas of the body.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 8.2: Identify the physiology of pain.

Question 31

Type: SEQ

The nurse is preparing to complete the admission assessment for a client who is being admitted to the acute care facility for complaints of severe pain. As the nurse plans actions relating to this task, the following steps will be taken. Organize in order the actions that should be taken by the nurse.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Contact the healthcare provider.

Choice 2. Discuss the unit routine with the client and family.

Choice 3. Ask the client when the pain first began.

Choice 4. Ask the client what helps to relieve the pain.

Choice 5. Assess the clients past coping methods for pain throughout her life.

Correct Answer: 3,4,5,2,1

Rationale 1: Contact the healthcare provider. The healthcare provider will need to be contacted about the current condition of the client but this cannot be completed until the client has been assessed. The assessment information will allow the nurse to provide information to the healthcare provider.

Rationale 2: Discuss the unit routine with the client and family. The client and family need to have information provided concerning unit policies but this is not an immediate task. Management of the clients admission data collection takes precedence.

Rationale 3: Ask the client when the pain first began. Determining the duration of the pain is the most important step that must be taken by the nurse. This information will provide a guide for the remaining information that will be sought from the client.

Rationale 4: Ask the client what helps to relieve the pain. The client in pain has likely been employing methods to manage the discomfort at home. Determining the measures being taken away from the acute care facility will help to lead the health care team in managing the current pain. This information can also be used to help indicate the severity of pain being experienced.

Rationale 5: Assess the clients past coping methods for pain throughout her life. An individuals methods of coping with pain will help to determine her tolerance and ability to manage current pain. This information is needed but does not take priority over assessing the duration of the pain being experienced or the methods being used to manage the current pain.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain

Leave a Reply