- A student asks the nurse what is the best way to assess a client’s pain. Which response by the nurse is best? a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Client’s self-report
ANS: D
Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objec- tive observations. However, the most accurate way to assess pain is to get a self-report from the client.
- A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best?
a. “Being able to sleep doesn’t mean pain doesn’t exist.”
b. “Have you ever experienced any type of pain?”
c. “The client should be assessed for drug addiction.”
d. “You’re right; I would put the medication back.”
ANS: A
A client’s description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not su- persede the client’s descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and ippant, and does not provide useful information. This amount of information does not war-
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rant an assessment for drug addiction. Putting the medication back and ignoring the client’s report of pain serves no useful purpose.
- The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the client’s long-term outcome?
a. “At least you know that the pain after surgery will diminish quickly.”
b. “Discuss acceptable pain control after your operation with the surgeon.”
c. “Opioids often cause nausea but you won’t have to take them for long.”
d. “The nursing sta will give you pain medication when you ask them for it.”
ANS: B
The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likeli- hood of chronic pain afterward. The nurse suggests that the client advocate for himself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side eects from opi- oids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.
- A nurse is assessing pain on a confused older client who has di culty with verbal expression. What pain as- sessment tool would the nurse choose for this assessment?
a. Numeric rating scale
b. Verbal Descriptor Scale
c. FACES Pain Scale-Revised
d. Wong-Baker FACES Pain Scale
ANS: C
All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is pre- ferred by both cognitively intact and cognitively impaired adults.
- The nurse is assessing a client’s pain and has elicited information on the location, quality, intensity, e ect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment?
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a. “Are you worried about addiction to pain pills?” b. “Do you attach any spiritual meaning to pain?”
c. “How high would you say your pain tolerance is?” d. “What pain rating would be acceptable to you?”
ANS: D
A comprehensive pain assessment includes the items listed in the question plus the client’s opinion on a func- tional goal, such as what pain rating would be acceptable to him or her. Asking about addiction is not warrant- ed in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important infor- mation, but getting the basics rst is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged
- A nurse is assessing pain in an older adult. What action by the nurse is best? a. Ask only “yes-or-no” questions so the client doesn’t get too tired.
b. Give the client a picture of the pain scale and come back later.
c. Question the client about new pain only, not normal pain from aging.
d. Sit down, ask one question at a time, and allow the client to answer.
ANS: D
Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication tech- nique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the client may not know how to use it. There is no normal pain from aging.
- The nurse receives a hand-o report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is “on the light constantly” asking for more pain medication. When assessing this client’s pain, what statement or question by the nurse is most appropriate?
a. “Help me understand how pain is a ecting you right now.”
b. “I wish I could do more; is there anything I can get for you?” c. “You cannot have more pain medication for 3 hours.”
d. “Why do you think the medication is not helping your pain?”
ANS: A
This is an example of therapeutic communication. A client who is preoccupied with physical symptoms and is “demanding” may have some psychosocial impact from the pain that is not being addressed. The nurse is pro- viding the client the chance to explain the emotional eects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more
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about the pain. Simply telling the client when the next medication is due also does not help the nurse under- stand the client’s situation. “Why” questions are probing and often make clients defensive, plus the client may not have an answer for this question.
- A nurse on the medical-surgical unit has received a hand-o report. Which client should the nurse see rst? a. Client being discharged later on a complicated analgesia regimen
b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
c. Postoperative client who received oral opioid analgesia 45 minutes ago
d. Client who has returned from physical therapy and is resting in the recliner
ANS: B
Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset ab- dominal pain needs to be seen rst. The postoperative client needs 45 minutes to an hour for the oral medica- tion to become eective and should be seen shortly to assess for eectiveness. The client going home requires teaching, which should be done after the rst two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.
- A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?
a. Assess physiologic indicators and vital signs.
b. Do not give pain medication as no pain is indicated.
c. Document the ndings and continue to monitor.
d. Try a small dose of analgesic medication for pain.
ANS: A
Assessing pain in a nonverbal client is dicult despite the use of a scale specically designed for this popula- tion. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be dicult to assess for eectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse does need to treat the client for pain.
- A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best?
a. “A multimodal approach is the preferred method of control.”
b. “Doctors are much more liberal with pain medications now.”
c. “Pain is so complex it takes di erent approaches to control it.”
d. “Clients are consumers and they demand lots of pain medicine.”
ANS: C
Pain is a complex phenomenon and often responds best to a regimen that uses dierent types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the student if the terminology is not understood. Doctors may be more liberal with pain medications, but that is not the best rea- son for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is dis- counting their pain experiences.
- A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the client’s care plan? a. As-needed pain medication after therapy
b. Client-controlled analgesia with a basal rate
c. Pain medications prior to therapy only
d. Round-the-clock analgesia with PRN analgesics
ANS: D
Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specic procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a good idea but needs basal (continu- ous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continu- ous, not just administered prior to therapy.
- A nurse on the postoperative inpatient unit receives a hand-o report on four clients using patient-con- trolled analgesia (PCA) pumps. Which client should the nurse see rst?
a. Client who appears to be sleeping soundly
b. Client with no bolus request in 6 hours
c. Client who is pressing the button every 10 minutes
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d. Client with a respiratory rate of 8 breaths/min
ANS: D
Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should rst check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that client’s pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.
- A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via pa- tient-controlled analgesia (PCA). What action by the student requires the RN to intervene?
a. Assesses the client’s pain level per agency policy
b. Monitors the client’s respiratory rate and sedation
c. Presses the button when the client cannot reach it
d. Reinforces client teaching about using the PCA pump
ANS: C
The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should inter- vene at this point. The other actions are appropriate.
- A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What nding in the client’s health history would lead the nurse to consult with the provider over the choice of medication?
a. 25–pack-year smoking history
b. Drinking 3 to 5 beers a day
c. Previous peptic ulcer
d. Taking warfarin (Coumadin)
ANS: B
The major serious side eect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side eects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.
- A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment ndings would lead the nurse to consult with the provider?
a. Bilateral lung crackles
b. Hypoactive bowel sounds
c. Self-reported pain of 3/10
d. Urine output of 20 mL/2 hr
ANS: D
Drugs in this category can aect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the- clock regimen to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client if he or she still wants it.
- A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?
a. Assess and record the client’s pain every 4 hours.
b. Ensure the client is eating a high- ber diet.
c. Monitor the client’s bowel function every shift.
d. Remove the old patch when applying the new one.
ANS: D
The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not oc- cur. The other actions are appropriate, but not as important for safety.
- A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose?
a. Hydrocodone and acetaminophen (Lorcet)
b. Hydromorphone (Dilaudid) c. Meperidine (Demerol)
d. Tramadol (Ultram)
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ANS: B
Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not choose Lorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadol should not be used due to the potential for interactions with the client’s sertraline. Meperidine is rarely used and is of- ten restricted.
- A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client’s oxygen saturation is 87%. What action should the nurse perform rst?
a. Apply oxygen at 4 L/min.
b. Attempt to arouse the client.
c. Give naloxone (Narcan).
d. Notify the Rapid Response Team.
ANS: B
The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the client’s respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a high- er Pasero Scale score.
- An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client?
a. Desipramine (Norpramin)
b. Duloxetine (Cymbalta)
c. Morphine sulfate
d. Nortriptyline (Pamelor)
ANS: B
Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, older adults do not tolerate tricyclic antidepressants very well, which eliminates de- sipramine and nortriptyline. Duloxetine would be the best choice for this older client.
- An emergency department (ED) manager wishes to start o ering clients nonpharmacologic pain control methodologies as an adjunct to medication. Which strategy would be most successful with this client popula- tion?
a. Listening to music on a headset
b. Participating in biofeedback c. Playing video games
d. Using guided imagery
ANS: A
Listening to music on a headset would be the most successful cognitive-behavioral pain control method for sev- eral reasons. First, in the ED, the nurse does not have time to teach clients complex modalities such as guided imagery or biofeedback. Second, clients who are anxious and in pain may not have good concentration, limiting the usefulness of video games. Playing music on a headset only requires the client to wear the headset and can be benecial without strong concentration. A wide selection of music will make this appealing to more people.
- An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important?
a. Discuss the need for home health care.
b. Give the client follow-up information.
c. Provide written discharge instructions.
d. Request a home safety assessment.
ANS: D
All these activities are appropriate when discharging a client whose needs will continue after discharge. A home safety assessment would be most important to ensure the safety of this older client.
- A nurse is caring for four clients receiving pain medication. After the hand-o report, which client should the nurse see rst?
a. Client who is crying and agitated
b. Client with a heart rate of 104 beats/min
c. Client with a Pasero Scale score of 4 d. Client with a verbal pain report of 9
ANS: C
The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unaccept- able somnolence and is an emergency. The nurse should see this client rst. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might bene t from talking or a com- forting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assess- ment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above nor- mal, and that client can be seen after the other two clients are cared for.
- A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?
a. Assess and record vital signs every 2 hours.
b. Have another nurse double-check the pump settings.
c. Instruct the client to report any unrelieved pain.
d. Monitor for numbness and tingling in the legs.
ANS: B
PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double-checked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling in the legs is an important function but will manifest after something has occurred to the client; moni- toring does not prevent the event from occurring.
- A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best? a. Ask the client about pain goals and if they are being met.
b. Ask the client why he or she is being uncooperative with therapy.
c. Increase the dose of analgesia given prior to therapy sessions.
d. Tell the client that physical therapy is required to regain function.
ANS: A
A comprehensive pain management plan includes the client’s goals for pain control. Adequate pain control is necessary to allow full participation in therapy. The rst thing the nurse should do is to ask about the client’s pain goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can assess for other factors inuencing the client’s behavior. Asking the client why he or she is being un- cooperative is not the best response for two reasons. First, “why” questions tend to put people on the defen- sive. Second, labeling the behavior is inappropriate. Simply increasing the pain medication may not be advanta- geous. Simply telling the client that physical therapy is required does not address the issue.
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Chapter 333
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Chapter 5419
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Chapter 5523
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Chapter 5629
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Chapter 5729
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Chapter 5825
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Chapter 5925
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PRACTICE50
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Alzheimers Disease3
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Parkinsons disease27
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lewis: hedache seizures26
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Chapter 44: iggy22
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Chapter 66; Brunner headache seizures17
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Resource 166
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Select all15
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Eye review78
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Final Review- Eye/Ear54
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Final Review- Blood16
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Final Review- Old stuff42
