focusNode
Didn't know it?
click below
Knew it?
click below
Embed Code - If you would like this activity on your web page, copy the script below and paste it into
your web page.
Normal Size Small Size show me how
| The wife of a client with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. the client is likely showing the effects of: | tolerance |
| Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort? | Endorphins |
| When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation, scoring a 4 on the Pasero & McCaffery Sedation Scale. What is the nurse's best action? | Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and naloxone |
| A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing: | visceral pain. |
| Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? | Respiratory |
| A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse? | Assess for medication prescription for breakthrough pain. |
| When asking an older adult client about abdominal pain, the client reports, “I don’t want to be a bother because nothing hurts too much.” The nurse notes that the client grimaces and splints the abdomen when moving, nurse should do? | Gently mention that the client appears to be experiencing pain that can be treated. |
| A client tells the nurse, “Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away.” Which nursing intervention will the nurse perform to practice according to the Gate Control Theory? | providing temple massage when head hurts |
| A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client? | “The pump is programmed so that it's not possible for you to overdose on your pain medication.” |
| Two hours after receiving a pain medication, the client reports still suffering from pain. Which question is most appropriate to ask the client? | “Tell me more about your pain.” |
| A nurse observes that a client who underwent knee surgery 2 weeks ago needs progressively larger doses of analgesics to get relief from pain. The nurse interprets this as: | tolerance |
| Which guideline regarding pain should be included in the nurse's education plan for a group of parents with infants and toddlers? | Pain can be a source of fear and threat to the toddler's security. |
| A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain? | increased blood pressure |
| The nurse is administering medications to a client with neuropathic pain. The client asks why he is getting an antidepressant medication since he is not depressed. What is the best response by the nurse? | "Antidepressants have been shown to have pain-relieving qualities in clients with neuropathic pain." |
| A client in pain believes that the pain is a punishment from God, and feels angry and resentful. Which is the most appropriate action by the nurse? | Encourage client to confer with a spiritual advisor. |
| The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data? | How does the pain develop and progress? |
| a 12-year-old boy was involved in an MVA. He has several broken bones and contusions. He rates his pain as a 7/10. The nurse plans to administer intravenous hydromorphone to relieve the pain. What side effect is the nurse most worried about? | Respiratory depression |
| You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so? | When obtaining patient vital signs |
| A nurse is caring for a client who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics? | sedation |
| A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain? | referred pain |
| After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client? | 3 |
| The nurse is caring for four clients. Which client does the nurse identify as the most likely to have undertreated pain? Select all that apply. | 29-year-old who has a speech impediment 34-year-old with schizophrenia 41-year-old who is from a different country 60-year-old with early onset dementia |
| A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse? | “It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression.” |
| Which assessment finding is consistent with the presence of pain? | restlessness |
| the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as: | biofeedback. |
| Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients? | Pain assessment may require multiple methods in order to ensure accurate pain data. |
| A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? | guarding of chest area |
| A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse? | Administer the pain medication. |
| The nurse is preparing to administer an NSAID to a client for pain relief. The nurse notices that the client is diagnosed with a bleeding disorder. What should the nurse do? | Contact the health care provider |
| Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take? | Reposition the client and gently massage the client’s back. |
| The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client? | Use massage and heat application to the lower back |
| A client is postoperative day 1 and the nurse's assessment reveals signs of pain, such as grimacing and guarding. Which is the most reliable method for assessing the client's pain? | Ask the client to describe and rate his or her pain. |
| After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what? | “I could use the TENS unit if I feel pain somewhere else on my body.” |
| The action of ibuprofen is to: | have an antiprostaglandin effect on the CNS. |
| A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique? | A nurse applies intermittent heat and cold to a client's leg. |
| Which of the following is considered to be the most potent neuromodulators? | Endorphins |
| A 92-year-old woman is on an inpatient unit following hip replacement surgery. The nurse asks her if she is in pain, and she tells the nurse that she is fine. The nurse knows what to be true regarding pain in the older adult? | Older adults have decreased opioid receptors. Older adults often believe that pain is a consequence of growing older. Older adults are more likely to be disabled by pain than younger adults. |
| A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action | Administer the medication if respiratory rate is > 9. |
| A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse’s best intervention in this situation? | Ask the boy to draw a cartoon about the color or shape of his pain. |
| , “Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away.” Which nursing intervention will the nurse perform to practice according to the Neuromatrix Theory? | teaching client to remove items from home that remind them of work |
| A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? | The dose that is delivered when the client activates the machine is preset. |
| The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply. | Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain. |
| A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? | The client is actively involved in pain management. |
| the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use | FLACC scale |
| Which medical client is most likely to be experiencing diffuse pain? | A client with shingles affecting her entire torso |
| A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action? | Avoid massaging this area and report the finding to the health care provider. |
| When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: | actively solicit information about the client's pain level. |
| The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use? | Wong-Baker FACES® scale |
| The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply. | Do not drive a vehicle while taking this medication. You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken. |
| The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? | A client who has a sprained ankle |
| The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate? | The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. |
| A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain? | the client's pain based on a pain rating |
| How should the nurse position the head of the bed for a client receiving epidural opioids? | Elevated 30 degrees |
| A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client? | Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. |
| Nurses assess clients who have physiologic responses to pain. Which examples of pain response are physiologic responses? Select all that apply. | Increased blood pressure Muscle tension and rigidity Nausea and vomiting |
| The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement? | “I should only take medication when my pain is intense.” |
| The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) | Encourage deep breathing. Play the client's favorite music. Promote a restful environment. |
| The client responds, “I take a little white pill to control my pain, but I don’t know the name of it,” and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention? | Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. |
| taking a history for a pregnant client who has been seen for chronic headaches for 2 years. client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess | “Can you describe the type of pain you are having?” |
| The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? | Examine the effectiveness of the current pain regimen |
| The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action? | Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. |
| When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: | actively solicit information about the client's pain level. |
| Evelyn is a 90-year-old woman who just returned from the operating room to your medical unit. She is otherwise healthy and has a history of some mild arthritis. As you examine Evelyn, you know that all of the following are signs of pain EXCEPT which? | Elevated kidney function |
| A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain? | CRIES Pain Scale |
| The nurse recognizes which statement is true of chronic pain? | It may cause depression in clients. |
| A nurse is assessing an adult client with back pain. The client is unable to speak English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain? | 0 to 10 numeric rating scale |
| A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. drug regimen as an effective method of pain control would be the client: | in the postoperative stage with occasional pain. |
| The nurse is caring for a client who has had back pain for 2 years, following a fall from a ladder. How does the nurse going off-shift report this kind of pain to the oncoming nurse? Select all that apply. | chronic somatic |
| Endogenous opioids such as endorphins: | contribute to analgesia. |
| Which client would be the best candidate to receive epidural analgesia for pain management? | A client recovering from recent hip replacement surgery |
| A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first? | Stop the PCA pump. |
| The nurse desiring to use laughter as a therapeutic modality for pain should assess for which therapeutic effects? | Decreased levels of epinephrine Increased pain threshold Increased ability to face difficult procedure |
| When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type | behavioral |
| Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take? | Reposition the client and gently massage the client’s back. |
| An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug? | The client exhibits restless, uncharacteristic behavior after receiving the drug. |
| Which medical client is most likely to be experiencing diffuse pain? | A client with shingles affecting her entire torso |
| The nurse is implementing environmental changes to promote a client’s comfort and pain management. Which action is an example of this type of intervention? | Closing the client’s room door to reduce unnecessary noises |
| Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy? | A chronic opioid therapy plan |
| a victim of domestic violence for years states to the nurse, “I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down.” Which reflects practice according to the Pattern Theory? | asking client how sensory stimuli produces pain |
| The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain? | “How long have you experienced this pain?” |
| A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? | Naloxone |
| A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as | “Acute pain tends to increase during the day and is called a routine pain response” |
| A nurse is evaluating the effectiveness of the preoperative education regarding pain control. Which statement by the client would indicate a need for further education? | "I will have my wife push the PCA button when I'm asleep." |
| A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released? | Endorphins |
| A client is prescribed pain medication every 4 to 6 hours as needed. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse? | Administer the pain medication |
Which nonpharmacologic nursing intervention is effective in helping relieve postoperative pain?
[2] According to study results, music therapy is an effective non-pharmacologic method to reduce pain severity. [18, 19] A study by Good et al. suggests that relaxation and music and combi- nation of both reduced postoperative pain.
Which pain scale should a nurse use to measure the intensity of pain in toddlers?
One behavioural tool to assess pain is the FLACC scale, for children aged two to seven. It assesses a child's pain based on their facial expression, leg and arm movements, extent of crying and ability to be consoled.
Which pain scale would the nurse use when assessing a 4 year old child?
FLACC: Face, Legs, Activity, Crying, Consolability scale has been validated from 2 mo to 7 years. FLACC uses 0-10 scoring. An example is available at: //www.anes.ucla.edu/pain/assessment_tool-flacc.htm.
Which situation would the nurse address first according to Maslow's hierarchy quizlet?
According to Maslow's hierarchy of needs, the nurse should address the physiological needs of the client first. In the given scenarios, the nurse should ideally attend to the client who complains of sleeplessness due to pain post-surgery on priority basis.