Health Assessment For Nursing Practice 5th Edition by Wilson

Health Assessment For Nursing Practice 5th Edition by Wilson

Chapter 6:

Pain Assessment Test Bank

MULTIPLE CHOICE

1. How do nurses assess a patient’s pain? a. By assessing physiologic changes of the patient b. By understanding the sensory experience related to the amount of tissue damage c. By the patient’s medical diagnosis or surgical procedure d. By asking the patient to rate the pain being experienced ANS: D Feedback A The pain perceived is unrelated to the physiologic changes of the patient. B Although pain occurs when tissues are damaged, there is no correlation between the amount of tissue damage and the degree and intensity of pain experienced. C There is no correlation between pain perceived and a medical diagnosis or surgical procedure. D Pain is whatever the patient says it is. One person cannot judge the perception or meaning of pain of another person. DIF: Cognitive Level: Understand REF: 54| 59 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain 2. The nurse notes in the patient’s history that the patient has persistent, malignant pain. What is the meaning of this type of pain? a. The pain has been present for at least 2 weeks. b. The pain began after recent surgery and is associated with healing incisions. c. The pain has been present for 6 or more months. d. The pain has been present since surgery to remove cancer. ANS: C Feedback A This time frame is too short. Chronic pain may be intermittent or continuous pain lasting more than 6 months. B This is a description of acute pain rather than chronic. C This is the definition of persistent or chronic pain. D Surgery to remove malignant tissue does not necessarily equate to malignant pain. DIF: Cognitive Level: Remember REF: 55 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain 3. A patient has had chronic back pain for several years. On assessment, the nurse notes that the patient sits quietly in a chair, reads a book, talks with a companion, and does not appear to be in pain. When questioned, the patient rates the pain as a 6 on a scale of 0 to 10. How does the nurse interpret these data? a. Many patients cannot be believed when they complain of severe pain lasting many months. b. Patients may not have the same objective responses to chronic pain because of compensation over time. c. The patient probably has already taken a very effective pain medication. d. This patient is probably not having as much pain as reported initially, and more assessment is required. ANS: B Feedback A Pain is whatever the patient says it is. Patients with chronic pain adapt to the pain and have more subtle manifestations than patients with acute pain. B Clinical manifestations of chronic pain are not those of physiologic stress because the patient adapts to the pain. C Patients with chronic pain adapt to the pain and have more subtle manifestations than patients with acute pain despite the effects of pain medication. D Pain is whatever the patient says it is. Patients with chronic pain adapt to the pain and have more subtle manifestations than patients with acute pain. DIF: Cognitive Level: Apply REF: 55 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain 4. Which patient would be expected to experience acute pain? a. A patient who had abdominal surgery 8 hours ago b. A patient who has cancer and has been receiving treatment for 4 months c. A patient who states that he or she has lived with severe pain for many years d. A patient who has been treated unsuccessfully over the past year for back pain ANS: A Feedback A Acute pain has a recent onset and results from tissue damage; is usually self-limiting; and ends when the tissue heals. B Acute pain has a recent onset and results from tissue damage; is usually self-limiting; and ends when the tissue heals. C This patient has experienced chronic pain for years. Acute pain has a recent onset and results from tissue damage; is usually self-limiting; and ends when the tissue heals. D This patient has experienced chronic pain for one year. Acute pain has a recent onset and results from tissue damage; is usually self-limiting; and ends when the tissue heals. DIF: Cognitive Level: Apply REF: 55 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain 5. Which patient has pain caused by abnormal processing of sensory input from the peripheral nervous system? a. The patient who has aching pain from muscle strain b. The patient who has burning pain along the sciatic nerve c. The patient who has cramping pain from a tumor in the colon d. The patient who has throbbing pain from arthritis ANS: B Feedback A The patient who has aching pain from muscle strain has nociceptor, somatic pain. B The patient who has burning pain along the sciatic nerve has neuropathic pain. C The patient who has cramping pain from a tumor in the colon has nociceptor, visceral pain. D The patient who has throbbing pain from arthritis has nociceptor, somatic pain. DIF: Cognitive Level: Analyze REF: 55-56 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 6. A patient reports “right shoulder pain that comes and goes” as the chief complaint. During the physical examination, the patient asks why the upper right abdomen is being examined for shoulder pain. What is the appropriate response from the nurse? a. “A comprehensive examination is required to determine the cause of your pain.” b. “There may be associated problems that have not produced any symptoms yet that we want to identify.” c. “Yes, this can be confusing, but if you will be patient I’m sure we can find something to help you.” d. “It does seem odd, but the gallbladder doesn’t have pain receptors of its own, so the pain shows up in the shoulder.” ANS: D Feedback A A focused examination is indicated at this time, not a comprehensive examination. B This patient’s pain is due to referred pain, not to associated problems that have not produced any symptoms of pain. C This response reflects concern for the patient’s pain, but does not address the patient’s questions about examining the abdomen. D Referred pain is pain felt at a site different from that of an injured or diseased organ. It commonly occurs during visceral pain because many organs have no pain receptors; thus, when afferent nerves enter the spinal cord, they stimulate sensory nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located. DIF: Cognitive Level: Apply REF: 55 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 7. A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain. He asks, “How I can be feeling pain in my foot—my foot is gone!” What is the appropriate response from the nurse? a. “After your amputation, pain perception increases.” b. “Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system.” c. “Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there.” d. “When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located.” ANS: C Feedback A “After your amputation, pain perception increases” is a definition of pain threshold. B “Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system” is a definition of neuropathic pain. C “Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there” is a definition of phantom pain. D “When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located” is a definition of referred pain. DIF: Cognitive Level: Analyze REF: 55 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 8. A patient who had extensive surgery asks the nurse for pain medication for a pain of 9 on a scale of 0 to 10. The nurse completes an assessment of this patient’s pain and agrees to give pain medication. When the nurse returns to the patient with the ordered intravenous pain medication, she notices the patient’s eyes are closed and he appears to be sleeping. What is the nurse’s appropriate action at this time? a. Lock up the medication in a safe location until the patient awakens. b. Arouse the patient to confirm he still wants the medication. c. Give the medication as ordered and agreed to. d. Consult a colleague about what action to take. ANS: C Feedback A The patient needs to receive the ordered pain medication now. B There is no reason to confirm the need for pain medication requested earlier. C Sleep is not synonymous with pain relief. When the patient reports a pain of 9 and asks for medication for which there is an order, he needs to receive the medication. D There is no reason to ask a colleague about giving the pain medication requested earlier. DIF: Cognitive Level: Apply REF: 54| 56 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain 9. In the labor and delivery department, the nurse notices that two women who are in labor are responding differently to their contractions. The first woman, who is having her first baby, has rated her pain as a “7,” seems agitated, and has asked for pain medication. The second woman, who is having her third baby, has also rated her pain as a “7,” but is calmer and says she does not need anything for pain at this time. What explains the differences in the outward responses to pain between these women? a. Pain tolerance b. Pain threshold c. Nociception d. Physiologic stress ANS: A Feedback A Pain tolerance is the duration or intensity of pain a person will endure before outwardly responding. A person’s culture, pain experience, expectations, role behaviors, and physical and emotional health influence pain tolerance. The second woman had experienced the birth process before and had different expectations than the first woman, who was having her first baby. B Pain threshold is the point at which a stimulus is perceived as pain. This threshold does not vary significantly among people or in the same person over time. C Nociception is the process of pain perception and involves transduction, transmission, perception, and modulation. D Physiologic stress stimulates the sympathetic nervous system causing tachycardia, increased respiratory rate, and dilated pupils, but does not necessarily affect pain response. DIF: Cognitive Level: Analyze REF: 58 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 10. A patient admitted to the emergency department with “excruciating chest pain, above the rating of 10,” has a heart rate of 55, rapid, irregular respirations, complains of nausea, and is too weak to move to the stretcher without aid. The nurse recognizes that this response to severe pain is due to the response of the _____ nervous system. a. Parasympathetic b. Sympathetic c. Central d. Peripheral ANS: A Feedback A During severe or deep pain the parasympathetic nervous system may cause pallor; rapid, irregular breathing; nausea; and vomiting. B The sympathetic nervous system responds to acute pain by increasing heart rate, increasing blood pressure, causing diaphoresis, increasing respiratory rate, increasing muscle tension, dilating pupils, and decreasing gastrointestinal motility. C The central nervous system includes the brain and spinal cord. The manifestations described in the case are due to parasympathetic nervous system stimulation. D The manifestations described in the case are due to parasympathetic nervous system stimulation. DIF: Cognitive Level: Remember REF: 59| 63 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain 11. A patient with gout is complaining of severe, throbbing pain in the great toe. What type of pain is this patient experiencing? a. Neuropathic pain b. Somatic pain c. Referred pain d. Visceral pain ANS: B Feedback A Neuropathic pain is caused by abnormal processing of sensory input from the peripheral nervous system. B Somatic pain arises from bone, joint, muscle, skin, or connective tissues and is usually aching or throbbing in quality and well located. C Referred pain is pain felt at a site different from that of an injured or diseased organ. D Visceral pain occurs with obstruction of a hollow organ and causes intermittent cramping pain. DIF: Cognitive Level: Remember REF: 59 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 12. A patient with a partial small bowel obstruction describes the pain as “cramping, off-and-on pain that spreads over my stomach.” What type of pain is this patient experiencing? a. Referred pain b. Phantom pain c. Somatic pain d. Visceral pain ANS: D Feedback A Referred pain is felt at a site different from that of an injured or diseased organ. B Phantom pain is associated with amputations. C Somatic pain arises from bone, joint, muscle, skin, or connective tissues and is usually aching or throbbing in quality and well located. D Visceral pain occurs with obstruction of a hollow organ and causes intermittent cramping pain. DIF: Cognitive Level: Remember REF: 59 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems MULTIPLE RESPONSE 1. A nurse is assessing a patient who complains of “awful” abdominal pain and rates it as a 9 on a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain? Select all that apply. a. Tachycardia b. Irritability c. Increased blood pressure d. Depression e. Insomnia f. Sweating ANS: A, C, F Correct: The sympathetic nervous system responds to acute pain by increasing heart rate, increasing blood pressure, causing diaphoresis, increasing respiratory rate, increasing muscle tension, dilating pupils, and decreasing gastrointestinal motility. Incorrect: Irritability, depression, and insomnia are manifestations of chronic rather than acute pain. DIF: Cognitive Level: Apply REF: 59| 63 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 2. The nurse is performing a symptom analysis of a patient with pain. Which questions below are appropriate for a symptom analysis? Select all that apply. a. “Have you had any other symptoms such as nausea, vomiting, and sweating?” b. “Where is the pain located?” c. “Have you had a pain like this before?” d. “What does the pain feel like?” e. “What do you do to make your pain better?” f. “In your culture, how are you encouraged to express your pain?” ANS: A, B, D, E Correct: “Have you had any other symptoms such as nausea, vomiting, and sweating?” “Where is the pain located?” “What does the pain feel like?” “What do you do to make your pain better?” These four questions are asked in a symptom analysis that includes the following variables: onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, self-treatment, and severity. Incorrect: “Have you had a pain like this before?” This question relates to the patient’s health history. “In your culture, how are you encouraged to express your pain?” This question relates to the patient’s culture and does not help analyze the patient’s pain experience. DIF: Cognitive Level: Apply REF: 59-60 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 3. How do nurses assess pain of neonates or of adults with dementia or decreased level of consciousness? Select all that apply. a. Ask family or caregivers what indicators they think may indicate the patient’s pain. b. Review results of blood tests for signs of pain. c. Administer the ordered analgesic to the patient. d. Identify any physiologic signs of pain. e. Examine the patient for possible causes of pain. ANS: A, C, D, E Correct: These four answers are the clinical practice recommendations of Herr and colleagues. Incorrect: Pain cannot be detected with laboratory tests. DIF: Cognitive Level: Understand REF: 62 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain