pain assessment questions nursing

Range-of-motion exercises and at least mild activity, not decreased activity, can help reduce pain and are important to prevent complications of immobility. Making an Accurate Chest Pain Assessment. He conducted first aid training and health seminars and workshops for teachers, community members, and local groups. Documentation is the final step in a comprehensive pain assessment. Which term refers to the pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity? Learn vocabulary, terms, and more with flashcards, games, and other study tools. Answer: D. Standing close to provide support. Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Administering pain medication as prescribed Strict limitation of motion only increases the client’s pain. 5, 28 Clearly, complex chronic pain conditions may have components of nociceptive, inflammatory, and neuropathic pain mechanisms. 1. During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury? 3 minutes Homans’ sign is used to evaluate the possibility of deep vein thrombosis. Referring the client for counseling and occupational therapy, Staying with the client as much as possible and building trust, Providing cutaneous stimulation and pharmacologic therapy, Providing distraction and guided imagery techniques. Your performance has been rated as %%RATING%%. Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily disfigurement from severe burns over the trunk and arms, is admitted to a pain center. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. D. Serum creatinine level of 0.6 mg/100 ml. Description. Assessing the medial malleoli for pitting edema. Even though the client may experience an aftermath phase, progress is still possible, as is effective rehabilitation. Referring the client for counseling and occupational therapy. A dry and intact hip dressing, blood pressure of 114/78 mm Hg, pulse rate of 82 beats per minute, and a left foot in functional anatomic position are all normal assessment findings that do not require medical intervention. With an abdominal assessment, auscultation always is performed before percussion and palpation because any abdominal manipulation, such as from palpation or percussion, can alter bowel sounds. 3. The home environment was not changed, and cutaneous stimulation, such as massage, vibration, or pressure, was not used. Answer: D. Left foot cold to touch; no palpable pedal pulse. lupy668. Pain is subjective, and each person has his own level of pain tolerance. The client reports pain reduction with decreased activity. The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop breast tumors. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient? Introduction: Abdominal pain is pain felt in any location between the groin and chest. Assessing the medial malleoli for pitting edema is appropriate for assessing venous function of the lower extremity. Nurse Salary 2020: How Much Do Registered Nurses Make? The answers to the sample questions are provided after the last question. Which statement would be the best way to end the history interview? Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures? 18. The client’s name, address, age, and phone number are biographical data. Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Albert who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. 4. C. Teaching the client the proper method for massaging inflamed, sore joints "CARNETT'S SIGN": a very simple test that can identify whether pain in the abdomen is arising from overlying muscle (the abdominal wall) or underlying abdominal organ (in the peritoneal cavity). Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. The nursing staff often performs a detailed evaluation of every patient who enters a nursing home. S-Signs, severity, symptoms. There is no need to notify the health care provider in this situation. D. Bracing the examiner’s hand against the client’s head. 20. A. 7 terms. Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. A normal potassium level is 3.5 to 5.5 mEq/L. Assessment is the first process in nursing. Physical assessment is being performed to Geoff by Nurse Tine. Nonpharmacologic pain relief interventions include cutaneous stimulation, back rubs, biofeedback, acupuncture, transcutaneous electric nerve stimulation, and more. 23. In the superior position, the speculum of the otoscope is nearest the tympanic membrane, and the most sensitive portion of the external canal is the proximal two-thirds. Tipping the client’s head away from the examiner, pulling the ear up and back, inserting the otoscope inferiorly, and bracing the examiner’s hand against the client’s head are all appropriate techniques used during an otoscopic examination. A. A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Telling the client to strictly limit the amount of movement of his inflamed joints She shows him a linear numeric pain scale and he describes the severity of his pain as “6 to 8.” He explains that the pain interferes with his sleep. A. Auscultation immediately after inspection and then percussion and palpation Which scientific rationale should the nurse remember when performing a breast examination on a female client? During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury? D. Obtaining an order for a stronger pain medication because the client’s pain has increased. B. Serum potassium level of 3.1 mEq/L T-Time of onset, duration and intensity. Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures? Answer: C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal. D. The client reports pain reduction with decreased activity. Obtaining a pulse oximeter reading and turning, coughing, and deep breathing will not help the client’s pain. When assessing the lower extremities for arterial function, which intervention should the nurse perform? With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. Get that perfect score in your NCLEX or NLE exams with this questionnaire. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. A 12-year-old student fall off the stairs, grabs his wrist, and cries, “Oh, my wrist! Client complaints of chest pain, dyspnea, or abdominal pain. Guidelines. A. 25. When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation? Ryan underwent an open reduction and internal fixation of the left hip. C. The position of choice for the breast examination is supine If this activity does not load, try refreshing your browser. People usually think of pain as having some physical cause (nociceptive pain). The client experiences decreased frequency of acute pain episodes. B. C. Explaining to the client that the pain should not be this severe 3 days postoperatively B. You are given one minute per question. D. Tympany. 20. Biographic information may include name, address, gender, race, occupation, and location of a living will or a durable power of attorney for health care. A. The pulmonic area is the second intercostal space to the left of the sternum. C. Palpation of tender areas first and then inspection, percussion, and auscultation Although removing glaring lights and excessive noise help to reduce or remove noxious stimuli, it is not specific to pain relief. D. Notifying the health care provider F. Encouraging the client to turn, cough, and deep breathe. Any items you have not completed will be marked incorrect. Intractable pain is moderate to severe pain that cannot be relieved by any known treatment. C. 4 minutes Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. A. The gate-control, specificity, and patter theories do not address pain control to the depth included in the central-control theory. B. C. Tricuspid area In planning pain reduction interventions, which pain theory provides information most useful to nurses? A. Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the review of body systems. Which is the best area for auscultating the apical pulse? - inadequate skills, knowledge, attitudes and beliefs about pain, its assessment and management and the nurses experience (Hall-Lord and Larsson… Text Mode – Text version of the exam 1. If you leave this page, your progress will be lost. Nurse Patrick is acquiring information from a client in the emergency department. 2. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. Which assessment examination requires Liza to wear gloves? 13. 28. B. Inserting the otoscope inferiorly into the distal portion of the external canal A. Pharmacologic therapy Answer: D. Using transcutaneous electric nerve stimulation. Environmental alteration You are given 1 minute per question, a total of 30 minutes in this quiz. Pain is a common symptom that children and older people experience. D. “Is there anything else you would like to tell me?”. Answer: A. C. Clear breath sounds and nonproductive cough The tail of Spence area must be included in self-examination Tipping the client’s head away from the examiner, pulling the ear up and back, inserting the otoscope inferiorly, and bracing the examiner’s hand against the client’s head are all appropriate techniques used during an otoscopic examination. Which intervention is the most appropriate for him? Answer: B. Buccal cyanosis and capillary refill greater than 3 seconds. Careful assessment and evaluation of the patient's pain will allow the nursing staff to determine the appropriate nursing intervention required. Only type A-delta fibers transmit sharp, piercing pain. Which scientific rationale would indicate that she understands the topic? 29. The pain is so sharp, I think I broke it.” Based on this data, the pain the student is experiencing is caused by impulses traveling from receptors to the spinal cord along which type of nerve fibers? The client continues normal growth and development with intact support systems. 10. D. Using transcutaneous electric nerve stimulation. 30. These measures are more effective than analgesics. C. Ophthalmic Help! Rather than being a symptom, NeP i… The tricuspid area is the fifth ICS to the left of the sternum. Referred pain is pain occurring at one site that is perceived in another site. In planning pain reduction interventions, which pain theory provides information most useful to nurses? 1. The nurse must also make sure the pain medication is due according to the health care provider’s orders. D. Oral. Answer: A. Assessing the client to rule out possible complications secondary to surgery. 11. Drugs list 1. Superficial pain has abrupt onset with sharp, stinging quality. Normally, when percussing a client’s chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. No one theory explains all the factors underlying the pain experience, but the central-control theory discusses brain opiates with analgesic properties and how their release can be affected by actions initiated by the client and caregivers. It is important to avoid these structures during the examination. The client reports no need for family support. C. Type C fibers Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. Pain is a nervous system triggered feeling usually associated with the physical disorder such as illness or injuries. During the abdominal examination, Tine should perform the four physical examination techniques in which sequence? This is often in contrast to the patient having chest pain of a cardiac origin whose pain is not made any better or worse with movement or palpation. Privacy is fundamental to the assessment process. The nurse must always believe the client’s complaint of pain. B. Buccal cyanosis and capillary refill greater than 3 seconds Obtaining an order for a strong medication may be appropriate after the nurse assesses the client and checks the chart to see whether the current analgesic is infective. B. Referred pain follows dermatome and nerve root patterns. C. The client continues normal growth and development with intact support systems. Aftermath reactions may occur but need not interfere with rehabilitation. Answer: C. These measures potentiate the effects of analgesics. Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Once you are finished, click the button below. A. R-Region or radiation. The Nursing Pain Assessment (OPQRST) Thanks for downloading this cheat sheet! Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead? Physical assessment for pain involves identification of objective signs of pain. Alert and oriented to date, time, and place 7. Using the nursing process, the nurse must be able to assess the client in order to identify pain as a problem. A. D. Mitral area. Here are a few great nursing mnemonics for patients with a complaint of pain or other symptoms when you want to get more information. (Select all that apply. C. Serum glucose level of 120 mg/dl Answer: D. Location of an advance directive. To prevent those kind of scenarios, we have created a cheat sheet that you can print and … 30 terms. Teaching the client’s family how to transfer the client into a wheelchair Take the Pop Quiz and see how good you are at NCLEX® Questions About Pain Want 6,000+ more practice questions? Past health status Acute pain is not expected at this stage of recovery. Which interventions should the nurse implement? A left foot cold to touch without palpable pedal pulse represents an abnormal finding on neurovascular assessment of the left leg. Family role and relationship patterns Which intervention is the most appropriate for him? His goal is to expand his horizon in nursing-related topics. Which is the best area for auscultating the apical pulse? Which assessment data should the nurse include when obtaining a review of body systems, A. God bless you. 15. If loading fails, click here to try again. D. Left foot cold to touch; no palpable pedal pulse. Christine Ann is about to take her NCLEX examination next week and is currently reviewing the concept of pain. C. These measures potentiate the effects of analgesics. Each patient brings his or her own past experiences of pain to the visit, as well as level of education, socioeconomic status, ethnicity, and individual pain threshold, which plays a role in how the patient will present and describe the current pain experience. D. Providing distraction and guided imagery techniques. The pain is so sharp, I think I broke it.” Based on this data, the pain the student is experiencing is caused by impulses traveling from receptors to the spinal cord along which type of nerve fibers? “What brought you to the clinic today?”, “Would you describe your overall health as good?”, “Do you understand what is happening?”, “Is there anything else you would like to tell me?”. Answer: A. Matteo is diagnosed with dehydration and underwent series of tests. Involving the child in care and providing distraction took his mind off the pain. The client’s pain sometimes impedes comprehensive assessment. Educational level, financial status, and family role and relationship patterns represent information associated with role and relationship patterns. The health care provider ordered the pain medication for routine postoperative pain that is expected after abdominal surgery, not for such complications as hemorrhage, infection, or dehiscence. C. History immunizations Nurse Renor is about to perform Romberg’s test to Pierro. Assessment of the client in pain should include identification of the type, severity (or intensity), onset, duration, location, and previous history of the pain. To ensure the latter’s safety, which intervention should nurse Renor implement? Homans’ sign is used to evaluate the possibility of deep vein thrombosis. Which is an example of biographic information that may be obtained during a health history? Then she let him watch TV and eat an apple. Aftermath of pain, a phase of the pain experience and the most neglected phase, addresses the client’s response to the pain experience. Involving the child in care and providing distraction took his mind off the pain. If you need more clarifications, please direct them to the comments section. However, if there are areas of skin breakdown or drainage, gloves should be used. The client’s name, address, age, and phone number are biographical data. D. 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