1. 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
... [Show More] 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 objective observations. However, the most accurate way to assess pain is to get a self-report from the client.
DIF: Remembering/Knowledge REF: 25
KEY: Pain| pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
2. 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 supersede the client’s descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client’s report of pain serves no useful purpose.
DIF: Understanding/Comprehension REF: 28 KEY: Pain| pain assessment
MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category:
Health Promotion and Maintenance
3. 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 staff 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 likelihood 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 effects from opioids, 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. [Show Less]