NURS FUNDAMENTAL NCLEX Comfort and Pain Management 92 Questions with Verified Answers
A nurse instructor is teaching a class of student nurses about
... [Show More] the nature of pain. Which statements accurately describe this phenomenon? Select all that apply.
a) Pain is whatever the physician treating the pain says it is.
b) Pain exists whenever the person experiencing it says it exists.
c) Pain is an emotional and sensory reaction to tissue damage.
d) Pain is a simple, universal, and easy-to-describe phenomenon.
e) Pain that occurs without a known cause is psychological in nature.
f) Pain is classified by duration, location, source, transmission, and etiology. - CORRECT ANSWER b, c, f
The classic definition of pain that is probably of greatest benefit to nurses and their patients: "Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does." The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 1994). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.
One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? Select all that apply.
a) A patient is receiving chemotherapy for bladder cancer.
b) An adolescent is admitted to the hospital for an appendectomy.
c) A patient is experiencing a ruptured aneurysm.
d) A patient who has fibromyalgia requests pain medication.
e) A patient has back pain related to an accident that occurred last year.
f) A patient is experiencing pain from second-degree burns. - CORRECT ANSWER a, d, e
Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns.
A patient complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain?
a) Cutaneous
b) Visceral
c) Superficial
d) Somatic - CORRECT ANSWER b) Visceral
The patient's pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.
A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain?
a) Transient pain
b) Superficial pain
c) Phantom pain
d) Referred pain - CORRECT ANSWER d) Referred pain
Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. Superficial pain originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically.
The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply.
a) A patient cradles a wrist that was injured in a car accident.
b) A child is moaning and crying due to a stomachache.
c) A patient's pulse is increased following a myocardial infarction.
d) A patient in pain strikes out at a nurse who attempts to bathe him.
e) A patient who has chronic cancer pain is depressed and withdrawn.
f) A child pulls away from a nurse trying to give him an injection. - CORRECT ANSWER a, b, f
Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature.
An elderly patient is confined to bedrest following cervical spine surgery to treat nerve pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to prevent the formation of pressure ulcers. What type of agent is the stimulus for pressure ulcers?
a) Mechanical
b) Thermal
c) Chemical
d) Electrical - CORRECT ANSWER a) Mechanical
Receptors in the skin and superficial organs may be stimulated by mechanical, thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores and pressure from a cast are mechanical stimulants. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. The jolt from a lightening bolt is an electrical stimulant.
A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in her legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques?
a) Prostaglandins
b) Substance P
c) Endorphins
d) Serotonin - CORRECT ANSWER c) Endorphins
Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells.
A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse?
a) "It's not a good idea to ask for pain medication regularly as it can be addictive."
b) "It is better to wait until the pain gets unbearable before asking for pain medication."
c) "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days."
d) "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain." - CORRECT ANSWER d) "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."
Many pain medications are ordered on a PRN (as needed) basis. Therefore, nurses must be diligent to assess patients for pain and administer medications as needed. A patient should not be afraid to request these medications and should not wait until the pain is unbearable. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time.
Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain?
a) Encouraging regular use of analgesics
b) Applying a moist heating pad to the area at prescribed intervals
c) Reviewing the pain experience with the patient
d) Ambulating the patient after administering medication - CORRECT ANSWER b) Applying a moist heating pad to the area at prescribed intervals
Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory.
The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient?
a) CRIES scale
b) COMFORT scale
c) FLACC scale
d) FACES scale - CORRECT ANSWER a) CRIES scale
The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES scale is used for children who can compare their pain to the faces depicted on the scale.
Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his pain medication. What would be a priority nursing diagnosis for this patient?
a) Acute Pain related to fear of taking prescribed postoperative medications
b) Impaired Physical Mobility related to surgical procedure
c) Anxiety related to outcome of surgery
d) Risk for Infection related to surgical incision - CORRECT ANSWER a) Acute Pain related to fear of taking prescribed postoperative medications
Mr. Wright's immediate problem is his pain that is unrelieved because he refuses to take his pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation.
When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter?
a) On a PRN (as needed) basis
b) Conservatively
c) Around the clock (ATC)
d) Intramuscularly - CORRECT ANSWER c) Around the clock (ATC)
The PRN protocol is totally inadequate for patients experiencing chronic pain. ATC doses of analgesics are more effective, whereas conservative pain management for whatever reason may also prove ineffective. Intramuscular administration is not practical on a long-range basis for a patient with chronic pain.
When assessing pain in a child, the nurse needs to be aware of what considerations?
a) Immature neurologic development results in reduced sensation of pain.
b) Inadequate or inconsistent relief of pain is widespread.
c) Reliable assessment tools are currently unavailable.
d) Narcotic analgesic use should be avoided. - CORRECT ANSWER b) Inadequate or inconsistent relief of pain is widespread.
Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored.
A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of:
a) Pruritus
b) Urinary retention
c) Vomiting
d) Respiratory depression - CORRECT ANSWER d) Respiratory depression
Too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening.
When assessing a patient receiving a continuous opioid infusion, the nurse immediately notifies the physician when the patient has:
a) A respiratory rate of 10/min with normal depth
b) A sedation level of 4
c) Mild confusion
d) Reported constipation - CORRECT ANSWER b) A sedation level of 4
Sedation level is more indicative of respiratory depression because a drop in level usually precedes it. A sedation level of 4 calls for immediate action because the patient has minimal or no response to stimuli. A respiratory level of 10 with normal depth of breathing is usually not a cause for alarm. Mild confusion may be evident with the initial dose and then disappear; additional observation is necessary. Constipation should be reported to the physician, but is not the priority in this situation.
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?
a) Administer the medication.
b) Ask the client if they want the medication.
c) Administer the medication with food.
d) Contact the physician. - CORRECT ANSWER d) Contact the physician.
The nurse should contact the physician regarding the diagnosis of a bleeding disorder and the order for the NSAID. NSAIDs are contraindicated in clients with bleeding disorders, as the action of the NSAID can interfere with the client's platelet function.
Three days after surgery, a patient continues to have moderate to severe incisional pain. Based on the gate control theory, what action should the nurse take?
a) Decrease external stimuli in the room during painful episodes.
b) Advise the patient to try to sleep following administration of pain medication.
c) Reposition the patient and gently massage the patient's back.
d) Administer pain medications in smaller doses but more frequently. - CORRECT ANSWER c) Reposition the patient and gently massage the patient's back.
The nurse would reposition the client and gently massage the client's back using the gate control theory of pain. The gate control theory provides the most practical model regarding the concept of pain. It describes the transmission of painful stimuli and recognizes a relation between pain and emotions. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area.
Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?
a) Cardiovascular
b) Respiratory
c) Peripheral Vascular
d) Nueromuscular - CORRECT ANSWER b) Respiratory
A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?
a) Visceral pain
b) Chronic pain
c) Cutaneous pain
d) Neuropathic pain - CORRECT ANSWER d) Neuropathic 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?
a) "I may need fewer pain medications with the TENS unit in place."
b) "Wearing the TENS unit should not interfere with my daily activities."
c) "One advantage of the TENS unit is it increases blood flow."
d) "I could use the TENS unit if I feel pain somewhere else on my body." - CORRECT ANSWER d) "I could use the TENS unit if I feel pain somewhere else on my body."
The client needs further instruction when she says she can use the TENS unit on other areas of the body. Such a statement would indicate that the client does not understand that the unit should be used as prescribed by the physician in the location defined by the physician.
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?
a) 2
b) 1
c) 3
d) 4 - CORRECT ANSWER c) 3
The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows:
1 = awake and alert; no action necessary
2 = occasionally drowsy but easy to arouse; requires no action
3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose
4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.
The nurse recognizes which of the following statements is true of chronic pain?
a) It can be easily described by the client.
b) It disappears with treatment.
c) It may cause depression in clients.
d) It is always present and intense. - CORRECT ANSWER c) It may cause depression in clients.
Which guideline regarding pain should be included in the nurse's education plan for a group of parents with infants and toddlers?
a) Toddlers often try to be brave and not cry.
b) Toddlers are often reluctant to express pain.
c) Infants cannot express pain until 8 months of age.
d) Pain can be a source of fear and threat to the toddler's security. - CORRECT ANSWER d) Pain can be a source of fear and threat to the toddler's security.
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?
a) Thorough client education is necessary to prevent overdoses.
b) The dose that is delivered when the client activates the machine is preset.
c) An antidote is automatically delivered if the client exceeds the recommended dose.
d) Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. - CORRECT ANSWER b) The dose that is delivered when the client activates the machine is preset.
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. What kind of pain is the client experiencing?
a) Visceral pain
b) Somatic pain
c) Cutaneous pain
d) Neuropathic pain - CORRECT ANSWER a) Visceral pain
How should the nurse position the head of the bed for a client receiving epidural opioids?
a) Elevated 30 degrees
b) Reverse trendelenberg
c) Flat
d) Trendelenberg - CORRECT ANSWER a) Elevated 30 degrees
A nurse is performing pain assessments on clients in a physician's office. Which clients would the nurse document as having acute pain? Select all that apply.
a) A client who has diabetic neuropathy
b) A client who fell and broke an ankle
c) a client who is having a myocardial infarction
d) A client who presents with the signs and symptoms of appendicitis
e) A client who has bladder cancer
f) A client who has rheumatoid arthritis - CORRECT ANSWER b, c, d
The nurse caring for a client receiving opioid therapy notes that the client's respirations are 7. What is the first action by the nurse?
a) Physically stimulate client.
b) Take the client's blood pressure.
c) Begin cardiac compressions.
d) Administer Narcan. - CORRECT ANSWER a) Physically stimulate client.
The first action by the nurse is to physically stimulate the client by shaking the client or using a loud sound, followed by reminders every few minutes to breathe deeply. If this is ineffective, Narcan can be used to reverse the respiratory depressant effect of the opioid.
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?
a) Medicate the boy with analgesics to reduce the anxiety of experiencing pain.
b) Ask the boy to draw a cartoon about the color or shape of his pain.
c) Ignore the boy's pain if he is not complaining about it.
d) Distract the boy so he does not notice his pain. - CORRECT ANSWER b) Ask the boy to draw a cartoon about the color or shape of his pain.
A client states that he is pain and requests the ordered 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?
a) Reassess the client's pain in 30 minutes.
b) Contact the client's physician.
c) Hold the pain medication.
d) Administer the pain medication. - CORRECT ANSWER d) Administer the pain medication.
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?
a) Melatonin
b) Dopamine
c) Endorphins
d) Serotonin - CORRECT ANSWER c) Endorphins
Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that certain measures, such as skin stimulation and relaxation techniques, release endorphins. [Show Less]