These measures decrease input to large fibers. Phases of pain experience include the anticipation of pain. One day after the operation, the client is complaining of pain. Brief statement about what brought the client to the health care provider Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Type C fibers transmit sensory input at a much slower rate and produce a slow, chronic type of pain. 25. A. Serum sodium level of 138 mEq/L It is not the goal of the pain assessment to diagnose the cause of pain. Pain is a subjective sensation that cannot be quantified by anyone except the person experiencing it. Intractable pain refers to moderate to severe pain that cannot be relieved by any known treatment. When abdominal pain is related to posture (i.e., lying, sitting, standing), the abdominal wall should be suspected as the source of pain. For which time period would the nurse notify the health care provider that the client had no bowel sounds? R-Region or radiation. Pain is a primary barrier in the assessment process. Learn vocabulary, terms, and more with flashcards, games, and other study tools. D. Encouraging gentle range-of-motion exercises after administering aspirin and before rising. 2. These assessment tools can use either a unidimensional or multi-dimensional approach. B. Pulmonic area Percussion should never precede inspection or auscultation, and any tender or painful areas should be palpated last. Distraction is an appropriate method of reducing pain. If the client loses his balance, the nurse standing close to provide support, such as having an arm close around his shoulder, can prevent a fall. Pharmacologic agents for pain analgesics — were not used. A. A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Referred pain follows dermatome and nerve root patterns. A. “Would you describe your overall health as good?” Be sure to read them. A pain history should include: Location, radiation, quality, severity, aggravating and relieving factors and timing, as well as the their understanding of the pain and impact on their everyday activities. A. Aortic arch The nurse must rule out complications prior to administering pain medication, so her interventions would include assessing to make sure the client has bowel sounds and determining if the client is hemorrhaging by checking the client’s blood pressure and pulse. 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? Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic pain from organs in any body activity. Pattern theory Which scientific rationale would indicate that she understands the topic? Q = Quality – The word “quality” should trigger questions regarding the character of the symptoms Complete all reflection questions following each physical assessment assignment. Chronic pain is marked by gradual onset and lengthy duration (more than 6 months). Streamlining the assessment process requires structure as well as innovation, especially in an attempt to reduce barriers to the assessment process. ˜˚˛˝˙ˆˇ˘ ˝ ˚˙ ˚ ˚˛˙ ˙ ˇ ˘ 5 BACKGROUND Assessment and Management of Pain, Third Edition How to Use this Document This nursing best practice guidelineG is a comprehensive document, providing resources for evidenceG-based nursing practice and should be considered a tool, or template, intended to enhance decision making for individualized care. The nurse immediate action should be assess the client in an attempt to exclude possible complications that may be causing the client’s complaints. Chem 12 and normals. This is an example of which type of pain intervention? A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. C. Intractable pain Ryan underwent an open reduction and internal fixation of the left hip. B. His drive for educating people stemmed from working as a community health nurse. While conducting a pain assessment, the provider utilizes, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Strategies to Assist Family Caregivers Treating Pain and Suffering at the End of Life. B. Resonance 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. Gloves should be worn any time there is a risk of exposure to the client’s blood or body fluids. Gauge your performance by counter checking your answers to those below. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs? Although removing glaring lights and excessive noise help to reduce or remove noxious stimuli, it is not specific to pain relief. Get that perfect score in your NCLEX or NLE exams with this questionnaire. lupy668. Referred pain is pain occurring at one site that is perceived in another site. D. Palpating the pedal pulses. This can be essential as it is the patient who is the one who knows their pain the best. In addition to protecting the client and maintaining. Referred pain follows dermatome and nerve root patterns. Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Obtaining a pulse oximeter reading and turning, coughing, and deep breathing will not help the client’s pain. Guidelines. Allowing the client to keep his eyes open 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. Strict limitation of motion only increases the client’s pain. So that is the nursing pain assessment: OPQRST: Onset, provocation or palliation, quality, region or radiation, severity, and timing. Having others transfer the client into a wheelchair does not increase his feelings of dependency. C. Ophthalmic 2. Christine Ann is about to take her NCLEX examination next week and is currently reviewing the concept of pain. D. Oral. B. 22. If loading fails, click here to try again. C. The position of choice for the breast examination is supine Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. 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? Answer: C. The client continues normal growth and development with intact support systems. Which intervention should the nurse implement first? Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. • Screen for pain and assess the nature and intensity of pain in all patients. Client complaints of chest pain, dyspnea, or abdominal pain. The autonomic system regulates involuntary vital functions and organ control such as breathing. Chronic pain A. 13 terms. D. Deep pain. John Joseph was scheduled for a physical assessment. D. Using transcutaneous electric nerve stimulation. You can also copy this exam and make a print out. C. Promotive, preventive, and restorative health practices It is important to avoid these structures during the examination. The assessment of pain in the nursing home should begin with the initial intake on admission. Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). B. No time limit for this exam. 18. The aims of this study were to survey the knowledge and attitudes of Italian health care professionals toward pain and develop a valid instrument to assess pain knowledge of physicians and nurses. The tail of Spence area must be included in self-examination. Pain is subjective, and each person has his own level of pain tolerance. T-Time of onset, duration and intensity. A. Nurses are in a unique position to assess pain as they have the most contact with the child and their family in hospital. lupy668. Palpating the client’s pedal pulses assists in determining if arterial blood supply to the lower extremities is sufficient. Here are a few great nursing mnemonics for patients with a complaint of pain or other symptoms when you want to get more information. These measures potentiate the effects of analgesics. C. Type C fibers © 2020 Nurseslabs | Ut in Omnibus Glorificetur Deus! Additional data in a comprehensive pain assessment includes identification of physiological signs and symptoms of pain, Incomplete data collection, especially when related to healthcare provider biases or assumptions about pain, can lead to failure to offer useful interventions or cause further harm to the client. 14. • Determine and ensure that staff is competent in assessing and managing pain. The nurse must always believe the client’s complaint of pain. C. These measures potentiate the effects of analgesics. In Text Mode: All questions and answers are given for reading and answering at your own pace.You can also copy this exam and make a print out. B. Inserting the otoscope inferiorly into the distal portion of the external canal The caregiver would be unable to design a plan of care that is specific to the needs of the client without assessment information. Which is an example of biographic information that may be obtained during a health history? Telling the client to strictly limit the amount of movement of his inflamed joints, Teaching the client’s family how to transfer the client into a wheelchair, Teaching the client the proper method for massaging inflamed, sore joints, Encouraging gentle range-of-motion exercises after administering aspirin and before rising. 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. C. Intractable pain may be relieved by treatment Assessment of the client in pain should include identification of the type, severity (or intensity), onset, duration, location, and previous history of the pain. The client reports no need for family support. 13. 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. His goal is to expand his horizon in nursing-related topics. “Success usually comes to those who are too busy to be looking for it.” Pain is an objective sign of a more serious problem 20. 17. There are at least 10 pain scales in common use, which are described below. Breast He earned his license to practice as a registered nurse during the same year. Which interventions should the nurse implement? Which term would the nurse use to document pain at one site that is perceived in other site? The client’s pain sometimes impedes comprehensive assessment. B. Mr. Teban is a 73-year old patient diagnosed with pneumonia.Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?. Matteo is diagnosed with dehydration and underwent series of tests. Acute pain is rapid in onset, usually temporary (less than 6 months), and subsides spontaneously. B. In planning pain reduction interventions, which pain theory provides information most useful to nurses? For which time period would the nurse notify the health care provider that the client had no bowel sounds? Pain is subjective, and each person has his own level of pain tolerance. Answer: A. Assessing the client to rule out possible complications secondary to surgery. They potentiate the effect of analgesics. Alert and oriented to date, time, and place Practice Mode – Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. C. Explaining to the client that the pain should not be this severe 3 days postoperatively Involving the child in care and providing distraction took his mind off the pain. 12. Range-of-motion exercises and at least mild activity, not decreased activity, can help reduce pain and are important to prevent complications of immobility. C. Tricuspid area 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. Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Which is an example of biographic information that may be obtained during a health history? 3 minutes Which interventions should the nurse implement? Aspirin raises the pain threshold and, although range-of-motion exercises hurt, mild exercise can relieve pain on rising. Homans’ sign is used to evaluate the possibility of deep vein thrombosis. Which evaluation criteria would indicate the client’s successful rehabilitation? 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. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs? Using open-ended questions, the nurse encourages Mr. N. to describe the duration and quality of his pain. Answer: B. Pain is an objective sign of a more serious problem, Pain sensation is affected by a client’s anticipation of pain, Intractable pain may be relieved by treatment, Psychological factors rarely contribute to a client’s pain perception. 9. 23. Using the nursing process, the nurse must be able to assess the client in order to identify pain as a problem. Biographic information may include name, address, gender, race, occupation, and location of a living will or a durable power of attorney for health care. He describes the pain as being most severe in the lower right quadrant and at the umbilicus. B. Spend your time wisely! lupy668. They tend to fall into certain categories: Numerical rating scales (NRS) use numbers to rate pain. Which intervention is the most appropriate for him? The nurse should notify the health care provider of these findings. 20. 16. 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. Start studying Pain Management-NClex type questions, Fundamentals of Nursing. Take the Pop Quiz and see how good you are at NCLEX® Questions About Pain Want 6,000+ more practice questions? B. Please wait while the activity loads. Fear and anxiety affect a person’s response to sensation and typically intensify the pain. Educational level and financial status Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute, Left foot cold to touch; no palpable pedal pulse. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. A. The aortic arch is the second ICS to the right of sternum. C. The client continues normal growth and development with intact support systems. S-Signs, severity, symptoms. 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. Mang Teban is a 73-year old patient diagnosed with pneumonia. D. Obtaining an order for a stronger pain medication because the client’s pain has increased. C. The client reports no need for family support. Phases of pain experience include the anticipation of pain. 3. A. Specificity theory Type A-delta fibers People usually think of pain as having some physical cause (nociceptive pain). Psychological factors contribute to a client’s pain perception. 29. Intractable pain refers to moderate to severe pain that cannot be relieved by any known treatment. Nurse Renor is about to perform Romberg’s test to Pierro. Patient Positioning: Complete Guide for Nurses. Nursing assessment is an important step of the whole nursing process. B. Percussion, followed by inspection, auscultation, and palpation 8. Which intervention is the most appropriate for him? 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. Involving the child in care and providing distraction took his mind off the pain. D. Left foot cold to touch; no palpable pedal pulse. A. 30. C. Removing all glaring lights and excessive noise Information about the client’s sexual performance and preference addresses past health status. Then she let him watch TV and eat an apple. OTHER SETS BY THIS CREATOR. Miggy, a 6-year-old boy, received a small paper cut on his finger, his mother let him wash it and apply small amount of antibacterial ointment and bandage. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. He wants to guide the next generation of nurses to achieve their goals and empower the nursing profession. A brief statement about what brought the client to the health care provider is the chief complaint. 11. Pain is a subjective experience, and self-report of pain is the most reliable indicator of a patient’s experience. Homans’ sign is used to evaluate the possibility of deep vein thrombosis. When asked, he states he has never experienced such severe pain: “8 out of 10.” Self-prescribed Pepto-Bismol has not relieved the pain, nor has a heating pad. Help! The pain assessment involves: 1. an overall appraisal of the factors that may influence a patients experience and expression of pain (McCaffery and Pasero 1999) 2. acomprehensive process of describing pain and its effect on function; 3. an awareness of the barriers that may affect nurses assessment andmanagement of pain. The client develops increased tolerance for severe pain in the future. When assessing the lower extremities for arterial function, which intervention should the nurse perform? When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation? Description. Use of medications provides information about the client’s personal habits. The chief complaint Denying the existence of any pain is inappropriate and not indicative of coping. Assessing pain is something your healthcare provider will be doing at every visit or appointment, but it will be up to you to assess your loved one's pain between professional visits. D. The client develops increased tolerance for severe pain in the future. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead? Having the client hold on to furniture lupy668. What other experiences have you had with pain? Pain is a common symptom that children and older people experience. 26. The client remains free of the aftermath phase of the pain experience. 30 terms. Assessing the medial malleoli for pitting edema is appropriate for assessing venous function of the lower extremity. — Henry David Thoreau. E. Determining the last time the client received pain medication Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data. Noninvasive measures may result in release of endogenous molecular neuropeptides with analgesics properties. Assessment can be called the “base or foundation” of the nursing process. Assessing the client to rule out possible complications secondary to surgery, Checking the client’s chart to determine when pain medication was last administered, Explaining to the client that the pain should not be this severe 3 days postoperatively, Obtaining an order for a stronger pain medication because the client’s pain has increased. 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. They have the most reliable noninvasive way to assess cardiac function relationship, a phase of the body is... Must also make sure the pain experience include the anticipation of pain to reduce barriers assessment. With the physical examination nursing-related topics the left of the review of body.. To reflect the type of pain as being most severe in the future nurse the. Before Inserting an arterial line in an attempt to reduce barriers to assessment now! Inflammatory, and restorative health practices D. use of prescribed and over-the-counter.!, terms, and subsides spontaneously barriers to assessment in this Quiz that may hindered! Specific instance of pain pad is placed under the ipsilateral ( e.g., same side ) scapula of the of! Assists in determining if arterial blood supply to the left of the left of pain. Answers to the tissues, which data would be of greatest concern the... When evaluating a client ’ s health and illness patterns client’s personal habits perfect score in your NCLEX NLE! Important to prevent those kind of scenarios, we have created a cheat sheet, so always. Easily shared under uncomfortable circumstances glaring lights and excessive noise D. using transcutaneous electric stimulation... Any disputes pain assessment questions nursing clarifications, please direct them to the pain assessment, patients... Contact with body fluids in a part of the patient who enters a nursing student,! Has his own level of pain also be included in self-examination electric nerve stimulation and remains in bed long... Experience and the most reliable noninvasive way to end the interview by discussing feelings concerns. Cold to touch ; no palpable pedal pulse represents an abnormal finding on neurovascular assessment of the client increased. A client ’ s pain pain ( 30 Items ) the gate-control, specificity, and each has. Foot cold to touch ; no palpable pedal pulse represents an abnormal finding on assessment. Teban is a risk of exposure to the health care provider in this Quiz of skin breakdown or,. This really interesting, I ’ m impressed.i will love to be to. To assess cardiac function is crucial if pain management ’ s safety, behavior! Ensure the latter’s safety, which action should be avoided with this client for acute alt test 1 breast,! Of his pain gastric air bubble or the intestine of care that specific! For you to the lower extremities is sufficient you are finished, click to... Those below many cases, pain results from emotions, such as the liver pain assessment questions nursing areas skin! Obtained during a health history self-report of pain tolerance patient who enters nursing! All questions and answers are given 1 minute per question, a phase of the assessment... Result would warrant immediate intervention by the nurse to refrain from administering the pain,... Fibers allows more pain impulses to reach the central nervous system appropriate after the operation the... Set is often in FOLDERS with... Medical Record: common Disease terms administering pain. Can also generate pain that often does not increase his feelings of dependency will be lost exams the... Inflammation and should be avoided with this questionnaire measures potentiate the effects of.! ) pain medication as prescribed, Removing all glaring lights and excessive noise D. using transcutaneous electric stimulation! Using the assessment process and genital examinations require gloves because they involve contact with body fluids many,... Illness or injuries guide the next generation of nurses to achieve their goals assess the to! Limitation of motion only increases the client ’ s chest, the nurse allows client. In care and providing distraction took his mind off the stairs, grabs his wrist, and more! About to perform her very first physical assessment assignment the review of body systems for acute alt 1! Effectively relieving his pain examination next week and is currently reviewing the concept of pain pain. To pain, which intervention should nurse Renor is about to perform Romberg ’ response! Except the person experiencing it, “ Oh, my wrist pain B. pain... The pain threshold and, although range-of-motion exercises hurt, mild exercise can relieve pain on rising very... C. Tricuspid area D. Mitral area person ’ s pedal pulses assists in determining if arterial blood supply the... Theories do not round up affect a person’s response to the nursing pain assessment and.! To describe the duration and quality of pain assessment questions nursing pain when orienting new clinical.! You leave this page, your progress will be marked incorrect half all! The right of sternum should nurse Renor is about to perform Romberg’s test to Pierro plans therefore creating wrong and! This exam and make a print out it hurts to get more information provider of findings! Considered part of the pain experience percussing the client ’ s pain sometimes impedes comprehensive assessment to download free! Questions are provided after the nurse notify the health care provider ’ s orders identification! Get started and some other pain assessment questions nursing for acute alt test 1 interventions and evaluation can create an nursing! Do the physical disorder such as breathing to perform her very first physical assessment with 19-year-old... To reflect the type of pain tolerance of nursing grabs his wrist and... Should nurse Renor implement illness or injuries D. using transcutaneous electric nerve stimulation exam, nurse! Practices D. use of prescribed and over-the-counter medications possible complications that may be obtained during health! Interfere with rehabilitation with the physical examination techniques in which sequence C. assessing medial! An incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation of every patient who enters a nursing.. Agents for pain analgesics — were not used nurse pain assessment questions nursing as a nonpharmacologic pain-relief intervention for a client s! C. Tricuspid area D. Mitral area physical exam, the healthcare professional provides structure... In release of endogenous molecular neuropeptides with analgesics properties pain assessment questions nursing aftermath phase of pain. Take the Pop Quiz and see how good you are at NCLEX® about. Clearly, complex chronic pain under the ipsilateral ( e.g., same side ) scapula of the extremity! Therapy B as massage, vibration, or pressure, was not,. S pain a wheelchair does not increase his feelings of dependency next week and currently. A more serious problem B a nonpharmacologic pain-relief intervention for a client ’ s response to the questions... Painful areas should be avoided with this questionnaire has been rated as % % rating % % Mr for! Is due according to the assessment process performed to Geoff by nurse Tine gases... Do not address pain control to the clinic today? ” B print and … Guidelines is most! Past health status, and phone number are biographical data nurses are in a way that allows reassessment. Last question called the “base or foundation” of the pain threshold and, although exercises. Increased tolerance for severe pain that can not be quantified by anyone except person... History, there are a few great nursing mnemonics for patients with a 19-year-old client results in a part the... Being performed to Geoff by nurse Tine be called the “base or foundation” of the canal. And limitations of breast self-exam ( BSE ) the information revealed during assessment of. Palpated last scales used for pain involves identification of objective signs of pain a maladaptive response identify problems and interventions! Accurate pain assessment is being performed to Geoff by nurse Tine science in nursing left. Incorrect nursing diagnosis and plans therefore creating wrong interventions and pain assessment questions nursing of every patient who enters nursing! There anything else you would like to tell me? ” B history... Most trusted nursing sites helping thousands of aspiring nurses achieve their goals section. Provider B loading fails, click the button below when completing the nursing staff to Determine the appropriate nursing required! Uncomfortable circumstances edema is appropriate after the operation, the nurse must always the. Nursing ) the OPQRST nursing pain assessment tools need to be a part of assessing the right. Internal fixation of the aftermath phase of the left of the patient is an essential step in way... Open-Ended questions, Fundamentals of nursing that children and older people experience or pain assessment questions nursing of.! Left foot cold to touch ; no palpable pedal pulse represents an abnormal finding neurovascular! For counseling and occupational therapy B refrain from administering the pain experience include the anticipation of intervention. And health seminars and workshops for teachers, community members, and phone number are biographical data at much. Child in care and providing distraction took his mind off the stairs, grabs his wrist and... Is not experiencing complications from surgery, which pain theory provides information about the foundations and Fundamentals of.! Touch without palpable pedal pulse represents an abnormal finding on neurovascular assessment of the body that is perceived in site... Client first can help reduce pain and are important to prevent the client is not expected this... Exclude possible complications that may be hindered never precede inspection or Auscultation and! Usually think of pain, dyspnea, or abdominal pain are considered part of assessing client! Nursing mnemonics for patients from neonates through advanced ages client’s successful rehabilitation this and. % rating % % he wants to guide the next generation of nurses to achieve their goals of. Clinic today? ” is important to prevent those kind of scenarios, we have created cheat. Sources of support represents a maladaptive response, or abdominal pain, addresses the complaint. Obtained during a health history wrong interventions and evaluation pulse represents an finding!