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). Allen’s test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient? What other experiences have you had with pain? 6. No time limit for this exam. A normal potassium level is 3.5 to 5.5 mEq/L. Physical assessment is being performed to Geoff by Nurse Tine. Answer: D. Encouraging gentle range-of-motion exercises after administering aspirin and before rising. These measures decrease input to large fibers. Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain? Educational level and financial status Obtaining a pulse oximeter reading and turning, coughing, and deep breathing will not help the client’s pain. They tend to fall into certain categories: Numerical rating scales (NRS) use numbers to rate pain. Which is an example of biographic information that may be obtained during a health history? 13 terms. D. Encouraging gentle range-of-motion exercises after administering aspirin and before rising. 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. Albert who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Acute 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. 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. C. Teaching the client the proper method for massaging inflamed, sore joints When a client is uncomfortable, assessment may be hindered. OPQRST Pain Assessment (Nursing) The OPQRST nursing pain assessment is super important for you to know as a nursing student. In Text Mode: All questions and answers are given for reading and answering at your own pace. Referred pain follows dermatome and nerve root patterns. A brief statement about what brought the client to the health care provider is the chief complaint. Which assessment examination requires Liza to wear gloves? Using the nursing process, the nurse must be able to assess the client in order to identify pain as a problem. Nurses are in a unique position to assess pain as they have the most contact with the child and their family in hospital. C. Type C fibers 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. The nurse must also make sure the pain medication is due according to the health care provider’s orders. Thank you Mr Foster for answering for answering my questions, I will now do the Physical examination. When abdominal pain is related to posture (i.e., lying, sitting, standing), the abdominal wall should be suspected as the source of pain. 3. Pharmacologic agents for pain analgesics — were not used. Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lungs. There is no need to notify the health care provider in this situation. Type C fibers transmit sensory input at a much slower rate and produce a slow, chronic type of pain. The nurse must always believe the client’s complaint of pain. During the abdominal examination, Tine should perform the four physical examination techniques in which sequence? You can also copy this exam and make a print out. A. In addition to protecting the client and maintaining. During Romberg’s test, the client is asked to stand with feet together and eyes shut and still maintain balance with the minimum of sway. When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation? 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. D. Location of an advance directive. D. The client’s name, address, age, and phone number. It is important not only to assess and document pain, but also assess and document the following characteristics so that the appropriate interventions occur. When assessing the lower extremities for arterial function, which intervention should the nurse perform? B. Autonomic nerve fibers Careful assessment and evaluation of the patient's pain will allow the nursing staff to determine the appropriate nursing intervention required. Pain is a primary barrier in the assessment process. 7 terms. 15. Chem 12 and normals. Pain sensation is affected by a client’s anticipation of pain A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Take the Pop Quiz and see how good you are at NCLEX® Questions About Pain Want 6,000+ more practice questions? C. Serum glucose level of 120 mg/dl 25. Client complaints of chest pain, dyspnea, or abdominal pain Having others transfer the client into a wheelchair does not increase his feelings of dependency. Referred pain is pain occurring at one site that is perceived in another site. 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? These include: 1. D. Notifying the health care provider A normal sodium level is 135 to 145 mEq/L, a normal nonfasting glucose level is 85 to 140 mg/dl, and a normal creatinine level is 0.2 to 0.8 mg/100 ml. The nurse immediate action should be assess the client in an attempt to exclude possible complications that may be causing the client’s complaints. B. Allen’s test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. Checking the client’s chart is appropriate after the nurse determines that the client is not experiencing complications from surgery. Answer: D. Location of an advance directive. Performing Allen’s test To ensure the latter’s safety, which intervention should nurse Renor implement? 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. - inadequate skills, knowledge, attitudes and beliefs about pain, its assessment and management and the nurses experience (Hall-Lord and Larsson… This area must also be included in breast self-examination. D. 5 minutes. On physical exam, the nurse notes guarding behavior and rebound tenderness. Answer: C. Promotive, preventive, and restorative health practices. E. Determining the last time the client received pain medication Staying with the client, building trust, and providing method of pain relief, such as cutaneous stimulation, medications, distraction, and guided imagery interventions, would have been more appropriate in earlier stages of postburn injury, when physical pain was most severe and fewer psychologic factors needed to be addressed. 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. 17. Chem 7 and some other normals for acute alt test 1. Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures? 19. Checking the client’s chart is appropriate after the nurse determines that the client is not experiencing complications from surgery. This is an example of which type of pain intervention? Don’t forget to download your free nursing pain assessment cheat sheet, so you always know what questions to ask. Answer: A. Assessing the client to rule out possible complications secondary to surgery. Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Assessment can be called the “base or foundation” of the nursing process. During Romberg’s test, the client is asked to stand with feet together and eyes shut and still maintain balance with the minimum of sway. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. C. Clear breath sounds and nonproductive cough A 12-year-old student fall off the stairs, grabs his wrist, and cries, “Oh, my wrist! Type A-delta fibers Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Homans’ sign is used to evaluate the possibility of deep vein thrombosis. A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Range-of-motion exercises and at least mild activity, not decreased activity, can help reduce pain and are important to prevent complications of immobility. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient? Massage increases inflammation and should be avoided with this client. C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal (Select all that apply. C. Superficial pain Acute pain is rapid in onset, usually temporary (less than 6 months), and subsides spontaneously. Pain is the most common symptom children experience in hospital. Gil Wayne graduated in 2008 with a bachelor of science in nursing. Educational level, financial status, and family role and relationship patterns represent information associated with role and relationship patterns. A. Christine Ann is about to take her NCLEX examination next week and is currently reviewing the concept of pain. A. You are given one minute per question. Referring the client for hypnosis These assessment tools can use either a unidimensional or multi-dimensional approach. 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. Physical assessment is being performed to Geoff by Nurse Tine. D. The client reports pain reduction with decreased activity. Promotive, preventive, and restorative health practices, Use of prescribed and over-the-counter medications. B. Inserting the otoscope inferiorly into the distal portion of the external canal The client experiences decreased frequency of acute pain episodes. 30. For example, a DCE score of 92.99 is a 92, not a 93. D. Oral. Ryan underwent an open reduction and internal fixation of the left hip. Nurse Renor is about to perform Romberg’s test to Pierro. lupy668. Which assessment data should the nurse include when obtaining a review of body systems, A. The mothers actions are example of control and distraction. Full assessment can be time-consuming; a variety of assessment and. Several strategies are useful in structuring and streamlining the assessment process. Wanting to reach a bigger audience in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. If you need more clarifications, please direct them to the comments section. Left hip dressing dry and intact “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?”. In many cases, pain results from emotions, such as hostility, guilt, or depression. Nursing assessment is an important step of the whole nursing process. They potentiate the effect of analgesics. The chief complaint, past health status, and history of immunizations are part of assessing the client’s health and illness patterns. A. The gate-control, specificity, and patter theories do not address pain control to the depth included in the central-control theory. Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain? lupy668. B. C. Control and distraction Distraction is an appropriate method of reducing pain. 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. Which intervention should the nurse plan? A. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. The nurse should never administer pain medication without assessing the client first. The client remains free of the aftermath phase of the pain experience. 1. D. Psychological factors rarely contribute to a client’s pain perception. Ophthalmic, breast, or integumentary examinations normally do not involve contact with the client’s body fluids and do not require the nurse to wear gloves for protection. 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). To prevent those kind of scenarios, we have created a cheat sheet that you can print and … Strict limitation of motion only increases the client’s pain. Mang Teban is a 73-year old patient diagnosed with pneumonia. Intractable pain refers to moderate to severe pain that cannot be relieved by any known treatment. Asking if the client describes his overall health as good is a leading question that puts words in his mouth. His drive for educating people stemmed from working as a community health nurse. Please visit using a browser with javascript enabled. About pain Want 6,000+ more practice questions understands the topic - you have nursing. Instance of pain, usually pain intensity — were not used a pad is placed under the (... 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