During the nursing assessment, which data represent information concerning health beliefs?

Medical Assistants must and will do problem focused assessments prior to the physician seeing the patient. Below are several videos on how to perform a detailed patient assessment on both an adult and pediatric patient. The practice questions that follow are indeed advanced for a medical assistant, however, there is a thin line between the medical assistant and nurse. Many times the physician does not have a nurse in their office at all. Therefore the medical assistant should be familiar with how to perform a problem based assessment as well as how to assess for pain. This assessment extends not only to adults and pediatric patients but to those patients with dementia.

Question 1
Mang 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?
A
Alert and oriented to date, time, and place
B
Buccal cyanosis and capillary refill greater than 3 seconds
C
Clear breath sounds and nonproductive cough
D
Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3

Question 2
During the nursing assessment, which data represent information concerning health beliefs?
A
Family role and relationship patterns
B
Educational level and financial status
C
Promotive, preventive, and restorative health practices
D
Use of prescribed and over-the-counter medications

Question 3
Nurse Patrick is acquiring information from a client in the emergency department. Which is an example of biographic information that may be obtained during a health history?
A
The chief complaint
B
Past health status
C
History immunizations
D
Location of an advance directive

Question 4
John Joseph was scheduled for a physical assessment. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs?
A
Dullness
B
Resonance
C
Hyperresonance
D
Tympany

Question 5
Matteo is diagnosed with dehydration and underwent series of tests. Which laboratory result would warrant immediate intervention by the nurse?
A
Serum sodium level of 138 mEq/L
B
Serum potassium level of 3.1 mEq/L
C
Serum glucose level of 120 mg/dl
D
Serum creatinine level of 0.6 mg/100 ml

Question 6
During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury?
A
Tipping the client’s head away from the examiner and pulling the ear up and back
B
Inserting the otoscope inferiorly into the distal portion of the external canal
C
Inserting the otoscope superiorly into the proximal two-thirds of the external canal
D
Bracing the examiner’s hand against the client’s head

Question 7
When assessing the lower extremities for arterial function, which intervention should the nurse perform?
A
Assessing the medial malleoli for pitting edema
B
Performing Allen’s test
C
Assessing the Homans’ sign
D
Palpating the pedal pulses

Question 8
Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves?
A
Breast
B
Integumentary
C
Ophthalmic
D
Oral

Question 9
Nurse Renor is about to perform Romberg’s test to Pierro. To ensure the latter’s safety, which intervention should nurse Renor implement?
A
Allowing the client to keep his eyes open
B
Having the client hold on to furniture
C
Letting the client spread his feet apart
D
Standing close to provide support

Question 10
Physical assessment is being performed to Geoff by Nurse Tine. During the abdominal examination, Tine should perform the four physical examination techniques in which sequence?
A
Auscultation immediately after inspection and then percussion and palpation
B
Percussion, followed by inspection, auscultation, and palpation
C
Palpation of tender areas first and then inspection, percussion, and auscultation
D
Inspection and then palpation, percussion, and auscultation

Question 11
Which assessment data should the nurse include when obtaining a review of body systems
A
Brief statement about what brought the client to the health care provider
B
Client complaints of chest pain, dyspnea, or abdominal pain
C
Information about the client’s sexual performance and preference
D
The client’s name, address, age, and phone number

Question 12
Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?
A
“What brought you to the clinic today?”
B
“Would you describe your overall health as good?”
C
“Do you understand what is happening?”
D
“Is there anything else you would like to tell me?”

Question 13
For which time period would the nurse notify the health care provider that the client had no bowel sounds?
A
2 minutes
B
3 minutes
C
4 minutes
D
5 minutes

Question 14
Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?
A
Aortic arch
B
Pulmonic area
C
Tricuspid area
D
Mitral area

Question 15
Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). Which scientific rationale should the nurse remember when performing a breast examination on a female client?
A
One half of all breast cancer deaths occur in women ages 35 to 45
B
The tail of Spence area must be included in self-examination
C
The position of choice for the breast examination is supine
D
A pad should be placed under the opposite scapula of the breast being palpated

Question 16
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. Which evaluation criteria would indicate the client’s successful rehabilitation?
A
The client remains free of the aftermath phase of the pain experience.
B
The client experiences decreased frequency of acute pain episodes.
C
The client continues normal growth and development with intact support systems.
D
The client develops increased tolerance for severe pain in the future.

Question 17
Christine Ann is about to take her NCLEX examination next week and is currently reviewing the concept of pain. Which scientific rationale would indicate that she understands the topic?
A
Pain is an objective sign of a more serious problem
B
Pain sensation is affected by a client’s anticipation of pain
C
Intractable pain may be relieved by treatment
D
Psychological factors rarely contribute to a client’s pain perception

Question 18
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. Then she let him watch TV and eat an apple. This is an example of which type of pain intervention?
A
Pharmacologic therapy
B
Environmental alteration
C
Control and distraction
D
Cutaneous stimulation

Question 19
Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures?
A
These measures are more effective than analgesics.
B
These measures decrease input to large fibers.
C
These measures potentiate the effects of analgesics.
D
These measures block transmission of type C fiber impulses.

Question 20
When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation?
A
The client distracts himself during pain episodes.
B
The client denies the existence of any pain.
C
The client reports no need for family support.
D
The client reports pain reduction with decreased activity.

Question 21
In planning pain reduction interventions, which pain theory provides information most useful to nurses?
A
Specificity theory
B
Pattern theory
C
Gate-control theory
D
Central-control theory

Question 22
Ryan underwent an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?
A
Left hip dressing dry and intact
B
Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
C
Left leg in functional anatomic position
D
Left foot cold to touch; no palpable pedal pulse

Question 23
Which term would the nurse use to document pain at one site that is perceived in other site?
A
Referred pain
B
Phantom pain
C
Intractable pain
D
Aftermath of pain

Question 24
Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement? (Select all that apply.)
A
Assessing the client’s bowel sounds
B
Taking the client’s blood pressure and apical pulse
C
Obtaining a pulse oximeter reading
D
Notifying the health care provider
E
Determining the last time the client received pain medication
F
Encouraging the client to turn, cough, and deep breathe

Question 25
Albert who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Which intervention is the most appropriate for him?
A
Referring the client for counseling and occupational therapy
B
Staying with the client as much as possible and building trust
C
Providing cutaneous stimulation and pharmacologic therapy
D
Providing distraction and guided imagery techniques

Question 26
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). Which intervention should the nurse implement first?
A
Assessing the client to rule out possible complications secondary to surgery
B
Checking the client’s chart to determine when pain medication was last administered
C
Explaining to the client that the pain should not be this severe 3 days postoperatively
D
Obtaining an order for a stronger pain medication because the client’s pain has increased

Question 27
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?
A
Acute pain
B
Chronic pain
C
Superficial pain
D
Deep pain

Question 28
A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?
A
Telling the client to strictly limit the amount of movement of his inflamed joints
B
Teaching the client’s family how to transfer the client into a wheelchair
C
Teaching the client the proper method for massaging inflamed, sore joints
D
Encouraging gentle range-of-motion exercises after administering aspirin and before rising

Question 29
Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?
A
Referring the client for hypnosis
B
Administering pain medication as prescribed
C
Removing all glaring lights and excessive noise
D
Using transcutaneous electric nerve stimulation

Question 30
A 12-year-old student fall off the stairs, grabs his wrist, and cries, “Oh, my wrist! Help! 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?
A
Type A-delta fibers
B
Autonomic nerve fibers
C
Type C fibers
D
Somatic efferent fibers

ANSWERS:
Mang 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?
Alert and oriented to date, time, and place
Buccal cyanosis and capillary refill greater than 3 seconds
Clear breath sounds and nonproductive cough
Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3
Question 1 Explanation:
Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data.

During the nursing assessment, which data represent information concerning health beliefs?
Family role and relationship patterns
Educational level and financial status
Promotive, preventive, and restorative health practices
Use of prescribed and over-the-counter medications
Question 2 Explanation:
The health-beliefs assessment includes expectations of health care; promotive, preventive, and restorative practices, such as breast self-examination, testicular examination, and seat-belt use; and how the client perceives illness. Use of medications provides information about the client’s personal habits. Educational level, financial status, and family role and relationship patterns represent information associated with role and relationship patterns.
Question
Nurse Patrick is acquiring information from a client in the emergency department. Which is an example of biographic information that may be obtained during a health history?
The chief complaint
Past health status
History immunizations
Location of an advance directive
Question 3 Explanation:
Biographic information may include name, address, gender, race, occupation, and location of a living will or a durable power of attorney for health care. The chief complaint, past health status, and history of immunizations are part of assessing the client’s health and illness patterns.
Question 4
John Joseph was scheduled for a physical assessment. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs?
Dullness
Resonance
Hyperresonance
Tympany
Question 4 Explanation:
Normally, when percussing a client’s chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lungs.
Question 5
Matteo is diagnosed with dehydration and underwent series of tests. Which laboratory result would warrant immediate intervention by the nurse?
Serum sodium level of 138 mEq/L
Serum potassium level of 3.1 mEq/L
Serum glucose level of 120 mg/dl
Serum creatinine level of 0.6 mg/100 ml
Question 5 Explanation:
A normal potassium level is 3.5 to 5.5 mEq/L. 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.
Question 6
During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury?
Tipping the client’s head away from the examiner and pulling the ear up and back
Inserting the otoscope inferiorly into the distal portion of the external canal
Inserting the otoscope superiorly into the proximal two-thirds of the external canal
Bracing the examiner’s hand against the client’s head
Question 6 Explanation:
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. It is important to avoid these structures during the 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.
Question 7
When assessing the lower extremities for arterial function, which intervention should the nurse perform?
Assessing the medial malleoli for pitting edema
Performing Allen’s test
Assessing the Homans’ sign
Palpating the pedal pulses
Question 7 Explanation:
Palpating the client’s pedal pulses assists in determining if arterial blood supply to the lower extremities is sufficient. Assessing the medial malleoli for pitting edema is appropriate for assessing venous function of the lower extremity. Allen’s test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. Homans’ sign is used to evaluate the possibility of deep vein thrombosis.
Question 8
Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves?
Breast
Integumentary
Ophthalmic
Oral
Question 8 Explanation:
Gloves should be worn any time there is a risk of exposure to the client’s blood or body fluids. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. 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. However, if there are areas of skin breakdown or drainage, gloves should be used.
Question 9
Nurse Renor is about to perform Romberg’s test to Pierro. To ensure the latter’s safety, which intervention should nurse Renor implement?
Allowing the client to keep his eyes open
Having the client hold on to furniture
Letting the client spread his feet apart
Standing close to provide support
Question 9 Explanation:
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. 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. Allowing the client to keep his eyes open, spread his feet apart, or hang on to a piece of furniture interferes with the proper execution of the test and yields invalid results.
Question 10
Physical assessment is being performed to Geoff by Nurse Tine. During the abdominal examination, Tine should perform the four physical examination techniques in which sequence?
Auscultation immediately after inspection and then percussion and palpation
Percussion, followed by inspection, auscultation, and palpation
Palpation of tender areas first and then inspection, percussion, and auscultation
Inspection and then palpation, percussion, and auscultation
Question 10 Explanation:
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. Percussion should never precede inspection or auscultation, and any tender or painful areas should be palpated last.
Question 11
Which assessment data should the nurse include when obtaining a review of body systems
Brief statement about what brought the client to the health care provider
Client complaints of chest pain, dyspnea, or abdominal pain
Information about the client’s sexual performance and preference
The client’s name, address, age, and phone number
Question 11 Explanation:
Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the review of body systems. This potion of the assessment elicits subjective information on the client’s perceptions of major body system functions, including cardiac, respiratory, and abdominal. The client’s name, address, age, and phone number are biographical data. A brief statement about what brought the client to the health care provider is the chief complaint. Information about the client’s sexual performance and preference addresses past health status.
Question 12
Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?
“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?”
Question 12 Explanation:
By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. 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. Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Asking if the client understands what is happening is a yes-or-no question that can elicit little information.
Question 13
For which time period would the nurse notify the health care provider that the client had no bowel sounds?
2 minutes
3 minutes
4 minutes
5 minutes
Question 13 Explanation:
To completely determine that bowel sounds are absent, the nurse must auscultate each of the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is too short a period to arrive at this conclusion.
Question 14
Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?
Aortic arch
Pulmonic area
Tricuspid area
Mitral area
Question 14 Explanation:
The mitral area (also known as the left ventricular area or the apical area), the fifth intercostal space (ICS) at the left midclavicular line, is the best area for auscultating the apical pulse. The aortic arch is the second ICS to the right of sternum. The pulmonic area is the second intercostal space to the left of the sternum. The tricuspid area is the fifth ICS to the left of the sternum.
Question 15
Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). Which scientific rationale should the nurse remember when performing a breast examination on a female client?
One half of all breast cancer deaths occur in women ages 35 to 45
The tail of Spence area must be included in self-examination
The position of choice for the breast examination is supine
A pad should be placed under the opposite scapula of the breast being palpated
Question 15 Explanation:
The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop breast tumors. This area must also be included in breast self-examination. One half of all women who die of breast cancer are older than age 65. The correct position for breast self-examination is not limited to the supine position; the sitting position with hands at sides, above head, and on the hips is also recommended. A pad is placed under the ipsilateral (e.g., same side) scapula of the breast being palpated.
Question 16
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. Which evaluation criteria would indicate the client’s successful rehabilitation?
The client remains free of the aftermath phase of the pain experience.
The client experiences decreased frequency of acute pain episodes.
The client continues normal growth and development with intact support systems.
The client develops increased tolerance for severe pain in the future.
Question 16 Explanation:
Even though the client may experience an aftermath phase, progress is still possible, as is effective rehabilitation. Aftermath reactions may occur but need not interfere with rehabilitation. Acute pain is not expected at this stage of recovery. Conditioning probably would produce less pain tolerance.
Question 17
Christine Ann is about to take her NCLEX examination next week and is currently reviewing the concept of pain. Which scientific rationale would indicate that she understands the topic?
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
Question 17 Explanation:
Phases of pain experience include the anticipation of pain. Fear and anxiety affect a person’s response to sensation and typically intensify the pain. Intractable pain is moderate to severe pain that cannot be relieved by any known treatment. Pain is a subjective sensation that cannot be quantified by anyone except the person experiencing it. Psychological factors contribute to a client’s pain perception. In many cases, pain results from emotions, such as hostility, guilt, or depression.
Question 18
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. Then she let him watch TV and eat an apple. This is an example of which type of pain intervention?
Pharmacologic therapy
Environmental alteration
Control and distraction
Cutaneous stimulation
Question 18 Explanation:
The mothers actions are example of control and distraction. Involving the child in care and providing distraction took his mind off the pain. Pharmacologic agents for pain analgesics — were not used. The home environment was not changed, and cutaneous stimulation, such as massage, vibration, or pressure, was not used.
Question 19
Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures?
These measures are more effective than analgesics.
These measures decrease input to large fibers.
These measures potentiate the effects of analgesics.
These measures block transmission of type C fiber impulses.
Question 19 Explanation:
Noninvasive measures may result in release of endogenous molecular neuropeptides with analgesics properties. They potentiate the effect of analgesics. No evidence indicates that noninvasive and nonpharmacologic measures are more effective than analgesics in relieving pain. Decreased input over large fibers allows more pain impulses to reach the central nervous system. There is no connection between type C fiber impulses and noninvasive and nonpharmacologic pain-control measures.
Question 20
When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation?
The client distracts himself during pain episodes.
The client denies the existence of any pain.
The client reports no need for family support.
The client reports pain reduction with decreased activity.
Question 20 Explanation:
Distraction is an appropriate method of reducing pain. Denying the existence of any pain is inappropriate and not indicative of coping. Exclusion of family members and other sources of support represents a maladaptive response. Range-of-motion exercises and at least mild activity, not decreased activity, can help reduce pain and are important to prevent complications of immobility.
Question 21
In planning pain reduction interventions, which pain theory provides information most useful to nurses?
Specificity theory
Pattern theory
Gate-control theory
Central-control theory
Question 21 Explanation:
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. The gate-control, specificity, and patter theories do not address pain control to the depth included in the central-control theory.
Question 22
Ryan underwent an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?
Left hip dressing dry and intact
Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
Left leg in functional anatomic position
Left foot cold to touch; no palpable pedal pulse
Question 22 Explanation:
A left foot cold to touch without palpable pedal pulse represents an abnormal finding on neurovascular assessment of the left leg. The client is most likely experiencing some complication from surgery, which requires immediate medical intervention. The nurse should notify the health care provider of these findings. 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.
Question 23
Which term would the nurse use to document pain at one site that is perceived in other site?
Referred pain
Phantom pain
Intractable pain
Aftermath of pain
Question 23 Explanation:
Referred pain is pain occurring at one site that is perceived in another site. Referred pain follows dermatome and nerve root patterns. Phantom pain refers to pain in a part of the body that is no longer there, such as in amputation. Intractable pain refers to moderate to severe pain that cannot be relieved by any known treatment. Aftermath of pain, a phase of the pain experience and the most neglected phase, addresses the client’s response to the pain experience.
Question 24
Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement? (Select all that apply.)
Assessing the client’s bowel sounds
Taking the client’s blood pressure and apical pulse
Obtaining a pulse oximeter reading
Notifying the health care provider
Determining the last time the client received pain medication
Encouraging the client to turn, cough, and deep breathe
Question 24 Explanation:
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 nurse must also make sure the pain medication is due according to the health care provider’s orders. Obtaining a pulse oximeter reading and turning, coughing, and deep breathing will not help the client’s pain. There is no need to notify the health care provider in this situation.
Question 25
Albert who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Which intervention is the most appropriate for him?
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
Question 25 Explanation:
Because it has been 6 months, the client needs professional help to get on with life and handle the limitations imposed by the current problems. 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.
Question 26
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). Which intervention should the nurse implement first?
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
Question 26 Explanation:
The nurse immediate action should be assess the client in an attempt to exclude possible complications that may be causing the client’s complaints. 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. The nurse should never administer pain medication without assessing the client first. 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. Checking the client’s chart is appropriate after the nurse determines that the client is not experiencing complications from surgery. Pain is subjective, and each person has his own level of pain tolerance. The nurse must always believe the client’s complaint of pain.
Question 27
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?
Acute pain
Chronic pain
Superficial pain
Deep pain
Question 27 Explanation:
Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic pain from organs in any body activity. Acute pain is rapid in onset, usually temporary (less than 6 months), and subsides spontaneously. Chronic pain is marked by gradual onset and lengthy duration (more than 6 months). Superficial pain has abrupt onset with sharp, stinging quality.
Question 28
A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?
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
Question 28 Explanation:
Aspirin raises the pain threshold and, although range-of-motion exercises hurt, mild exercise can relieve pain on rising. Strict limitation of motion only increases the client’s pain. Having others transfer the client into a wheelchair does not increase his feelings of dependency. Massage increases inflammation and should be avoided with this client.
Question 29
Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?
Referring the client for hypnosis
Administering pain medication as prescribed
Removing all glaring lights and excessive noise
Using transcutaneous electric nerve stimulation
Question 29 Explanation:
Nonpharmacologic pain relief interventions include cutaneous stimulation, back rubs, biofeedback, acupuncture, transcutaneous electric nerve stimulation, and more. Hypnosis is considered an alternative therapy. Medications are pharmacologic measures. Although removing glaring lights and excessive noise help to reduce or remove noxious stimuli, it is not specific to pain relief.
Question 30
A 12-year-old student fall off the stairs, grabs his wrist, and cries, “Oh, my wrist! Help! 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?
Type A-delta fibers
Autonomic nerve fibers
Type C fibers
Somatic efferent fibers
Question 30 Explanation:
Type A-delta fibers conduct impulses at a very rapid rate and are responsible for transmitting acute sharp pain signals from the peripheral nerves to the spinal cord. Only type A-delta fibers transmit sharp, piercing pain. Somatic efferent fibers affect the voluntary movement of skeletal muscles and joints. Type C fibers transmit sensory input at a much slower rate and produce a slow, chronic type of pain. The autonomic system regulates involuntary vital functions and organ control such as breathing.

Pain Assessment Questions

1. Which statement indicates the development of opioid tolerance?

Larger doses of opioids are needed to control pain, as compared to several weeks earlier.
Stimulants are needed to counteract the sedating effects of opioids.
The patient becomes anxious about knowing the exact time of the next dose of opioid.
The patient no longer experiences constipation from the usual dose of opioid.

2. The pain management nurse observes a patient with complex regional pain syndrome who is not wearing the right-side jacket sleeve. The patient reports intense, right arm pain upon light touch. The nurse recognizes this pain as:

allodynia.
hypoalgesia.
neuritis.
paresthesia.

3. A 45-year-old patient who reports pain in the foot that moves up along the calf says: “My right foot feels like it is on fire.” The patient reports that the pain started yesterday, and he or she has no prior history of injury or falls. Which components of pain assessment has the patient reported?

Aggravating and alleviating factors.
Exacerbation, with associated signs and symptoms.
Intensity, temporal characteristics, and functional impact.
Location, quality, and onset.

4. A 53-year-old patient who is receiving ibuprofen 400 mg twice a day, for chronic, low back pain develops lower-extremity edema. The pain management nurse suspects that the edema is caused by:

a decrease in renal function.
a low creatinine level.
an increase in glomerular filtration rate.
an increase in plasma proteins.

5. A distinguishing feature of a cluster headache is that it occurs:

bilaterally.
globally.
occipitally.
unilaterally.

6. A 73-year-old patient with cancer is in the hospital for pain control and rates pain as a “12” on the Numeric Rating Scale of 0 to 10. Thirty minutes after receiving IV pain medication, the patient reports no pain relief. The pain management nurse calls the physician for additional orders for pain medication. The nurse’s actions demonstrate:

analgesic titration.
empathy.
independence.
patient advocacy.

7. Which behavioral therapy works best to relieve pain with muscle tension and spasms in patients who are anxious about their pain?

Distraction.
Hypnosis.
Relaxation.
Stress management.

8. The pain management nurse follows the recommended protocol for preventing constipation when starting a patient on opioids by:

adding bulk fiber to the diet.
giving the patient enemas as needed.
increasing fluids and exercise.
using a bowel stimulant and stool softener.

9. A 35-year-old, male patient with testicular cancer is joking and playing cards with his roommate. When assessed by the pain management nurse, the patient rates his pain as a 7 on a Numeric Rating Scale of 0 to 10. The nurse concludes that the patient’s behavior:

is an emotional reaction to having cancer.
is in anticipation of future pain.
is more indicative of the need for pain medication than the pain rating.
may be in conflict with the pain rating, and accepts the report of pain.

10. An older adult patient is discharged from the hospital with nortriptyline (Pamelor) for neuropathic pain. Which statement indicates the patient’s need for additional education?

“I will chew sugarless gum and mints.”
“I will drink carbonated beverages.”
“I will take my medication at breakfast.”
“I will use a humidifier at bedtime.”

11. Which nonpharmacologic intervention is difficult to use with older adults who are cognitively impaired?

Aromatherapy.
Distraction.
Guided imagery.
Heat application.

12. An 85-year-old, male patient with a history of prostate cancer and metastasis to the lumbar spine, is receiving methadone (Dolophine), 10 mg, three times a day. The patient’s spouse tells the pain management nurse that the patient exhibits a lack of motivation, loss of appetite, and an inability to get out of bed. The nurse initially focuses on:

need for antidepressants.
physical therapy evaluation.
psychological evaluation.
the patient’s pain assessment.

13. The pain management nurse assesses a patient with complex regional pain syndrome. The nurse is concerned about the patient’s depressed mood, because she or he has said: “I can’t live with this pain.” The nurse further assesses for suicide risk, because:

decreased pain thresholds lead to suicidal thoughts.
suicidal thoughts are common in patients with chronic pain.
suicidal thoughts are often expressed by patients with acute pain.
verbalization of suicidal thoughts is a way for patients to get attention.

14. A 45-year-old patient is diagnosed with lumbar radiculopathy. The patient’s pain is not well controlled by an opioid medication. Which medication class does the pain management nurse identify as being the first-line, adjuvant medication for this diagnosis?

Acetaminophen-containing drugs.
Nonsteroidal anti-inflammatory drugs.
Serotonin reuptake inhibitor antidepressants.
Tricyclic antidepressants.

15. Biofeedback is a therapy used to:

develop psycho-physiologic self-regulation.
enhance drug delivery.
increase release of serotonin.
promote neuronal regeneration.

16. The pain management nurse notices a male patient grimacing as he moves from the bed to a chair. The patient tells the nurse that he is not experiencing any pain. The nurse’s response is to:

clarify the patient’s report by reviewing the patient’s nonverbal behavior.
confronting the patient’s denial of pain.
obtaining an order for pain medication.
supporting the patient’s stoic behavior.

17. The pain management nurse assesses a 67-year-old patient for reports of episodic, sudden-onset, right-sided facial pain. The patient describes the pain as fleeting, electric-like and triggered by light touch and brushing of the teeth. The nurse suspects:

facet syndrome.
myofascial pain syndrome.
temporomandibular disorder.
trigeminal neuralgia.

18. When assessing an infant for pain, the pain management nurse recognizes that:

a lack of a physiologic or behavioral response means a lack of pain.
if something causes pain in an adult, it can cause pain in an infant.
the parent’s observations should not be included in the patient’s assessment of pain.
Wong-Baker FACES Scale is an appropriate assessment tool.

19. A patient is utilizing a heating pad at home for the treatment of a muscle spasm. The pain management nurse notes the patient is on a transdermal fentanyl (Duragesic) patch. What will the nurse include in the patient’s education?

Avoid using the heating pad directly over the patch.
Cover the patch with a cloth while using the heating pad.
Remove the patch while using the heating pad.
Stop the use of the heating pad until the patch is discontinued.

20. The main responsibilities of the nurse on the interdisciplinary, chronic pain management team are to:

assess level of function; design a therapeutic exercise plan; and monitor functional progress.
provide a comprehensive, psychosocial evaluation; implement cognitive behavior interventions; and teach problem-solving techniques.
provide ergonomic training; develop pain management strategies to apply in the workplace; and facilitate the return to work.
review the medical history; monitor medications; and provide education for the patient and family.

21. The pain management nurse is assessing a trauma patient’s readiness for discharge, by determining the level of comfort the patient prefers. The nurse completes this portion of the pain assessment by asking about the patient’s:

aggravating and alleviating factors.
functional pain goal.
intensity of pain.
onset of pain.

22. A patient with fibromyalgia reports symptoms of unrelieved pain. To determine whether the patient is also experiencing other conditions, the pain management nurse will ask the patient about:

constipation, dizziness, and pruritus.
evening pain and stiffness.
hyperactivity, followed by periods of heavy sleep.
loss of appetite and increased feelings of anxiety.

23. The pain management nurse, concerned with metabolite accumulation in a patient with decreased creatinine clearance, decides to utilize:

fentanyl transdermal patch (Duragesic).
methadone (Dolophine).
morphine (MS-IR).
oxycodone (Roxicodone).

24. Following surgery to the left elbow, a patient is receiving a continuous, upper-extremity, peripheral nerve block. The pain management nurse immediately notifies the anesthesia provider of:

a change in level of sensory or motor function to the left hand.
a new complaint of left great-toe pain with a reported history of gout.
new orders written by the surgeon to increase frequency of oral oxycodone from every six hours as needed, to every four hours as needed.
patient refusal to participate in physical therapy.

25. A 12-year-old oncology patient who is receiving in-home care without IV access needs medication for breakthrough pain. The pain management nurse’s most effective route of administration to recommend is:

intranasal.
nebulized.
oral transmucosal.
transdermal.

ANSWERS:
Question 1
The right answer was Larger doses of opioids are needed to control pain, as compared to several weeks earlier.

Question 2
The right answer was allodynia.

Question 3
The right answer was Location, quality, and onset.

Question 4
The right answer was a decrease in renal function.

Question 5
The right answer was unilaterally.

Question 6
The right answer was patient advocacy.

Question 7
The right answer was Relaxation.

Question 8
The right answer was using a bowel stimulant and stool softener.

Question 9
The right answer was may be in conflict with the pain rating, and accepts the report of pain.

Question 10
The right answer was “I will take my medication at breakfast.”

Question 11
The right answer was Guided imagery.

Question 12
The right answer was the patient’s pain assessment.

Question 13
The right answer was suicidal thoughts are common in patients with chronic pain.

Question 14
The right answer was Tricyclic antidepressants.

Question 15
The right answer was develop psycho-physiologic self-regulation.

Question 16
The right answer was clarify the patient’s report by reviewing the patient’s nonverbal behavior.

Question 17
The right answer was trigeminal neuralgia.

Question 18
The right answer was if something causes pain in an adult, it can cause pain in an infant.

Question 19
The right answer was Avoid using the heating pad directly over the patch.

Question 20
The right answer was review the medical history; monitor medications; and provide education for the patient and family.

Question 21
The right answer was functional pain goal.

Question 22
The right answer was loss of appetite and increased feelings of anxiety.

Question 23
The right answer was fentanyl transdermal patch (Duragesic).

Question 24
The right answer was a change in level of sensory or motor function to the left hand.

Question 25
The right answer was oral transmucosal.

Which data from the nursing evaluation represent information about health beliefs?

Which assessment data should the nurse include when doing a physical assessment?

What are the types of data in assessing in nursing?

What are the types of data in health assessment?

Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68 year old woman hospitalized due to pneumonia?