Nursing Health Assessment and Pain Practice Quiz 3

Answer: A – The client distracts himself during pain episodes.

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.

Answer: D – Central-control theory

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.

Answer: D – Left foot cold to touch; no palpable pedal pulse

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,

Answer: A – Referred pain

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.

Answer: A – Referring the client for counseling and occupational therapy

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.

Answer: A – Assessing the client to rule out possible complications secondary to surgery

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,

Answer: D – Deep pain

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.

Answer: D – Encouraging gentle range-of-motion exercises after administering aspirin and before rising

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.

Answer: D – Using transcutaneous electric nerve stimulation

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.

Answer: A – Type A-delta fibers

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.