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NurseDive Free Nursing Practice Question
Which component of pain assessment is addressed by asking a client to rate his or her current level of discomfort on a scale of 0-10?
A. Intensity
Intensity is one of the key components of pain assessmentand it is measured by asking a client to rate his or her current level of discomfort on a scale of 0-10. This helps to quantify the severity of pain and monitor its changes over time.
B. Quality
Quality is wrong because quality refers to the nature or characteristics of pain, such as burning, stabbing, throbbing, etc.It is usually assessed by asking the client to describe the pain in his or her own words.
C. Onset
Onset is wrong because onset refers to the time when the pain started or what triggered it.It is usually assessed by asking the client about the mechanism of injury or etiology of pain, if identifiable.
D. Duration (Source: https://quizlet.com/303867498/pain-management-nclex-practice-quiz-25-questions-flash-cards/).
Duration is wrong because duration refers to how long the pain lasts or how often it occurs.It is usually assessed by asking the client about the course or temporal pattern of pain, such as constant, intermittent, or episodic.
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Full Explanation
The correct answer is choice A. Intensity. Intensity is one of the key components of pain assessment and it is measured by asking a client to rate his or her current level of discomfort on a scale of 0-10.
This helps to quantify the severity of pain and monitor its changes over time.
Choice B. Quality is wrong because quality refers to the nature or characteristics of pain, such as burning, stabbing, throbbing, etc. It is usually assessed by asking the client to describe the pain in his or her own words.
Choice C. Onset is wrong because onset refers to the time when the pain started or what triggered it. It is usually assessed by asking the client about the mechanism of injury or etiology of pain, if identifiable.
Choice D. Duration is wrong because duration refers to how long the pain lasts or how often it occurs. It is usually assessed by asking the client about the course or temporal pattern of pain, such as constant, intermittent, or episodic.
Similar Questions
A nurse is caring for an older adult client who has difficulty communicating verbally due to aphasia following a stroke.
Which of the following strategies should the nurse use to assess this client’s pain? (Select all that apply.)
A. Ask yes or no questions
This can help the client to communicate their pain level and location with minimal language difficulty.
B. Use a visual analog scale (VAS)
This is a self-report pain scale that uses a line with endpoints labeled as “no pain” and “worst pain imaginable”.The client can point to a position on the line that corresponds to their pain intensity.VAS has been shown to be feasible, valid and reliable for stroke patients with mild-to-moderate aphasia.
C. Observe for nonverbal cues
This can include facial expressions, body movements, vocalizations, and changes in vital signs that may indicate pain.Nonverbal cues are especially important for clients with severe aphasia who cannot use self-report scales.
D. Use open-ended questions
This is wrong because open-ended questions require more complex language skills and may frustrate the client with aphasia.The nurse should use simple and direct questions that can be answered with yes or no, gestures, or pointing.
E. Involve family members or caregivers (Source: https://quizlet.com/580119875/pain-management-ati-flash-cards/).
They can provide information about the client’s pain history, preferences, and behaviors that may indicate pain.They can also help the nurse communicate with the client and interpret their responses.
Full Explanation
The correct answer is choice A, B, C, and E. The nurse should use the following strategies to assess this client’s pain:
• Ask yes or no questions: This can help the client to communicate their pain level and location with minimal language difficulty.
• Use a visual analog scale (VAS): This is a self-report pain scale that uses a line with endpoints labeled as “no pain” and “worst pain imaginable”. The client can point to a position on the line that corresponds to their pain intensity. VAS has been shown to be feasible, valid, and reliable for stroke patients with mild-to-moderate aphasia.
• Observe for nonverbal cues: This can include facial expressions, body movements, vocalizations, and changes in vital signs that may indicate pain. Nonverbal cues are especially important for clients with severe aphasia who cannot use self-report scales.
• Involve family members or caregivers: They can provide information about the client’s pain history, preferences, and behaviors that may indicate pain. They can also help the nurse to communicate with the client and interpret their responses.
Choice D is wrong because open-ended questions require more complex language skills and may frustrate the client with aphasia. The nurse should use simple and direct questions that can be answered with yes or no, gestures, or pointing.
A nurse is caring for a patient who has been prescribed fentanyl patches for chronic cancer pain management at home. Which statement by the patient indicates that he understands how to use this medication safely?
A. “I will change the patch every other day.”
Changing the patch every other day would result in inadequate pain relief and withdrawal symptoms.
B. “I will apply the patch to a hairy area for better adhesion.”
Applying the patch to a hairy areawould interfere with the absorption of the drug and reduce its effectiveness
C. “I will remove the old patch before applying a new one.”
The patient should remove the old patch before applying a new one to avoid overdose and adverse effects of fentanyl.Fentanyl patches are designed to deliver a constant amount of opioid analgesic over a period of time, usually 72 hours.
D. “I will cut the patch in half if I need a lower dose.”.
Cutting the patch in halfwould damage the integrity of the patch and cause erratic or rapid release of the drug, which could be fatal.Fentanyl patches should be applied to a clean, dry, hairless area of intact skin on the upper torso or upper arm.
Full Explanation
The correct answer is choice C. The patient should remove the old patch before applying a new one to avoid overdose and adverse effects of fentanyl. Fentanyl patches are designed to deliver a constant amount of opioid analgesic over a period of time, usually 72 hours.
Therefore, changing the patch every other day (choice A) would result in inadequate pain relief and withdrawal symptoms.
Applying the patch to a hairy area (choice B) would interfere with the absorption of the drug and reduce its effectiveness.
Cutting the patch in half (choice D) would damage the integrity of the patch and cause erratic or rapid release of the drug, which could be fatal. Fentanyl patches should be applied to a clean, dry, hairless area of intact skin on the upper torso or upper arm.
A nurse is administering naloxone to a patient who has overdosed on heroin. What is the expected outcome of this intervention?
A. The patient will experience increased euphoria and sedation.
This is wrong because naloxone does not increase euphoria and sedation, but rather reverses them by blocking opioid receptors.
B. The patient will experience severe withdrawal symptoms and agitation
This is wrong because naloxone does not cause severe withdrawal symptoms and agitation, but rather mild to moderate ones that are not life-threatening.
C. The patient will experience decreased respiratory rate and blood pressure.
This is wrong because naloxone does not decrease respiratory rate and blood pressure, but rather increases them by reversing opioid overdose. Normal ranges for respiratory rate are 12 to 20 breaths per minute and for blood pressure are 90/60 mmHg to 120/80 mmHg.
D. The patient will experience improved mental status and oxygenation.
The patient will experience improved mental status and oxygenation.This is because naloxone is a medication that can rapidly reverse an opioid overdose by blocking the effects of opioids and restoring normal breathing.Naloxone can be given as a nasal spray or an injection.
Full Explanation
The correct answer is choice D. The patient will experience improved mental status and oxygenation. This is because naloxone is a medication that can rapidly reverse an opioid overdose by blocking the effects of opioids and restoring normal breathing. Naloxone can be given as a nasal spray or an injection.
Choice A is wrong because naloxone does not increase euphoria and sedation, but rather reverses them by blocking opioid receptors.
Choice B is wrong because naloxone does not cause severe withdrawal symptoms and agitation, but rather mild to moderate ones that are not life-threatening.
Choice C is wrong because naloxone does not decrease respiratory rate and blood pressure, but rather increases them by reversing opioid overdose.
Normal ranges for respiratory rate are 12 to 20 breaths per minute and for blood pressure are 90/60 mmHg to 120/80 mmHg.