Chapter 043

Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 43: Pain Management
MULTIPLE CHOICE
1. Which one of the following nursing interventions for a client in pain is based on the gatecontrol theory?
1. Giving the client a back massage
2. Changing the clients position in bed
3. Giving the client a pain medication
4. Limiting the number of visitors
ANS: 1
The gate-control theory suggests that cutaneous stimulation activates larger, fastertransmitting A-beta sensory nerve fibers. This decreases pain transmission through smalldiameter A-delta and C fibers. A back massage is a nursing intervention based on the
gate-control theory. Changing the clients position in bed is not a form of cutaneous
stimulation used to relieve pain. Giving the client a pain medication is a pharmacological
approach to relieving pain. Limiting the number of visitors may provide a quiet
environment conducive to relaxation, but it is not based on the gate-control theory.
DIF: A
REF: 1053-1054
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological
Pain Management; Physiological Integrity/Basic Care and Comfort
2. A priority nursing intervention when caring for a client who is receiving an epidural
infusion for pain relief is to:
1. Use aseptic technique
2. Label the port as an epidural catheter
3. Monitor vital signs every 15 minutes
4. Avoid supplemental doses of sedatives
ANS: 3
When clients are receiving epidural analgesia, monitoring occurs as often as every 15
minutes, including assessment of respiratory rate, respiratory effort, and skin color.
Complications of epidural opioid use include nausea and vomiting, urinary retention,
constipation, respiratory depression, and pruritus. A common complication of epidural
anesthesia is hypotension. Assessing vital signs is the priority nursing intervention.
Because of the catheter location, strict surgical asepsis is needed to prevent a serious and
potentially fatal infection. To reduce the risk for accidental epidural injection of drugs
intended for IV use, the catheter should be clearly labeled epidural catheter.
Supplemental doses of opioids or sedative/hypnotics are avoided because of possible
additive central nervous system adverse effects.
DIF:
REF: 1078
OBJ: Analysis
Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
43-2
TOP: Nursing Process: Planning

3. The nurse should describe pain that is causing the client a burning sensation in the
epigastric region as:
1. Referred
2. Radiating
3. Deep or visceral
4. Superficial or cutaneous
ANS: 3
Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may
be described as a burning sensation. Referred pain is felt in a part of the body separate
from the source of pain, such as with a myocardial infarction, in which pain may be
referred to the jaw, left arm, and left shoulder. Radiating pain feels as though it travels
down or along a body part, such as low back pain that is accompanied by pain radiating
down the leg from sciatic nerve irritation. Superficial or cutaneous pain is of short
duration and is localized as in a small cut.
DIF: A
REF: 1056
OBJ: Comprehension
4. Which of the following is most appropriate when the nurse assesses the intensity of the
clients pain?
1. Ask about what precipitates the pain.
2. Question the client about the location of the pain.
3. Offer the client a pain scale to objectify the information.
4. Use open-ended questions to find out about the sensation.
ANS: 3
Descriptive scales are a more objective means of measuring pain intensity. Asking the
client what precipitates the pain does not assess intensity, but rather it is an assessment of
the pain pattern. Asking the client about the location of pain does not assess the intensity
of the clients pain. To determine the quality of the clients pain, the nurse may ask openended questions to find out about the sensation experienced.
DIF: A
REF: 1063
OBJ: Comprehension
5. The nurse on a postoperative care unit is assessing the quality of the clients pain. In
order to obtain this specific information about the pain experience from the client, the
nurse should ask:
Test Bank
1.
2.
3.
4.
43-3
What does your discomfort feel like?

What activities make the pain worse?
How much does it hurt on a scale of 0 to 10?
How much discomfort are you able to tolerate?
ANS: 1
To determine the quality of the clients pain the nurse might say, What does your
discomfort feel like? It is more accurate to have clients describe the pain in their own
words whenever possible. Inquiring about what activities make the pain worse is a type
of question directed at determining the pain pattern. Having the client rate his or her pain
on a pain scale is a method of measuring the intensity of pain. To determine the clients
expectations, the nurse may ask the client, How much discomfort are you able to
tolerate?
DIF: A
REF: 1063-1065
OBJ: Comprehension
6. When a clients husband questions how a patient-controlled analgesia (PCA) pump
works, the nurse explains that the client:
1. Has control over the frequency of the intravenous (IV) analgesia
2. Can choose the dosage of the drug received
3. May request the type of medication received
4. Controls the route for administering the medication
ANS: 1
With a PCA system the client controls medication delivery. The PCA system is designed
to deliver no more than a specified number of doses. The client does not choose the
dosage. The health care provider prescribes the type of medication to be used. The
advantage for the client is that he or she may self-administer opioids with minimal risk
for overdose. The client does not control the route for administration. Systemic PCA
typically involves IV drug administration but can also be given subcutaneously.
DIF: A
REF: 1076
OBJ: Comprehension
TOP: Nursing Process: Implementation
7. An older client with mild musculoskeletal pain is being seen by the primary care
provider. The nurse anticipates that treatment of this clients level of discomfort will
include:
1. Fentanyl
2. Diazepam
3. Acetaminophen
4. Meperidine hydrochloride
ANS: 3
Test Bank
43-4
A nonopioid analgesic, such as acetaminophen, is used to effectively treat mild

musculoskeletal pain. Fentanyl is about 100 times more potent than morphine. It is
typically used for cancer pain, not mild musculoskeletal pain. Diazepam is given as an
antianxiety agent. Meperidine hydrochloride is an opioid analgesic used to treat moderate
to severe acute pain, not mild pain.
DIF: A
REF: 1073
OBJ: Comprehension
8. Before inserting a Foley catheter, the nurse explains that the client may feel some
discomfort. This is an example of:
1. Distraction
2. Reducing pain perception
3. Anticipatory response
4. Self-care maintenance
ANS: 3
Pain can be prevented by anticipating painful events. Before performing procedures, the
nurse considers the clients condition, aspects of the procedure that may be
uncomfortable, and techniques to avoid causing pain. The nurse who tells the client that
the urinary catheter insertion may feel uncomfortable is an example of anticipatory
response. Distraction directs a clients attention to something else and thus can reduce the
awareness of pain and even increase tolerance. Reducing pain perception means to
remove stimuli that are uncomfortable or to prevent stimuli that are painful, such as
changing wet linens, or preventing constipation with fluids, diet, and exercise. Self-care
maintenance implies the client is able to carry out necessary activities to care for himself
or herself. This may include pain management measures.
DIF: A
REF: 1073
OBJ: Comprehension
9. The nurse knows that a PCA pump would be most appropriate for the client who:
1. Has psychogenic discomfort
2. Is recovering after a total hip replacement
3. Experiences renal dysfunction
4. Recently experienced a cerebrovascular accident (stroke)
ANS: 2
Test Bank
43-5
Patient-controlled analgesia is a safe method for postoperative pain management, such as

the client recovering from total hip replacement surgery. PCA would not be the mode of
choice for treating psychogenic pain or for the client with renal dysfunction. The client
with renal impairment would be at increased risk for drug toxicity because of decreased
drug excretion. Clients must be able to understand the use of the equipment and be
physically able to locate and press the button to deliver the dose. The client who recently
experienced a cerebrovascular accident may have difficulty managing the PCA system.
DIF: C
REF: 1076
OBJ: Analysis
10. A client with chronic back pain has an order for a transcutaneous electrical nerve
stimulation (TENS) unit for pain control. The nurse should instruct the client to:
1. Keep the unit on high
2. Use the unit when pain is perceived
3. Remove the electrodes at bedtime
4. Use the therapy without medications
ANS: 2
When a client feels pain, the TENS unit is turned on and a buzzing or tingling sensation
is created. The tingling sensation can be applied until pain relief occurs. The client may
adjust the intensity of skin stimulation. It does not have to remain on high. The electrodes
do not have to be removed at bedtime. Medication can be administered with a TENS unit.
DIF: A
REF: 1071
OBJ: Comprehension
11. The nurse caring for a terminally ill client with liver cancer understands which of the
following goals would be most appropriate?
1. Increasingly administer narcotics to oversedate the client and thereby decrease the
pain.
2. Continue to change the analgesics until the right narcotic is found that completely
alleviates the pain.
3. Adapt the analgesics as the nursing assessment reveals the need for specific
medications.
4. Withhold analgesics because they are not being effective in relieving discomfort.
ANS: 3
Test Bank
43-6
The best choice of treatment often changes as the clients condition and the
characteristics of pain change. It is realistic to expect that a terminally ill clients need for
pain medication will change over time with disease progression. The goal is not to
oversedate the client but to provide pain control without excessive sedation. It would be
unrealistic to expect that the pain of terminal cancer will be completely alleviated.
Analgesics should not be withheld, because this would only increase the clients level of
pain. The medication regimen may need to be adapted to meet the clients needs.
DIF: C
REF: 1078-1079
OBJ: Analysis
12. A client is having severe, continuous discomfort from kidney stones. Based on the
clients experience, the nurse anticipates which of the following findings in the clients
assessment?
1. Tachycardia
2. Diaphoresis
3. Pupil dilation
4. Nausea and vomiting
ANS: 4
Acute severe or deep pain, as with kidney stones, will cause a parasympathetic response.
The client would likely exhibit nausea and vomiting. Tachycardia is a response of
sympathetic stimulation, commonly seen with pain of low to moderate intensity and
superficial pain. Diaphoresis is a response of sympathetic stimulation, commonly seen
with pain of low to moderate intensity and superficial pain. Pupil dilation is a response of
sympathetic stimulation, commonly seen with pain of low to moderate intensity and
superficial pain.
DIF: A
REF: 1064
OBJ: Comprehension
13. Nurses working with clients in pain need to recognize and avoid common misconceptions
and myths about pain. In regard to the pain experience, which of the following is correct?
1. The client is the best authority on the pain experience.
2. Chronic pain is mostly psychological in nature.
3. Regular use of analgesics leads to drug addiction.
4. The amount of tissue damage is accurately reflected in the degree of pain
perceived.
ANS: 1
Test Bank
43-7
A clients self-report of pain is the single most reliable indicator of the existence and
intensity of pain and any related discomfort. Pain is individualistic. A misconception
about pain is that chronic pain is psychological. The belief that administering analgesics
regularly will lead to drug addiction is a misconception. Another misconception about
pain is that the amount of tissue damage is accurately reflected in the degree of pain
perceived.
DIF: C
REF: 1057
OBJ: Analysis
14. A nonpharmacological approach that the nurse may implement for clients experiencing
pain that focuses on promoting pleasurable and meaningful stimuli is:
1. Acupressure
2. Distraction
3. Biofeedback
4. Hypnosis
ANS: 2
Pleasurable stimuli cause the release of endorphins. The nurse assesses activities enjoyed
by the client that may act as distractions. Distraction directs a clients attention to
something else and thus can reduce the awareness of pain and even increase tolerance.
Acupressure does not focus on promoting pleasurable and meaningful stimuli.
Acupressure is finger pressure applied therapeutically at selected points on the body.
Biofeedback focuses on an individuals physiological responses (e.g., blood pressure or
tension) and ways to exercise voluntary control over those responses. Hypnosis does not
focus on promoting pleasurable and meaningful stimuli. Hypnosis is a condition
resembling sleep in which the mind is susceptible to suggestions.
DIF: A
REF: 1071
OBJ: Comprehension
15. Which of the following is the most appropriate nursing intervention for a client who is
receiving epidural analgesia?
1. Change the tubing every 48 to 72 hours.
2. Change the dressing every shift.
3. Secure the catheter to the outside skin.
4. Use a bulky occlusive dressing over the site.
ANS: 3
To prevent catheter displacement, the catheter should be secured carefully to the outside
skin. The infusion tubing should be changed every 24 hours to prevent infection. To
prevent infection, the dressing should not be routinely changed over the site. A
transparent dressing should be used over the site to secure the catheter and aid inspection.
Test Bank
43-8
DIF: A
REF: 1078
OBJ: Comprehension
16. The client is experiencing breakthrough pain while receiving opioids. An order is written
for the client to receive a transmucosal fentanyl unit. In teaching about this medication,
the nurse should instruct the client to:
1. Swab the unit over the cheeks
2. Do not chew the unit after administration
3. Take no more than two units per episode of discomfort
4. Allow the unit to dissolve slowly in the mouth over 15 minutes or more
ANS: 2
The unit needs to be left intact and not chewed. The unit is placed in the clients mouth
and swabbed over the inside of the cheeks and lower gums. No more than two units
should be used per breakthrough pain episode. The unit needs to be allowed to dissolve
and absorb over a 15-minute period.
DIF: A
REF: 1080
OBJ: Comprehension
17. When caring for a client who is experiencing continuous severe pain, the nurse should
expect that the pain management plan would include:
1. Focusing on intramuscular administration of analgesics
2. Waiting for pain to become more intense before administering opioids
3. Administering opioids with nonopioid analgesics for severe pain experiences
4. Administering large doses of opioids initially to clients who have not taken the
medications before
ANS: 3
To treat a client who is experiencing continuous severe pain, the nurse should expect the
client to receive opioid and nonopioid analgesics for severe pain experiences.
Intramuscular administration of analgesics is not expected because the injection itself is
painful, and there may be inconsistent erratic absorption of the drug. The nurse should
administer opioids before the clients pain becomes intense. It is easier to maintain pain
control than it is to get intense pain under control. Large doses of opioids are not given
initially to clients who have not taken the medications before because they may cause
respiratory depression. The expectation is to begin with lower doses and titrate upward.
DIF: A
REF: 1073-1074
OBJ: Comprehension
Test Bank
43-9
18. Which of the following symptoms would the nurse expect with a client who is
experiencing acute pain?
1. Bradycardia
2. Bradypnea
3. Diaphoresis
4. Decreased muscle tension
ANS: 3
An expected assessment finding of a client experiencing acute pain would be diaphoresis
resulting from sympathetic nerve stimulation. Additional assessment findings of a client
experiencing acute pain would be an increased heart rate, respiratory rate, and muscle
tension.
DIF: A
REF: 1054
OBJ: Comprehension
19. Which of the following statements made by a nurse shows the greatest understanding of
the personal nature of the pain experience?
1. I have experienced pain before, and so I have great compassion for anyone dealing
with pain.
2. People handle pain differently, but everyone in pain is only interested in having
the pain stop.
3. Managing a clients pain is the single most important thing a nurse can do for a
client experiencing pain.
4. I can only accept what the client reports concerning the pain being felt and attempt
to intervene successfully in its management.
ANS: 4
The nurse cannot see or feel the clients pain. Pain is purely subjective; no two persons
experience pain in the same way, and no two painful events create identical responses or
feelings in a person. A nursing responsibility requires that the nurse make good faith
attempts to help minimize the pain and to advocate for the client to this end. The
remaining options, while not inappropriate, do not express the most therapeutic attitude
toward the nursing role regarding client pain.
DIF: C
REF: 1057
OBJ: Analysis
20. Which of the following statements made by a nurse requires follow-up with additional
instruction regarding the personal nature of pain?
1. I have experienced pain before, and so I have great compassion for anyone dealing
with pain.
Test Bank
43-10
2. My postsurgical clients get the prescribed pain medications on schedule with no

diversion from that schedule.
3. If I were experiencing severe pain, I certainly would want someone to devote their
time to managing for me.
4. Clients dont always request pain medication, and so I always ask them if they
want it according to the schedule.
ANS: 2
The nurse cannot see or feel the clients pain. Pain is purely subjective; no two persons
experience pain in the same way, and no two painful events create identical responses or
feelings in a person. Flexibility is a necessary component in pain management. The
remaining options do not require follow-up because they do not express any attitudes that
are not compatible with good nursing care of the client in pain.
DIF: C
REF: 1057
OBJ: Analysis
21. Which of the following statements made by a client reporting severe pain expresses the
most insight into how pain impacts a clients energy reserves?
1. I cant sleep if I dont get something for this pain.
2. If only I could get an hour when I was free of this pain.
3. Im exhausted physically and emotionally trying to live with this pain.
4. I dont see how I can continue to cope with this pain; I need some relief.
ANS: 3
Pain is exhausting and demands a persons energy. The remaining options do express this
fact but not as directly as the answer.
DIF: C
REF: 1066
OBJ: Analysis
22. Which of the following statements made by a nurse caring for a client reporting severe
pain expresses the most insight into how pain impacts a clients energy reserves?
1. If I cant get his pain under control, his recovery will take a lot longer.
2. Pain certainly interferes with the clients ability to rest and recuperate.
3. Im going to call for another pain prescription so he can get some rest.
4. Trying to cope with pain is using up the energy that his recovery requires.
ANS: 4
Pain is exhausting and demands a persons energy. The remaining options do express this
fact but not as directly as the answer.
DIF: C
REF: 1066
OBJ: Analysis
Test Bank
43-11

23. Which of the following statements made by the nurse regarding the clients selfassessment of pain requires immediate follow-up regarding the personal nature of pain?
1. The medication should be providing enough relief; try to ambulate her.
2. Ive never known anyone to have such pain after that procedure.
3. He should be able to ambulate with only minimal pain by now.
4. She says shes in pain, but she doesnt act like she is in pain.
ANS: 4
It is not the responsibility of clients to prove that they are in pain; it is the nurses
responsibility to accept clients report of pain. Although the other options appear to be
insensitive to the clients pain, they are not as overtly critical.
DIF: C
REF: 1057
OBJ: Analysis
24. The nurse recognizes that the most likely reason a runner who has injured his ankle
during a race is not aware of it until after he crosses the finish line is that:
1. The emotional exhilaration of running the race masked the pain of the injury
2. His endorphin levels were high as a result of the physical stressors of the race
3. He was mentally distracted by the need to concentrate on the ever-changing nature
of the race
4. The physical effects of the injury slowly increased during the race and reached
pain-producing capacity only after the race
ANS: 2
Stress, exercise, and other factors increase the release of endorphins, raising an
individuals pain threshold (the point at which a person feels pain). Because the amount
of circulating substances varies with each individual, the response to pain will be
different. Although the other options may have affected his pain perception, they did not
exert as much influence as the answer.
DIF: C
REF: 1053
OBJ: Analysis
25. Which of the following statements by the nurse reflects a need for immediate follow-up
regarding the physical effects of chronic pain on body function?
1. His pulse and blood pressure are within his normal baseline limits, so Im sure the
pain medication is working.
2. Please take his pulse and blood pressure, and let me know if they are elevated
above his normal baselines.
Test Bank
43-12
3. If his pulse and blood pressure are above his normal baseline, let me know, and I
will medicate him for pain.
4. Unmanaged pain usually manifests itself in both an elevated pulse and blood
pressure.
ANS: 1
Except in cases of severe traumatic pain, which sends a person into shock, most people
reach a level of adaptation in which physical signs return to normal. Thus clients in pain
will not always have changes in their vital signs. Changes in vital signs are more often
indicative of problems other than pain. Although the remaining options recognize the
phenomena, they are not assuming that no elevation of vital signs means the absence of
pain.
DIF: C
REF: 1054
OBJ: Analysis
TOP: Nursing Process: Assessment/Planning
26. A client with a history of chronic back pain is questioning the need to keep asking for
pain medication, fearing that he will be viewed as being weak by his family. The most
therapeutic nursing response to this client would be:
1. Chronic back pain is very difficult to deal with; utilize the pain medication
because thats what its there for.
2. Your family wont think youre weak; they want you to be comfortable, and the
medication will help.
3. Taking the medication as prescribed will help you to be more active; your family
will be happy you can do things with them again.
4. Its important that you manage your pain as effectively as possible; it really
doesnt matter what other people think about you.
ANS: 3
As a nurse, you encourage clients to accept pain-relieving measures so that they remain
active. Clients who have a low pain tolerance (level of pain a person is willing to put up
with) are sometimes inaccurately perceived as whiners or weak. The client needs to learn
that effective, appropriate pain management is essential to his physical and emotional
well-being. Although the remaining options are not incorrect, they do not display the
degree of understanding the answer does.
DIF: C
REF: 1081
OBJ: Analysis
27. A client who is scheduled for the second in a series of painful dressing changes asks for
my pain medication now so its working when the dressing is changed is most likely
expressing:
1. A great fear of the expected pain
Test Bank
43-13
2. A need to be in control of his pain

3. An understanding that it is easier to prevent the pain than to stop the pain
4. An acceptance of the pain that the dressing change will obviously cause him
ANS: 3
Clients often seek relief before pain occurs, having learned that pain is easier to prevent
than to treat. Although the other options may not be incorrect, the likelihood is greater for
the answer.
DIF: C
REF: 1055
OBJ: Analysis
28. The nurse inquires of a postoperative client as to the need for pain medication. The client
denies the need then but 30 minutes later reports, I am really in a lot of pain. Can you
bring me my pain pill now? The nurse recognizes that the most immediate need for
client education is related to explaining that:
1. His oral medication will take approximately 30 minutes to affect his pain
2. There may be a need to administer his pain medication via the intravenous route
3. Pain medication is more effective if blood levels are maintained at a constant level
4. His pain will be more effectively managed if he reports a need for pain medication
while the pain is still tolerable
ANS: 4
Teach clients the importance of reporting their pain sooner rather than later because the
pain is better managed while it is still tolerable. Medication routes do affect the amount
of time it will take to feel relief, and blood levels are a factor in pain management as well.
The answer addresses the most general and immediate educational need.
DIF: C
REF: 1055
OBJ: Analysis
29. The nurse is caring for a cognitively impaired client who has experienced a painful
procedure. The nurse is most effective in determining the clients pain medication needs
when using which of the following assessment methods?
1. Medicating the client with the as-needed (prn) analgesic as often as ordered
2. Utilizing the pain face scale to assess the clients pain experience
3. Asking the client to rate his or her pain on a scale of 1 to 10, with 10 being the most
severe pain
4. Observing the clients body movements and facial expressions for typical pain
behaviors
ANS: 4
Test Bank
43-14
Body movements and facial expressions that indicate pain include clenching the teeth,
holding the painful part, bent posture, and grimaces. Some clients cry or moan, are
restless, or make frequent requests of a nurse. You will soon learn to recognize patterns of
behavior that reflect pain. This becomes especially important in clients who are unable to
report their pain, such as the cognitively impaired. However, lack of pain expression does
not necessarily mean that the client is not experiencing pain. The remaining options are
not always as effective for the cognitively impaired or reflect inappropriate use of
analgesics.
DIF: C
REF: 1067
OBJ: Analysis
30. The nurse is attempting to ambulate a postoperative client who continues to rate his pain
as a 7 on a scale of 0 to 10, with 10 being the most severe. The client is reluctant to walk
and consents to move only to the chair, reporting that it hurts too much to walk. The
nurses primary concern regarding the clients recovery related to his pain experience is
that:
1. His pain medications are not effectively managing his pain
2. He does not fully understand the importance of ambulation
3. He is expending too much of his energy dealing with the pain
4. He is not ready to participate in the activities needed to recover quickly
ANS: 4
Efforts aimed at teaching and motivating the client toward self-care are often hampered
until the pain is successfully managed. Thus a primary nursing goal is to provide pain
relief that allows clients to participate in their recovery. Although the remaining options
are not inappropriate, they do not express the major concern regarding his recovery.
DIF: C
REF: 1070
OBJ: Analysis
31. The nurse is attempting to ambulate an older adult client who recently experienced a fall
at the assisted living facility where he resides. The client is reluctant to walk and consents
to move only to the chair, reporting that it hurts too much to walk. Which of the
following nursing interventions is most therapeutic regarding this client?
1. Allow the client to remain in bed in order to conserve his energy.
2. Transfer him to the chair, realizing some activity is preferable to none.
3. Call his health care provider to discuss the apparent ineffectiveness of his pain
medications.
4. Assess the client for other factors that may be affecting his ability and motivation
to ambulate.
ANS: 4
Test Bank
43-15
The perception of pain is affected by both physical and emotional factors. The client may
be expressing concern over his ability or desire to return to the assisted living facility and
so perceives the pain as a barrier to ambulating. Thus physical pain can cause
psychological pain and vice versa. The other options are either not therapeutic or not the
initial action to be taken.
DIF: C
REF: 1070
OBJ: Analysis
32. A client with chronic pain states, I just want to be pain-free. Do something to make that
happen. The most therapeutic response is:
1. Together we will all work at making your pain tolerable.
2. I will do everything I can to manage your pain; I promise.
3. Are you feeling depressed or anxious because of your pain?
4. You sound anxious. Would you like something for your nerves?
ANS: 1
Complete pain relief is not always achievable, but reducing pain to a tolerable level is
realistic. The remaining options either address issues other than pain or make promises
that may be difficult or impossible to keep.
DIF: C
REF: 1070
OBJ: Analysis
33. The greatest barrier to a 3-year-old clients ability to self-assess her pain is:
1. A limited vocabulary
2. Increased separation anxiety
3. Reluctance to talk to strangers
4. Inability to grasp the concept of pain
ANS: 1
Young children who have not developed full vocabularies have difficulty verbally
describing and expressing pain to parents or caregivers. Toddlers and preschoolers are
unable to recall explanations about pain or associate pain with experiences that occur in
various situations. The remaining options may have an effect on self-assessment of pain,
but only to a limited degree.
DIF: C
REF: 1057
OBJ: Analysis
Test Bank
43-16
34. The nurse is discussing the effects of pain with an older adult client diagnosed with
osteoarthritis. The most therapeutic response to the clients comment of, I wonder
whether it would hurt if I took a nap in the afternoon? would be:
1. As long as it did not interfere with your getting a good nights sleep.
2. Id suggest taking your nap right after you take your pain medication.
3. If it helps you cope better with the pain, I dont see any harm in taking a nap.
4. I think a nap is a good idea because we seem to feel pain more when we are tired.
ANS: 4
Fatigue heightens the perception of pain and decreases coping abilities. If fatigue occurs
along with sleeplessness, the perception of pain is even greater. Pain is often experienced
less after a restful sleep than at the end of a long day. The other options are not
inappropriate but are not as informative regarding the benefit of rest on the perception or
effects of pain.
DIF: A
REF: 1057-1059
OBJ: Analysis
35. Which of the following statements is the most appropriate response to a clients
statement, I thought you could tell I was in pain?
1. How do you express a need for pain medication if not by asking?
2. Im so very sorry; may I get you your pain medication right now?
3. I dont think its wise to assume I can effectively read your mind regarding the
need for pain medication.
4. I will make a point of asking you to rate your pain at least every 2 hours, so this
miscommunication wont happen again.
ANS: 4
Be sensitive to variations in communication styles. Some cultures feel nonverbal
expression of pain is sufficient to describe the pain experience, whereas others assume
that if pain medication is appropriate, the nurse will bring it; thus asking is inappropriate.
The remaining options are not as effective at addressing the root of the problem or
providing a possible solution.
DIF: C
REF: 1061-1062
OBJ: Analysis
36. A 44-year-old client shares with the admitting nurse that the client is having epigastric
pain that the client identifies as a 7 on a 0 to 10 scale. In order to plan for the pain
management of this client, which is the most appropriate response from the nurse?
1. "What would be a satisfactory level of pain control for us to achieve?"
2. "You dont look like youre in that much pain."
3. "Youll be pain-free following your surgery."
Test Bank
43-17
4. "Ive cared for a client with a nail in his head who only rated his pain as a 5; are
you sure your pain is a 7?"
ANS: 1
Complete pain relief is not always achievable, but reducing pain to a tolerable level is
realistic. Thus a primary nursing goal is to provide pain relief that allows clients to
participate in their recovery. Successful pain management does not necessarily mean pain
elimination, but rather attainment of a mutually agreed-upon pain-relief goal that allows
clients to control their pain instead of the pain controlling them. A person in pain feels
distress or suffering and seeks relief. However, you as the nurse cannot see or feel the
clients pain. It is realistic that the client will most likely experience postoperative pain.
The nurse should not use a pain scale to compare the pain of one client to that of another
client.
DIF: B
REF: 1060
OBJ: Analysis
37. The home care nurse notes that a 67-year-old female diabetic clients blood glucose level
has been elevated since she strained her back the previous week. The client states that she
cannot understand why her blood glucose level is elevated. The nurse suspects the most
likely cause for the elevated blood sugar is:
1. The decreased activity level of the client since the injury
2. Parasympathetic stimulation from the bodys normal response to pain
3. The client is consuming more food as a comfort measure
4. The client may not be taking her medication as ordered
ANS: 2
An increased blood glucose level is the bodys physiological response to pain, which is
triggered by the parasympathetic nervous system in order to provide additional glucose
for additional energy.
DIF: A
REF: 1067
OBJ: Comprehension
38. A client with chronic pain presents in the emergency department of the local hospital
stating I just cant take this anymore. On questioning the client, the nurse discovers that
the client have experienced chronic pain since being involved in an accident 2 years
previously. The client states that he has been labeled a drug seeker because he is
looking for relief for the pain and feels hopeless, angry, and powerless to do anything
about the situation. The nurse understands that this client is at risk for:
1. Criminal activity
2. Opioid abuse
3. Suicide
Test Bank
43-18
4. Drug addiction
ANS: 3
The possible unknown cause of noncancer pain, combined with the unrelenting pain and
uncertainty of its duration, frustrates the client, frequently leading to psychological
depression and perhaps suicide. There is no evidence to demonstrate a relationship
between chronic pain and criminal activity. Health care workers are usually less willing
to treat chronic noncancer pain with opioids, although a recent policy statement supports
the use of opioids for noncancer pain. In addition, the American Society of
Anesthesiologists developed the Practice Guidelines for Chronic Pain Management,
which includes the use of opioids. Many health care providers and clients fear addiction
when long-term opioid use is prescribed to manage pain, although this fear is often
inappropriate. Because of this concern, health care providers require opioid agreements
and random urine testing in clients who require long-term opioid therapy. The
effectiveness of agreements is lacking, and there are ethical concerns about using them
for all clients who require long-term opioid therapy. This raises the question as to whether
agreements protect clients or health care providers.
DIF: A
REF: 1057
OBJ: Comprehension
39. A client who had knee replacement surgery the previous day refuses to take any pain
medication, even though he rates his pain as an 8 on a 0 to 10 scale. Upon questioning the
client the nurse learns that the reason for refusing pain medication is because he is
concerned about injuring the knee and not feeling it. The best information that the nurse
can provide this client is to explain that:
1. The pain medication will help speed his recovery time
2. He need not worry about becoming addicted to the pain medication
3. He will not be perceived as weak for taking the pain medication
4. He is being a difficult client and needs to comply with the health care providers
orders
ANS: 1
Acute pain seriously threatens a clients recovery by resulting in prolonged
hospitalization, increased risks of complications from immobility, and delayed
rehabilitation. Physical or psychological progress is delayed as long as acute pain
persists, because the client focuses all energy on pain relief. Thus a primary nursing goal
is to provide pain relief that allows clients to participate in their recovery.
DIF: A
REF: 1057
OBJ: Comprehension
Test Bank
43-19
40. A 38-year-old client presents to the pain clinic with complaints of phantom pain. The
client was involved in a farming accident 3 years previously that resulted in a below-theelbow amputation of his right arm. The nurse knows that phantom pain is categorized as:
1. Painful polyneuropathy
2. Somatic pain
3. Sympathetically maintained pain
4. Deafferentation pain
ANS: 4
Deafferentation pain comes from injury to either the peripheral or central nervous system.
Phantom pain reflects injury to the peripheral nervous system. In painful polyneuropathy
the client feels pain along the distribution of many peripheral nerves; examples include
diabetic neuropathy, alcohol-nutritional neuropathy, and Guillain-Barr syndrome.
Somatic pain comes from bone, joint, muscle, skin, or connective tissue. It is usually
aching or throbbing in quality and is well localized. Sympathetically maintained pain is
associated with dysregulation of the autonomic nervous system; examples include pain
associated with reflex sympathetic dystrophy/causalgia (complex regional pain
syndrome, type I, type II).
DIF: A
REF: 1054
OBJ: Comprehension
41. The daughter of an 88-year-old female client tells the nurse that her mother has recently
quit going on walks in the neighborhood because of pain in her legs. Which of the
following is the best response from the nurse?
1. "I would like to speak with your mother to get more information."
2. "Older people frequently suffer from arthritis that can cause leg pain."
3. "Your mother probably has poor circulation in her legs, which is causing the pain."
4. "She is lucky to be as healthy as she is at her age."
ANS: 1
The presence of pain in an older adult requires aggressive assessment, diagnosis, and
management. Pain is not an inevitable part of aging.
DIF: A
REF: 1055
OBJ: Comprehension
42. The nursery nurse is explaining postcircumcision care to a new mother. Which of the
following statements by the new mother indicates that additional teaching needs to occur?
1. Babies dont experience pain, so I dont need to worry about hurting him when I
touch the penis.
2. I need to be careful not to put his diaper on too tight to avoid discomfort.
3. I can comfort my baby following the procedure by holding him.
Test Bank
43-20
4. The health care provider will numb the area before performing the procedure.
ANS: 1
Term neonates have the same sensitivity to pain as older infants and children. Preterm
neonates have a greater sensitivity to pain than term neonates or older children.
DIF: C
REF: 1055
OBJ: Analysis
43. Taking into consideration the hospice clients chronic pain from bone cancer, the most
appropriate person to collaborate with regarding management of pain is:
1. Occupational therapist to devise a splint for the clients leg
2. Physical therapist to determine exercises to strengthen the leg muscles
3. Art therapist to provide creative therapy as a diversion
4. An oncology nurse
ANS: 4
An oncology nurse specialist is very familiar with pharmacological and
nonpharmacological interventions that are most effective for chronic/persistent pain. The
client is terminally ill, and although occupational therapy, physical therapy, and art
therapy are all important therapies to consider, in this case the most appropriate discipline
is the nurse who cares for this type of client and is familiar with the interventions that
would be most appropriate.
DIF: C
REF: 1056
OBJ: Analysis
44. In creating the plan of care for a newly diagnosed breast cancer client, the nurse is
concerned about pain control. The client has expressed an interest in relaxation therapy as
a complementary pain therapy. The nurse knows that the best time to teach the client is:
1. Immediately following the clients mastectomy
2. Before giving pain medication to evaluate if the complementary therapy works
3. Immediately preceding surgery
4. When the client is comfortable
ANS: 4
For effective relaxation, teach techniques only when the client is not distracted by acute
discomfort. The nurse would want to teach the client before the surgery so that the client
could practice the technique before experiencing postsurgical pain.
DIF: B
REF: 1057
OBJ: Application
Test Bank
43-21
45. A client who ruptured his spleen in a motor vehicle accident rates his postoperative pain
as a level 8 on a 0 to 10 pain scale. After administering pain medication, the nurse
discusses the use of complementary therapies with the client to explore ways to reduce
the pain. The client would like to try a massage. The nurse delegates this task to the
assistive personnel (AP). Which of the following instructions is most important for the
nurse to share with the AP?
1. "You need to warm the bottle of lotion before using it."
2. "Report any changes in the clients skin condition to me immediately."
3. "Do not massage the clients legs."
4. "Massage each body part at least 10 minutes."
ANS: 3
The nurse should instruct the AP not to massage the clients legs or calf muscles, because
there is a risk for dislodging a vascular clot. The nurse needs to know about changes in
the condition of the clients skin, but this can be obtained after the clients massageit is
not as critical as the AP's knowing not to massage the clients legs before beginning the
massage.
DIF: B
REF: 1057
OBJ: Application
MULTIPLE RESPONSE
1. Which of the following client outcomes reflect the positive aspects of effective pain
management? (Select all that apply.)
1. The client with arthritis in both hands knitting for pleasure
2. A client rating his chronic back pain as a 3 on a scale of 0 to 10
3. A client with type 2 diabetes walking 5 miles in a Fourth of July parade
4. A client who has undergone surgery ambulating to the bathroom on the first
postoperative day
5. A client with knee replacement surgery returning to his job as a mail carrier
6. A client with terminal cancer going home on outpatient chemotherapy
ANS: 1, 2, 4, 5, 6
Effective pain management improves quality of life, reduces physical discomfort,
promotes earlier mobilization and return to work, results in fewer hospital/clinic visits,
and shortens hospital stays, thus reducing health care costs. The remaining option does
not involve a client who is normally dealing with pain.
DIF: C
REF: 1068
OBJ: Analysis
Test Bank
43-22
2. The nurse recognizes which of the following client outcomes as being a result of
ineffective pain management? (Select all that apply.)
1. Client expressing feelings of despair and hopelessness
2. Inability to self-ambulate distance from bed to bathroom
3. Stage 1 pressure ulcer development on coccyx and left hip
4. Client rating pain as 4 on a scale of 0 to 10 30 minutes after pain medication
5. Postponement of discharge because of the inability to perform activities of daily
living
6. Postponement of physical therapy because of clients inability to tolerate knee
flexion
ANS: 1, 2, 3, 5, 6
Acute pain seriously threatens a clients recovery by resulting in prolonged
hospitalization, increased risks of complications from immobility, and delayed
rehabilitation. Physical or psychological progress is delayed as long as acute pain persists
because the client focuses all energy on pain relief. A pain rating of 4 reflects tolerable
pain, which may be a realistic expectation in some cases of chronic pain.
DIF: C
REF: 1070
OBJ: Analysis
3. Which of the following outcomes are directly related to functional impairment of the
older client experiencing pain? (Select all that apply.)
1. Inability to prepare food to meet nutritional requirements
2. Inability to exit home quickly in the case of a fire
3. Development of skin breakdown on buttocks
4. Development of an irregular heart rhythm
5. Displaying signs of clinical depression
6. Feeling alone, unloved, and forgotten
ANS: 1, 2, 3, 5, 6
Once an older client suffers pain, there can be serious impairment of functional status.
Pain has the potential to reduce mobility, activities of daily living (ADLs), social
activities outside the home, and activity tolerance. There is no apparent connection
between pain and the development of a dysrhythmia.
DIF: C
REF: 1072
OBJ: Analysis

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Potter & Perry: Fundamentals of Nursing, 7th Edition

TOP: Nursing Process: Planning

What does your discomfort feel like?

A nonopioid analgesic, such as acetaminophen, is used to effectively treat mild

Patient-controlled analgesia is a safe method for postoperative pain management, such as

2. My postsurgical clients get the prescribed pain medications on schedule with no

MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological

2. A need to be in control of his pain

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