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A nurse is caring for patients who are nonverbal. What are examples of behavioral responses to pain? Select all that apply.
- A. Cradling a wrist that was injured in a car accident
- B. Moaning and crying from abdominal pain
- C. Increasing pulse following a myocardial infarction
- D. Striking out at a nurse who attempts to provide a bath
- E. Acting depressed and withdrawn while experiencing chronic cancer pain
- F. Pulling away from a nurse trying to give an injection
Correct Answer: A,B,D,F
Rationale: Behavioral responses include cradling an injured area (A), moaning and crying (B), striking out (D), and pulling away (F). Increased pulse (C) is a physiologic response, and depression/withdrawal (E) is an affective response.
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The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient?
- A. CRIES
- B. COMFORT
- C. FLACC
- D. FACES
Correct Answer: A
Rationale: The CRIES Pain Scale is designed for neonates and infants from 0 to 6 months (A), making it ideal for a NICU neonate. COMFORT (B) is for critically ill pediatric patients, FLACC (C) for infants and children 2 months to 7 years, and FACES (D) for children who can compare pain to facial expressions.
When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse received in shift report that the patient has consistently refused pain medication. To help promote comfort, which additional data will the nurse gather? Select all that apply.
- A. Patient's understanding of or fear of taking prescribed analgesics
- B. Assessment of any current pain
- C. Presence of anxiety or additional stressors
- D. Assessment of the surgical incision for infection
- E. What the patient has eaten to this point
- F. Whether the patient is using the incentive spirometer
Correct Answer: A,B,C,D
Rationale: To promote comfort, the nurse should assess fears of analgesics (A), current pain (B), anxiety or stressors (C), and incision for infection (D), as these may explain refusal and pain behaviors. Diet (E) and spirometer use (F) are less directly related to pain management.
Based on the objective and subjective assessment of this patient, where should the nurse focus the initial efforts of the interprofessional team?
- A. Collaborating with the endocrinologist to manage the patient's blood glucose and A1c
- B. Consulting psychiatry to set up a medication regimen to treat the patient's anxiety and depression
- C. Working with the provider, the patient, and the patient's wife to address functional pain goals
- D. Providing detailed information on the microvascular and macrovascular complications of type 2 diabetes
Correct Answer: C
Rationale: The priority is addressing Carla's functional pain goals (C) to improve her quality of life, as her pain impacts her daily functioning and stress affects her diabetes management. While glucose control (A) and psychiatric consultation (B) are relevant, pain management is the immediate focus. Education on complications (D) is secondary to addressing current pain.
A nurse in a rehabilitation facility is evaluating patients with chronic pain to develop an interprofessional plan of care. Which patients would the nurse identify who could benefit from a multimodal approach to pain management? Select all that apply.
- A. Patient receiving chemotherapy for bladder cancer
- B. Adolescent who had an appendectomy
- C. Patient who is experiencing a ruptured aneurysm
- D. Patient with fibromyalgia requesting pain medication
- E. Patient having back pain related to an accident that occurred last year
- F. Patient experiencing pain from second-degree burns
Correct Answer: A,D,E
Rationale: Chronic pain, lasting beyond the normal healing period, benefits from a multimodal approach. Patients with cancer pain (A), fibromyalgia (D), and chronic back pain (E) fit this criterion. Appendectomy (B) and burns (F) typically involve acute pain, and a ruptured aneurysm (C) is an emergency requiring immediate intervention.
How will the nurse and Carla know that the treatment plan has been effective?
- A. Carla is completely pain free but is taking large doses of OTC acetaminophen.
- B. Carla reports some pain but states she was able to engage in the full walking tour with occasional rest periods.
- C. Carla admits that she is not taking the medication because she has just learned to live with the pain.
- D. Carla tried a few nonpharmacologic recommendations but has opted to simply double the prescribed dose.
Correct Answer: B
Rationale: The treatment plan is effective if Carla achieves her functional goal of completing a walking tour with minimal pain and occasional rest (B), aligning with her stated goals of 1/10 pain at rest and 3/10 with activity. Complete pain relief with high acetaminophen doses (A) risks toxicity, ignoring medications (C) indicates nonadherence, and doubling doses (D) is unsafe.