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A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?
- A. Assess pain physiological indicators and vital signs.
- B. Do not give pain medication as no pain is indicated.
- C. To present the findings and continue to monitor.
- D. Try a human state of analgesic medication for pain.
Correct Answer: A
Rationale: Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain, he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness.
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A faculty member explains to students the process by which pain is perceived by the client. Which processes does the faculty member include in the discussion? (Select all that apply.)
- A. Induction
- B. Modulation
- C. Sensory perception
- D. Transduction
- E. Transmission
Correct Answer: B,C,D,E
Rationale: The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission. Induction is not a recognized process in pain perception.
A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?
- A. Ask the client why he is being uncooperative with therapy
- B. Ask the client about his pain goals and if they are being met
- C. Increase the dose of analgesia given prior to therapy sessions
- D. Tell the client that physical therapy is required to regain function
Correct Answer: B
Rationale: Adequate pain control is necessary for therapy participation. Asking about the client's pain goals and whether they are being met helps identify barriers to participation. Labeling the client as uncooperative is inappropriate, increasing medication without assessment may be unsafe, and stating therapy is required does not address the underlying issue.
A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?
- A. Assesses the clients pain level per agency policy
- B. Monitor the clients respiratory rate and sedation
- C. Presses the button when the client cannot reach it
- D. Reinforces client teaching about using the PCA pump
Correct Answer: C
Rationale: The client is the only person who should press the PCA button. If the client cannot reach it, the student should either question the client or adjust the button's position, not press it for the client. The other actions are appropriate.
A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Opioid-Induced Sedation Scale score indicating excessive sedation and oxygen saturation below 95%. What action should the nurse perform first?
- A. Apply oxygen at 2 L/min
- B. Notify the provider immediately
- C. Administer naloxone (Narcan)
- D. Encourage deep breathing exercises
Correct Answer: C
Rationale: Excessive sedation and low oxygen saturation indicate opioid-induced respiratory depression. Administering naloxone (Narcan) is the first action to reverse opioid effects and ensure client safety. Applying oxygen or notifying the provider may follow, but naloxone is the priority. Encouraging deep breathing is insufficient in this scenario.
A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client is to the client. The nurse issues the client is to the possibly sleep with the severe pain the client described. What response by the experienced nurse is best?
- A. Being able to sleep dosent means pain doesit exist.
- B. Have you ever experienced any type of pain?
- C. The client should be assessed for drugg addiction.
- D. Your right right I would pain the medication back.
Correct Answer: A
Rationale: A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain cited. Physiologic changes due to pain vary from the client to client, and assessments of pain should not supervised the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippain, and does not provide useful information. This amount of information does not be the client is to the client.