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A patient reports diffuse abdominal pain that is difficult to localize. The nurse documents this as which type of pain?
- A. Cutaneous
- B. Visceral
- C. Superficial
- D. Somatic
Correct Answer: B
Rationale: Visceral pain is poorly localized and originates in body organs like the abdomen (B). Cutaneous and superficial pain (A, C) involve the skin or subcutaneous tissue, while somatic pain (D) originates in tendons, ligaments, bones, or nerves and is more localized.
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A pregnant woman has received an epidural analgesic prior to delivery. Assessment for which outcome to the medication will the nurse prioritize?
- A. Pruritus
- B. Urinary retention
- C. Vomiting
- D. Respiratory depression
Correct Answer: D
Rationale: Respiratory depression (D) is the priority outcome to monitor with epidural opioids, as it is life-threatening. Pruritus, urinary retention, and vomiting (A, B, C) are less critical side effects.
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.
The nurse applies the gate control theory of pain to provide pain relief to a patient with chronic lower back pain. What nursing intervention will help relieve pain by 'closing the gate'?
- A. Encouraging regular use of analgesics
- B. Applying moist heat to the area at intervals
- C. Reviewing the pain experience with the patient
- D. Ambulating the patient after administering medication
Correct Answer: B
Rationale: The gate control theory suggests stimulating large nerve fibers to block pain signals. Applying moist heat (B) stimulates these fibers to 'close the gate,' reducing pain perception. Analgesics (A), reviewing pain (C), or ambulation post-medication (D) do not directly target this mechanism.
A nurse is assessing a patient receiving a continuous opioid infusion. For which outcome of treatment would the nurse immediately notify the primary care provider?
- A. A respiratory rate of 11/min with normal depth
- B. A sedation level of 4
- C. Mild forgetfulness
- D. Reported constipation
Correct Answer: B
Rationale: A sedation level of 4 (somnolent, minimal/no response) indicates risk of respiratory depression, requiring immediate provider notification and possible naloxone (B). A respiratory rate of 11/min (A) is not alarming, and forgetfulness or constipation (C, D) are less urgent.
A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors?
- A. Older adult on bedrest following cervical spine surgery
- B. Patient with a severe sunburn being treated for dehydration
- C. Industrial worker who has burns caused by a caustic acid
- D. Patient experiencing cardiac disturbances from an electrical shock
Correct Answer: A
Rationale: Mechanical activation of pain receptors occurs from friction or pressure, such as pressure sores from bedrest in an older adult post-cervical spine surgery (A). Sunburn (B) and acid burns (C) are thermal and chemical stimulants, respectively, while electrical shock (D) is an electrical stimulant.