Nokea
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.
You may also like to solve these questions
When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end-of-life care is most effectively relieved through which method?
- A. Providing the highest effective dose of an opioid on a PRN (as needed) basis
- B. Using nonopioid drugs conservatively
- C. Applying multimodal nonpharmacologic and nonopioid pharmacologic therapies
- D. Administering a continuous intravenous infusion on a regular basis
Correct Answer: C
Rationale: Multimodal nonpharmacologic and nonopioid therapies (C) are preferred for chronic pain unrelated to cancer or palliative care. High-dose PRN opioids (A) are not ideal, nonopioids should not be used conservatively (B), and continuous IV infusions (D) are typically for acute or palliative settings.
Which question by the nurse will be most helpful in determining whether a patient who is experiencing a myocardial infarction has referred pain?
- A. Did your chest pain last 2 minutes or less?
- B. Was the pain on the surface of your chest?
- C. Is this pain in your residual limb shooting or burning?
- D. Are you having any arm or shoulder pain?
Correct Answer: D
Rationale: Referred pain is perceived in an area distant from its origin, such as arm or shoulder pain during a myocardial infarction (D). Questions about duration (A), surface location (B), or phantom limb pain (C) are less relevant to identifying referred pain in this context.
Based on this opening description of pain, what other information would be helpful in determining the plan of care? Select all that apply.
- A. Assessment of the quality of care provided by the endocrinologist
- B. Carla's wife's objective view of the patient's pain progression
- C. Identification of anything that seems to trigger the pain
- D. Interventions that have been tried-what worked and what did not work
- E. Other symptoms that may be related or associated with the pain experience
Correct Answer: B,C,D,E
Rationale: To develop an effective plan of care, the nurse needs Carla's wife's perspective on pain progression (B), triggers for the pain (C), past interventions and their effectiveness (D), and associated symptoms (E). Assessing the endocrinologist's care quality (A) is irrelevant to the immediate pain management plan.
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.
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.