NUR109 M7.4: ATI Engage Fundamentals: Pain
A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take?NUR109 M7.4: ATI Engage
The nurse should evaluate the client for pain by observing their behavior. In patients who may have difficulty expressing pain verbally, behavioral observation is essential for assessing pain accurately.
A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at the greatest risk for respiratory depression?
A client who had surgery 3 hours ago and is receiving IV hydromorphone PRN is at the highest risk for respiratory depression. This is because IV hydromorphone is a potent opioid and the client is in the early postoperative period when the effects of anaesthesia may still be present.
A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain?NUR109 M7.4: ATI Engage
The client being diaphoretic (sweating) is an objective indicator of pain. Diaphoresis is a physiological response to pain and stress.
A nurse is providing end-of-life care for a client who is unresponsive and near death. The client’s family asks the nurse about managing the client’s pain. Which of the following statements should the nurse make to the client’s family?
The nurse should inform the family that their family member has the right to receive effective pain management, even in end-of-life care. Comfort and pain management are essential in providing dignified end-of-life care.
A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply.)
Staff members who understand the information should recognize that a client’s religious beliefs might affect the way they respond to pain. They should also understand that the client’s past pain experiences can influence their current pain and pain management. Additionally, they should be aware that pain control might be harder to achieve if the nurse and client speak different primary languages.NUR109 M7.4: ATI Engage
A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client’s pain?
This client’s pain should be categorized as chronic pain. Chronic pain lasts for an extended period, typically more than three to six months, and often persists long after the initial injury has healed.
A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply.)
The nurse should use the FLACC Pain Scale for the following clients:
A 3-year-old toddler who has a fractured femur
A 14-year-old client who has severe cognitive and developmental delays
A 5-year-old preschooler who is experiencing pain during a sickle cell crisis
The FLACC Pain Scale is suitable for these age groups and situations to assess pain effectively.
A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? (Select all that apply.)
Increased discomfort can be indicated by the following nonverbal signs: grimacing, restlessness, and increased diaphoresis. These are physical manifestations that suggest a higher level of pain.
A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.)NUR109 M7.4: ATI Engage
The nurse should include the following information when discussing TENS treatment with the client:
“You can be taught how to use TENS therapy at home.”
“The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas.”
“We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy.”
A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.)NUR109 M7.4: ATI Engage
The nurse should include the following methods of cutaneous stimulation:
Transcutaneous electronic stimulating unit (TENS unit)
Massage
Acupuncture
Cold therapy
These methods can be effective in providing relief and comfort for clients experiencing pain.
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