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Verified Test Bank Ch9 Pain Assessment

Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 9 Pain Assessment

An adolescent states to the nurse during a pain assessment, "I don't know how to describe my pain, it just hurts and I don't understand why I just cannot have something for it." Which action should the nurse take?

1. Leave the room and come back later.

2. Provide questions that require yes or no answers related to pain.

3. Ask the client what they would like to have for pain.

4. Continue with the assessment.

Page Ref: 119

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9.4: Examine factors that influence perception and expression of pain.

MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.

The nurse is working at a pain clinic and is preparing an orientation for new staff nurses. Which definition of pain should the nurse include in the orientation?

1. Pain is validated after determining the cause.

2. Pain is an unpleasant sensation, typically experienced upon movement.

3. Pain is whatever the experiencing person says it is.

4. Pain is very subjective, so observation must be used to assess the characteristics.

Page Ref: 114

Cognitive Level: Remembering

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Define pain.

MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.

A patient tells the nurse they are experiencing jaw, chest, and arm pain. Which type of pain should the nurse suspect is occurring?

1. Phantom pain.

2. Radiating pain.

3. Intractable pain.

4. Cutaneous pain.

Page Ref: 117

Cognitive Level: Remembering

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain.

MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.

The nurse is caring for two postoperative clients that had the same procedure, but one client reports greater pain than the other. Which pain theory should the nurse recognize is useful in explaining this phenomenon?

1. Pattern.

2. Specificity.

3. Stress.

4. Gate control.

Page Ref: 114

Cognitive Level: Remembering

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.1: Define pain.

MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.

A client asks the nurse why they are feeling pain in the area with edema. Which response should the nurse provide?

1. The edema damages the tissue.

2. The edema puts pressure on the pain receptors.

3. The edema irritates the tissue.

4. The edema causes the cells of the tissue to die.

Page Ref: 115

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain.

MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.

A cooperative, well-dressed, postoperative client that grimaces when sitting down rates their pain 2 out of 10. The nurse suspects which of the following?

1. The client should increase their activity to build up tolerance.

2. The client that does not identify pain as severe does not require treatment.

3. The client's recovery is going well based on the pain rating.

4. The client has adapted to the pain and is able to control behaviors.

Page Ref: 118

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.4: Examine factors that influence perception and expression of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

A patient that appears to be moving around easily and smiling rates their pain at 7 out of 10 and requests pain medication. Which action should the nurse take?

1. Wait 30 minutes and see if the client is still requesting the pain medicine.

2. Administer half the ordered dose of pain medication.

3. Administer the pain medication as prescribed.

4. Inform the healthcare provider that the client is exaggerating their pain.

Page Ref: 114

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain.

MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.

A client with a coronary artery blockage is experiencing pain. Which should the nurse recognize is the physiological basis for the pain?

1. Tissue ischemia.

2. Trauma to the tissues.

3. Muscle spasm.

4. Blockage of a duct.

Page Ref: 115

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain.

MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.

The nurse is assessing a client admitted with severe abdominal pain. Which essential components of a pain assessment should the nurse include? Select all that apply.

1. Description of the pain.

2. Temperature, pulse, respirations, and blood pressure.

3. Pain intensity rating.

4. Family medical history.

5. Previous pain experience.

Page Ref: 122

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain.

MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.

A client asks the nurse how ibuprofen will relieve their back pain. Prior to answering the question, which phase of nociception should the nurse recognize ibuprofen has an effect on?

1. Transduction.

2. Transmission.

3. Perception.

4. Modulation.

Page Ref: 115

Cognitive Level: Remembering

Client Need & Sub: Pharmacological and Parenteral Therapies; Expected Actions/Outcomes

Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

The nurse is assessing the impact a client's migraine pain has on their daily functioning. Which assessment tool should the nurse use?

1. Psychological well-being inventory.

2. Body diagram tool.

3. Intensity rating scale.

4. Brief pain inventory.

Page Ref: 125

Cognitive Level: Understanding

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain.

MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.

Which term describes the amount of pain stimulation that is needed for an individual to feel pain?

1. Pain threshold.

2. Pain tolerance.

3. Somatic interval.

4. Cephalgia reporting.

Page Ref: 118

Cognitive Level: Remembering

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain.

MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.

A client with a right above-the-knee amputation tells the nurse their right foot hurts. Which type of pain should the nurse understand the client may be experiencing?

1. Phantom pain.

2. Radiating pain.

3. Intractable pain.

4. Cutaneous pain.

Page Ref: 117

Cognitive Level: Remembering

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain.

MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.

The nurse is assessing a client admitted with chronic back pain. Which assessment findings related to the pain should the nurse anticipate? Select all that apply.

1. Sudden onset of pain.

2. Pain that interferes with daily activities.

3. Pain described as being low intensity.

4. Prolonged pain duration.

5. Pain causing a sharp elevation in body temperature.

Page Ref: 116

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain.

MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.

A client asks the nurse why they were prescribed a tricyclic antidepressant for pain. Which should the nurse understand prior to providing a response to the client?

1. The action of the prescription decreases the perception of pain.

2. The action of the prescription interferes with the transduction of pain.

3. The action of the prescription increases the modulation phase of pain.

4. The action of the prescription blocks the transmission of pain.

Page Ref: 115

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.4: Examine factors that influence perception and expression of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

The new nurse states to the preceptor, "My client keeps saying he is in pain. I don't believe him because I had the same surgery last year and didn't feel nearly as bad as he claims." Which response should the preceptor provide?

1. "It sounds as if your client is a drug seeker."

2. "You should contact the healthcare provider."

3. "I would call the nursing supervisor for this one."

4. "Pain differs from person to person."

Page Ref: 114

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.4: Examine factors that influence perception and expression of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

The nurse is performing an assessment on a client experiencing chronic back pain. Which findings should the nurse anticipate? Select all that apply.

1. Increased pulse rate.

2. Increased respiratory rate.

3. Normal pulse rate.

4. Normal blood pressure.

5. Diaphoresis.

Page Ref: 117

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain.

MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.

The nurse is planning to implement nonpharmacological pain interventions for a preschool age client. Which interventions should the nurse implement? Select all that apply

1. Offer a glucose-coated pacifier.

2. Sit with the child and allow the child to "blow bubbles."

3. Explain to the child the cause of the pain.

4. Teach the child how to use of guided imagery.

5. Hold the child.

Page Ref: 119

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

The nurse is preparing to assess a client with chronic pain. Which objective finding should the nurse anticipate?

1. Restlessness.

2. Rubbing painful area.

3. Related tissue injury.

4. Warm, dry skin.

Page Ref: 117

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.4: Examine factors that influence perception and expression of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

A child tells the nurse their throat is sore. Which assessment finding should the nurse anticipate to be associated with the child's statement?

1. Dehydration.

2. Headache.

3. Stomachache.

4. Decreased food intake.

Page Ref: 119

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

The nurse is reviewing the environmental factors that influence a client's pain. Which internal environmental factor should the nurse anticipate will influence the client's pain?

1. Noise.

2. Support systems.

3. Previous experiences.

4. Family role.

Page Ref: 120

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.4: Examine factors that influence perception and expression of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

A spouse of a postoperative client tells the nurse that they do not understand why no pain medication has been given. Which response should the nurse provide the spouse?

1. "Some clients do not require analgesics."

2. "I am monitoring your spouse for nonverbal pain cues."

3. "I am going to talk to your spouse about refusing the pain prescription."

4. "Some clients are too sedated to realize they need something for pain control."

Page Ref: 121

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

The nurse is performing a pain assessment on a client who is unable to communicate verbally. Which vital sign data should the nurse understand is associated with acute pain? Select all that apply.

1. Temperature of 100.6 degrees.

2. Pulse rate 94.

3. Respiratory rate 32.

4. Blood pressure 158/92 mmHg.

5. Facial grimacing.

Page Ref: 117

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain.

MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.

The nurse is preparing to conduct a focused interview for a pain assessment. Which components should the nurse include in the interview? Select all that apply

1. Pain history.

2. Socioeconomic status.

3. Direct observation.

4. Medication history.

5. Psychosocial assessment.

Page Ref: 121

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain.

MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.

The nurse is assessing the history of treatment for a client with pain. Which question should the nurse include in the assessment?

1. "What have you done to relieve the pain?"

2. "Do you rest when you have pain?"

3. "What were you doing just before the pain started?"

4. "Does your pain move or is it in just one place?"

Page Ref: 123

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Examine factors that influence perception and expression of pain.

MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.

The nurse is completing an admission assessment for a client with severe pain. Which order of action should the nurse take?

1: Contact the healthcare provider.

2: Discuss the unit routine with the client and family.

3: Ask the client when the pain first began.

4: Ask the client what helps to relieve the pain.

5: Assess the client's past coping methods for pain throughout their life.

Page Ref: 121

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain.

MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.

The nurse is assessing a client who is recovering from open-heart surgery. Which assessment data is most reflective of a client's pain response?

1. Family report of pain.

2. Response from the client based on use of a pain tool.

3. Observations of the client's behaviors while asleep.

4. Measurement of vital signs.

Page Ref: 124

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain.

MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.

An older client tells the nurse they have had joint pain for years. Which should the nurse recognize is a common finding in the older client experiencing pain?

1. Clients start to complain of many types of pain as they age.

2. The joint pain is probably not the real reason the client is in the office.

3. The client is most likely depressed.

4. Older adults frequently avoid seeking treatment for their pain.

Page Ref: 119

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain.

MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.

A young adult male client of Arab descent is admitted to the medical-surgical unit for a ruptured appendix. The client's parents are at the bedside for most of the day. The nurse who is providing care notes that the client denies pain while on day shift but request medication every four hours during the night. Which explanation for this client behavior is the most probable?

1. The night nurse had more time to spend with the client.

2. The client must be afraid or lonely at night and is trying to get attention.

3. The client may not report pain in the presence of parents based on their influence or cultural beliefs.

4. The client was asking for medication at night to facilitate sleep.

Page Ref: 177-178

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9.4: Examine factors that influence perception and expression of pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

A client with terminal cancer tells the nurse that nothing helps relieve their pain. Which type of pain should the nurse recognize the client is experiencing?

1. Referred pain.

2. Intractable pain.

3. Retractable pain.

4. Radiating pain.

Page Ref: 117

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain.

MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.

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DOCX

Chapter Number:

Created Date:

Aug 21, 2025

Chapter Name:

Chapter 9 Pain Assessment

Author:

Cynthia Fenske

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Verified Test Bank Ch9 Pain Assessment

Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 9 Pain Assessment

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