HESI Pain Flashcards
Scenario
An adult female, mother of two, visits the pain clinic of the regional Medical Center in her community. She arrives at the pain management clinic with complaints of back pain rated 6 out of 10. She tells the nurse “to the pain is so bad at times, that I am unable to take care of my children.”
Pain assessment
During the nurses, initial interview, the client shares information about her home, career, and family. The nurse evaluates the information to determine psychosocial factors that may impact pain management.
Which information obtained by the nurses most likely to influence the clients perception of her pain?
Clients younger child is an infant who feeds every three hours
Rationale: feeding an infant every three hours interrupt, sleep and result in fatigue. Fatigue often heightens the perception of pain and impairs coping skills.
To assess the quality of the clients pain, the nurse would ask which question?
How would you describe the pain you’re experiencing?
Rationale: the quality of pain experiences typically a “descriptive term such as ‘ shooting’…”
Which behavior does the client exhibit, that the nurse documents as objective science of acute pain?
Frequent grimacing
Rationale: grimacing, is an observable indicator of pain.
The nurse would predict what psychological effects of the clients pain? (SATA)
Tachycardia
Rationale: autonomic metabolic response, related to the stress caused by pain.
Decreased or slower movement
Rationale: pain causes guarding of the effect area, and therefore decreased mobility.
Increased blood pressure
Rationale: autonomic metabolic response, related to stress caused by pain.
Nursing process
After completing the pain assessment, the nurse develops a plan of care, identifying pain and anxiety is priority problems.
The nurse considers interventions to include in the plan of care. Before implementing interventions, what action is most important for the nurse to take?
Discuss the plan of care with the client.
Rationale: after considering interventions to implement, the nurse should review the plan of care with the client and seek client input.
Which nursing intervention(s) would the nurse choose to implement to determine the ideology of the client anxiety? (SATA)
Continue to interview the client
Rationale: client is best source of information, and although she may not understand the symptoms and causes she is experiencing, the nurse can investigate by interviewing.
Provide an anxiety screening tool for the client to utilize
Rationale: evidence based screening tools available to help assess the client and identify causes of anxiety.
Obtain clients medical history
Rationale: several medical conditions can cause anxiety.
Which is the best goal for the nurse to include in the plan of care related to the problem statement of “acute pain related to strain on muscles with movement?”
Client reports pain of less than on a 0 to 10 scale
Rationale: the goal is a broad statement that reflects a positive direction for the clients problem, in this case, acute pain.
Non-steroid, anti-inflammatory drugs (NSAIDs)
The nurse consult with the clinical Director, a pain management healthcare provider (HCP), who recommends the NSA and alternating heat and cold applications, as well as back exercises. The nurse provides client teaching about these treatments. The client tells the nurse that she does not know what an NSAID is.
Which medication should the nurse suggest as a common NSAID?
Ibuprofen
Rationale: ibuprofen is an NSAID that has anti-inflammatory properties.
Other options:
Diphenhydramine -antihistamine
Alprazolam -benzodiazepine
Calcium carbonate -antacid
The client states she has buffered acetyl acid (ASA) at home she uses for fever that should help with the pain and inflammation. She comments that when her four-year-old child had a virus. She almost gave them half a dose of the ASA for their fever, but didn’t know if she should.
What should the nurse explain medication safety and educate the client about facts regarding ASA for children?
All ASA products should be avoided in children, unless specifically prescribed.
Rationale: ASA products are associated with Reye’s syndrome and children.
Application of heat and cold
The client tells the nurse that she has an electric heating pad at home that she used when she had menstrual cramps. And asks if that would work for her back.
Which response by the nurses accurate?
The dry heat provided by your heating pad will help relieve your pain by promoting muscle relaxation.
Rationale: heat, whether dry or moist, promotes muscle, relaxation, and relief of pain caused by stiffness or spasm by vasodilation
The client states that she has also been applying a cold pack, an hour at a time to help heal her back pain as quickly as possible. But then her back becomes red colored, and asks why that would cause that to happen.
Which instruction is most important for the nurse to provide regarding the clients statement?
The cold pack should only be applied for approximately 20 minutes at a time.
Rationale: the nurse should further explain that the cold should only be applied as prescribed, for 20 to 30 minutes at a time and also tell the client to remove the cold pack if her skin appears reddened before the prescribed time has elapsed.
How should the nurse explain the mechanism that causes the skin to become reddened from prolonged exposure to the cold?
Reflex vasodilation occurs following the initial vasoconstricting effects of cold.
Rationale: cold causes vasoconstriction. After prolonged exposure, reflex vasodilation occurs to restore adequate blood supply to the tissues.
TENS unit
The client returns to the pain clinic in a week and reports that her pain has worsened. The pain management physician recommends the use of a transcutaneous electrical nerve stimulator (TENS) unit and states they will prescribe a stronger analgesic. The client appears confused when the physician explains the TENS unit.
Which explanation by the nurse best describes the TENS unit soothes pain?
It says, stimulating pulses through the skin, to block pain signals from reaching the brain.
Rationale: transcutaneous, electrical nerve stimulation is considered a type of cutaneous stimulation in which electrodes attached to a battery-operated unit, stimulate the skin from underlying tissues near the area of localized pain.
After the nurse explains how the TENS units is pain, the client wants to know the best way to apply and use the unit. Which instructions to the nurse include? (SATA)
Place the electrodes directly over the site of pain
Make sure the equipment is not damaged
