HEALTH ASSESSMENT 6

Which of the following factors is the most reliable indicator of pain in an adult patient?

• Changes in physical functioning.

• Nonverbal behaviours.

• The patient’s self-report.

• Changes in the vital signs

Answer explanation

RATIONALE: Pain is subjective in nature. Therefore, a patient's self-report is the most reliable indicator of pain.

Which of the following measurements is incorrect about pain?

• Pain exists whenever the patient says it does.

• Pain is always accompanied by changes in the vital signs.

• Pain is whatever the patient says it is.

• Pain protects a patient from injury.

Answer explanation

RATIONALE: The statement that pain is always accompanied by changes in vital signs is a myth. There are situations

when changes in vital signs in a client with pain, does not occur.

While examining a broken arm of a 4 –year- old boy, which of the following is the appropriate assessment tool to evaluate his pain status?

• 0-10 numeric rating scale

• The Wong – Baker Scale

• 0 – 5 Numeric rating Scale

• Simple descriptor scale

Answer explanation

RATIONALE: The Wong-Baker scale can be introduced at 4 to 5 years of age.

Which of the following statements is true about pain in infants?

• Infants do not remember pain.

• Infants can report pain

• Infants do feel pain

• Infant’s pain may be assessed by using the Wong – Baker’s Face Pain Rating Scale.

Answer explanation

RATIONALE: Infants do feel pain. They may not be able to verbalize pain; however, there are behavioural and physiologic cues that support that the infant is in pain.

To assess the SITE of pain, which of the following questions should be asked by the nurse?

• Where is your pain?

• When did your pain start?

• How much pain do you have now?

• What makes your pain better?

Answer explanation

RATIONALE: “Where is your pain?” is the appropriate question to ask to assess for the site / location of pain.

The pain that originate from muscle, bones, joints, tendons or blood vessels is known as:

• Cutaneous pain

• Referred pain

• Visceral pain

• Somatic pain

Answer explanation

RATIONALE: Somatic pain originates from muscles, bones, joints, tendons or blood vessels.

Referred pain is described as:

• Originating from internal organs such as the gallbladder or stomach

• Originating from skin or subcutaneous structures.

• Felt at a particular site, but originates from another location.

• Felt at the site of injury and the surrounding areas.

Answer explanation

RATIONALE: Referred pain is felt at a particular site, but originates from another location.

You are a nurse in a medical emergency room and caring a 23-year-old female. As you are assessing, she complained that she had “burning sensation during urination”. This is an example of:

• Provocative / Palliative

• Quality / Quantity

• Region / Radiation

• Timing

Answer explanation

RATIONALE: “Burning sensation during urination” is a part of assessment that reveals the characteristics or quality of pain.

It describes the maximum amount and the duration of pain that an individual is willing to endure. It varies amongst people

• Pain receptor

• Pain threshold

• Pain tolerance

• Pain sensation

Answer explanation

RATIONALE: Pain tolerance is the maximum amount and the duration of pain that an individual is willing to endure. It

varies amongst people

You are a nurse working in a surgical ward and caring for a 53-year-old man who had an above the knee amputation in his right leg. He complained of severe pain from his right lower leg. You are knowledgeable that this is:

• Intractable pain

• Phantom pain

• Psychogenic pain

• Radiating pain

Answer explanation

RATIONALE: Phantom pain is actual pain felt in a body part that is no longer present.