NRSG 2220-EXAM 1 (MOD 1-5) QUESTIONS WITH
COMPLETE SOLUTIONS!!
General Survey: Answer - -Provides clues to overall health
-Begins the moment of contact
-First impressions
-Challenges your observational skills
-Usually includes vital signs, height and weight. We are focusing on skillful
observations
What do you look for in skilled observation (general survey)? Answer - -Signs
of distress
-Stature/Build
-Dressing/Grooming
-Posture/Gait/Coordination
-Eye contact
-Level of consciousness, mood
- Speech patterns
-Vision or hearing problems
-Nutritional state
-Significant others accompanying patient
,Healthy hair=
(general survey) Answer - Healthy protein stores in body
Pain is a subjective or objective experience? Answer - Subjective
-highly individual
-ethnocultural considerations
Expression of pain does not = Answer - degree of pain
5th vital sign? Answer - Pain
How do you care for the patient in pain? Answer - -Important to believe the
pain is real
-Your goal is to reduce/eliminate pain and manage pain so that patient can
resume normal lifestyle
Best indicator of pain? Answer - Patient reporting their pain to you
Standards to treat/manage pain as put in place by the Joint Commission
Answer - These standards uphold the idea that the patient has the right to have
their pain managed effectively.
One important standard is to determine a pain rating goal with your patient.
Their plan of care is set on mutually set goals
Characteristics of Pain Answer - COLD ERA
,COLD ERA Answer - C:haracter of the compaint
O:nset of the symptom
L:ocation of the complaint
D:uration of the problem
E:xacerbated by what?
R:elieved by what?
A:ssociated symptoms problem
OLD CARTS Answer - O:nset
L:ocation
D:uration
C:haracter
A:ggravating factors/associated factors
R:elieving factors
T:emporal factors
S:everity
Duration of pain (3) Answer - Acute
-rapid onset, varies with intensity, protective in nature
Chronic
-can be intermittent or persistent, long-standing pain and it interferes with
ability to function
Acute on chronic
-someone who has chronic pain and then has acute exacerbation of pain on
top of chronic pain
, Remission of pain Answer - No symptoms of pain at the time
Exacerbation Answer - Symptoms may reappear and get worse
Source of Pain (3) Answer - Cutaneous/Superficial:
-Pain at skin level, tend to be painful because of all nerve endings
Somatic:
-Pain that comes from tendons, ligaments, bones, vessels, pain tends to be
more diffuse, hard to pinpoint
Visceral:
-pain originates from organs, poorly localized
Etiology of Pain Answer - -Referred Pain: Pain perceived in an area distant from
where pain is actually originating. (MI, pain in arm not in heart)
-Neuropathic Pain: Injury or peripheral or central nerves (crushed vertebrae in
neck may result in pain in hands or wherever those nerves innervate)
-Intractable Pain: Pain that is resistant to interventions, regardless of what we
do we cannot get to goal pain
-Phantom Pain: Pain in a limb that is no longer there, common in amputation
patients, sensory information is still in brain even though no limb
-Psychogenic Pain: no physical cause, may be pain from significant mental
event
How do patients respond to pain? (3) Answer - -Voluntary Behavioral
Responses: Moving away from painful stimuli (pull away from you),
grimacing/moaning, restless, trying to guard the painful area
COMPLETE SOLUTIONS!!
General Survey: Answer - -Provides clues to overall health
-Begins the moment of contact
-First impressions
-Challenges your observational skills
-Usually includes vital signs, height and weight. We are focusing on skillful
observations
What do you look for in skilled observation (general survey)? Answer - -Signs
of distress
-Stature/Build
-Dressing/Grooming
-Posture/Gait/Coordination
-Eye contact
-Level of consciousness, mood
- Speech patterns
-Vision or hearing problems
-Nutritional state
-Significant others accompanying patient
,Healthy hair=
(general survey) Answer - Healthy protein stores in body
Pain is a subjective or objective experience? Answer - Subjective
-highly individual
-ethnocultural considerations
Expression of pain does not = Answer - degree of pain
5th vital sign? Answer - Pain
How do you care for the patient in pain? Answer - -Important to believe the
pain is real
-Your goal is to reduce/eliminate pain and manage pain so that patient can
resume normal lifestyle
Best indicator of pain? Answer - Patient reporting their pain to you
Standards to treat/manage pain as put in place by the Joint Commission
Answer - These standards uphold the idea that the patient has the right to have
their pain managed effectively.
One important standard is to determine a pain rating goal with your patient.
Their plan of care is set on mutually set goals
Characteristics of Pain Answer - COLD ERA
,COLD ERA Answer - C:haracter of the compaint
O:nset of the symptom
L:ocation of the complaint
D:uration of the problem
E:xacerbated by what?
R:elieved by what?
A:ssociated symptoms problem
OLD CARTS Answer - O:nset
L:ocation
D:uration
C:haracter
A:ggravating factors/associated factors
R:elieving factors
T:emporal factors
S:everity
Duration of pain (3) Answer - Acute
-rapid onset, varies with intensity, protective in nature
Chronic
-can be intermittent or persistent, long-standing pain and it interferes with
ability to function
Acute on chronic
-someone who has chronic pain and then has acute exacerbation of pain on
top of chronic pain
, Remission of pain Answer - No symptoms of pain at the time
Exacerbation Answer - Symptoms may reappear and get worse
Source of Pain (3) Answer - Cutaneous/Superficial:
-Pain at skin level, tend to be painful because of all nerve endings
Somatic:
-Pain that comes from tendons, ligaments, bones, vessels, pain tends to be
more diffuse, hard to pinpoint
Visceral:
-pain originates from organs, poorly localized
Etiology of Pain Answer - -Referred Pain: Pain perceived in an area distant from
where pain is actually originating. (MI, pain in arm not in heart)
-Neuropathic Pain: Injury or peripheral or central nerves (crushed vertebrae in
neck may result in pain in hands or wherever those nerves innervate)
-Intractable Pain: Pain that is resistant to interventions, regardless of what we
do we cannot get to goal pain
-Phantom Pain: Pain in a limb that is no longer there, common in amputation
patients, sensory information is still in brain even though no limb
-Psychogenic Pain: no physical cause, may be pain from significant mental
event
How do patients respond to pain? (3) Answer - -Voluntary Behavioral
Responses: Moving away from painful stimuli (pull away from you),
grimacing/moaning, restless, trying to guard the painful area
