NSG240 EXAM 3 UPDATED ACTUAL Questions and CORRECT
Answers
Acute Pain Pain that lasts seconds to < 6 months
Chronic Pain Pain that lasts > 6 months or longer; pain can be intermittent or continuous
Wong-Baker Faces Scale 0: No pain
2: Hurts a little bit
4: Hurts a little bit more
6: Hurts even more
8: Hurts a lot
10: Hurts the worst
Numeric Pain Scale Ask the patient to verbalize their pain on a scale from 0 (no pain) to 10 (severe
pain)
Slight Pain 1-3
Moderate Pain 4-7
Severe Pain 8-10
Subjective Data The ranking that the patient verbalizes on a numeric scale from 0-10
Objective Data Vital signs (e.g. heart rate or BP indicates pain)
PQRST Provocation and Palliation
Quality
Region and Radiation
Severity
Time
Provocation and Palliation What provoked the pain? (e.g. coughing, movement, lifting, twisting)
What improves the pain? (e.g. repositioning, analgesia, relaxation)
Quality What does the pain feel like? (Throbbing? Dull? Aching? Burning? Crushing?
Shooting?)
Is it continuous or intermittent?
Region and Radiation Where is the pain located? Does it radiate to other areas? (e.g. back, shoulders,
chest, arms, legs)
Severity Ask the patient to rate their pain on the numeric scale from 0-10
Time When did the pain begin?
Has the pain changed since this time?
Have you had pain like this before?
, Pain Interventions Pharmacologic vs. Nonpharmacologic
Pharmacologic Medicines. Start low (Tylenol), then escalate (advil/NSAIDS, narcotics if
appropriate)
Non-Pharmacologic PlaneTree-type interventions to reduce pain and stress such as:
-Distractions: music therapy/TV/convos
-Breathing exercises
-Positioning, elevation
-Wedge pillow or heel protectors
-TENS/ESTIM, acupressure, hypnosis
Types of Postural Misalignments Lordosis
Kyphosis
Flat Back
Sway Back
Scoliosis
Lordosis Lower back significantly curves inward with the pelvis tilting anteriorly
Kyphosis Upper back is abnormally rounded with a forward tilt in the pelvis
Flat Back A loss in the curvature to the spine referred to as straight back
Sway Back The back extends backward while the lower back abnormally curves inward and
the pelvis tilts forward, positioning the head in front of the pelvis; results from loss
of muscle tone in the abdomen and lower back, which allows the spine to sag
Scoliosis C- or S- shaping of the spine
Postural/Positioning Nursing Interventions -Alignment in neutral position
-Support natural spine curves
-Remove pressure points
-Prevent hyperextension/lateral rotation
-Temporary wheelchair use
-Use call bell for assistance
-Protect heel: pillows, boots, positioning devices
Based on CS -Keep patient mobile- avoid prolonged bed rest
-If severe lordosis, patient may require prescribed brace
-Pressure ulcer care and dressing type to be addressed later
Stage 1 Pressure Injury Intact skin, non-blanchable redness/no maroon or purplish discoloration
Stage 2 Pressure Injury Partial thickness skin loss: a pink/red wound bed that is moist and viable; may
include a ruptured or intact serum-filled blister
Stage 3 Pressure Injury Full-thickness skin loss: fat (adipose) and granulation tissue can be seen in the
ulcer. Rolled wound edges, slough, or eschar may be present as well as tunneling
and undermining. Fascia, muscle, ligaments, tendons, cartilage, and bone are NOT
visible
Answers
Acute Pain Pain that lasts seconds to < 6 months
Chronic Pain Pain that lasts > 6 months or longer; pain can be intermittent or continuous
Wong-Baker Faces Scale 0: No pain
2: Hurts a little bit
4: Hurts a little bit more
6: Hurts even more
8: Hurts a lot
10: Hurts the worst
Numeric Pain Scale Ask the patient to verbalize their pain on a scale from 0 (no pain) to 10 (severe
pain)
Slight Pain 1-3
Moderate Pain 4-7
Severe Pain 8-10
Subjective Data The ranking that the patient verbalizes on a numeric scale from 0-10
Objective Data Vital signs (e.g. heart rate or BP indicates pain)
PQRST Provocation and Palliation
Quality
Region and Radiation
Severity
Time
Provocation and Palliation What provoked the pain? (e.g. coughing, movement, lifting, twisting)
What improves the pain? (e.g. repositioning, analgesia, relaxation)
Quality What does the pain feel like? (Throbbing? Dull? Aching? Burning? Crushing?
Shooting?)
Is it continuous or intermittent?
Region and Radiation Where is the pain located? Does it radiate to other areas? (e.g. back, shoulders,
chest, arms, legs)
Severity Ask the patient to rate their pain on the numeric scale from 0-10
Time When did the pain begin?
Has the pain changed since this time?
Have you had pain like this before?
, Pain Interventions Pharmacologic vs. Nonpharmacologic
Pharmacologic Medicines. Start low (Tylenol), then escalate (advil/NSAIDS, narcotics if
appropriate)
Non-Pharmacologic PlaneTree-type interventions to reduce pain and stress such as:
-Distractions: music therapy/TV/convos
-Breathing exercises
-Positioning, elevation
-Wedge pillow or heel protectors
-TENS/ESTIM, acupressure, hypnosis
Types of Postural Misalignments Lordosis
Kyphosis
Flat Back
Sway Back
Scoliosis
Lordosis Lower back significantly curves inward with the pelvis tilting anteriorly
Kyphosis Upper back is abnormally rounded with a forward tilt in the pelvis
Flat Back A loss in the curvature to the spine referred to as straight back
Sway Back The back extends backward while the lower back abnormally curves inward and
the pelvis tilts forward, positioning the head in front of the pelvis; results from loss
of muscle tone in the abdomen and lower back, which allows the spine to sag
Scoliosis C- or S- shaping of the spine
Postural/Positioning Nursing Interventions -Alignment in neutral position
-Support natural spine curves
-Remove pressure points
-Prevent hyperextension/lateral rotation
-Temporary wheelchair use
-Use call bell for assistance
-Protect heel: pillows, boots, positioning devices
Based on CS -Keep patient mobile- avoid prolonged bed rest
-If severe lordosis, patient may require prescribed brace
-Pressure ulcer care and dressing type to be addressed later
Stage 1 Pressure Injury Intact skin, non-blanchable redness/no maroon or purplish discoloration
Stage 2 Pressure Injury Partial thickness skin loss: a pink/red wound bed that is moist and viable; may
include a ruptured or intact serum-filled blister
Stage 3 Pressure Injury Full-thickness skin loss: fat (adipose) and granulation tissue can be seen in the
ulcer. Rolled wound edges, slough, or eschar may be present as well as tunneling
and undermining. Fascia, muscle, ligaments, tendons, cartilage, and bone are NOT
visible
