ATI Engage Fundamentals (Physiologic
Concepts for Nursing Practice): Pain
A nurse is caring for an older adult client who has a cognitive impairment and is
postoperative. Which of the following actions should the nurse take?
- Use the Crying, Requires Oxygen, Increases Vital Signs, Expression, Sleeplessness
(CRIES) pain scale.
The CRIES pain scale is used to assess pain in infants born at 38 weeks of gestation or
greater. It would not be an appropriate scale for an older adult client. A client who has a
cognitive impairment should be observed for the presence of nonverbal signs such as
guarding, grimacing, restlessness, and other behavioral changes.
- Reassure family members that older adult clients have a decreased ability to sense pain.
As age increases, pain seems to increase for neuropathic conditions and for joint and lower
extremity conditions. Research suggests that pain tolerance does not change significantly as
a person ages.
- Evaluate the client for pain by observing their behavior.
Clients who have cognitive impairment might be unable to appropriately report their pain.
The nurse should observe for behaviors that suggest pain is present such as guarding,
grimacing, restlessness, and other behavioral changes.
- Assign a pain scale number based on the FACES pain scale.
The FACES pain scale is appropriate to use in children ages 3 and up. The scale is intended
for clients to rate their own pain, not for others to rate the pain of the client.
A nurse is reviewing information for several clients on the unit. The nurse should recognize
that which of the following clients is at greatest risk for respiratory depression?
- A client who has chronic pain and recently started taking paroxetine
Any client could experience respiratory difficulties; however, paroxetine is not known to
directly cause respiratory depression. Therefore, there is another client the nurse should
identify as having the greatest risk.
- A client who has cancer and has taken oxycodone PRN for several months
Any client could experience respiratory difficulties; however, a client who has been taking an
opioid medication long term has a significantly lower risk of respiratory depression than a
,client who is newly taking the medication. Therefore, there is another client the nurse should
identify as having the greatest risk.
-A client who has been accidentally taking twice the amount of prednisone as prescribed
Any client could experience respiratory difficulties; however, prednisone is not known to
directly cause respiratory depression. Therefore, there is another client the nurse should
identify as having the greatest risk.
- A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN
Use of an opioid medication can decrease the respiratory rate, and the first 4 hr
postoperative are when the client is at highest risk for surgical complications. Therefore, the
nurse should identify that the client who had surgery 3 hr ago and is receiving IV
hydromorphone is at greatest risk for respiratory depression.
A nurse is caring for a client who has kidney stones. Which of the following manifestations is
an objective indicator of pain?
- The client is diaphoretic.
MY ANSWERThe nurse should identify that sweating is an objective manifestation of pain.
Objective data is information the nurse can gather by using their five senses. Sweating can
be visually noticed by the nurse.
- The client is experiencing stabbing pain.
This is a characteristic of pain, but the nurse would not be able to observe or measure this
type of pain. Anything the client reports to the nurse and cannot be measured or noted using
the five senses is a subjective finding.
- The client is nauseated.
The nurse would not be able to measure nausea. The client would need to tell the nurse they
are feeling nauseated. Therefore, this is a subjective finding of pain.
- The client states feeling dizzy.
The nurse could not measure dizziness. Anything the client reports to the nurse and cannot
be measured or noted using the five senses is a subjective finding.
A nurse is providing end-of-life care for a client who is unresponsive and near death. The
client's family asks the nurse about managing the client's pain. Which of the following
statements should the nurse make to the client's family?
- "Your family member will not require pain medication."
, According to the American Society for Pain Management Nursing and the Hospice and
Palliative Nurses Association position statement, end-of-life effective pain management is a
basic human right. Clients who are receiving end-of-life care should receive special
consideration for pain management.
- "Your family member can inform the provider about their decision for pain management."
The client is unresponsive and near death and will not be able to communicate their desires
to the provider. If the client were alert and responsive, they would be legally able to give
verbal consent and make decisions about pain management.
- "Your family member has the right to receive effective pain management."
According to the American Society for Pain Management Nursing and the Hospice and
Palliative Nurses Association position statement, end-of-life effective pain management is a
basic human right. Clients who are receiving end-of-life care should receive special
consideration for pain management.
- "Your family member will not be able to tolerate the effects of pain medications."
According to the American Society for Pain Management Nursing and the Hospice and
Palliative Nurses Association position statement, end-of-life effective pain management is a
basic human right. Clients who are receiving end-of-life care should receive special
consideration for pain management, and dosing will be based on the individual.
A nurse is assisting with a staff in-service regarding pain control. Which of the following
statements by a staff member indicates an understanding of the information? (Select all that
apply.)
- "A client's religious beliefs might affect the way they respond to pain" is correct. The nurse
should be aware of factors that could inhibit communication with the client and prevent pain
control, such as differences in ethnic backgrounds or religious beliefs.
- "Herbal therapies are not permitted for a client receiving prescription pain medication" is
incorrect. If a client chooses to use herbal medications, the nurse should advocate for the
client to be able to continue using them. The nurse should consult with the provider and
pharmacist to ensure there are no interactions or special precautions needed in order to
protect the client.
- "The client's past pain experiences are not related to their current pain and pain
management" is correct.
The client's past pain experiences are not related to their current pain and pain
management.
Concepts for Nursing Practice): Pain
A nurse is caring for an older adult client who has a cognitive impairment and is
postoperative. Which of the following actions should the nurse take?
- Use the Crying, Requires Oxygen, Increases Vital Signs, Expression, Sleeplessness
(CRIES) pain scale.
The CRIES pain scale is used to assess pain in infants born at 38 weeks of gestation or
greater. It would not be an appropriate scale for an older adult client. A client who has a
cognitive impairment should be observed for the presence of nonverbal signs such as
guarding, grimacing, restlessness, and other behavioral changes.
- Reassure family members that older adult clients have a decreased ability to sense pain.
As age increases, pain seems to increase for neuropathic conditions and for joint and lower
extremity conditions. Research suggests that pain tolerance does not change significantly as
a person ages.
- Evaluate the client for pain by observing their behavior.
Clients who have cognitive impairment might be unable to appropriately report their pain.
The nurse should observe for behaviors that suggest pain is present such as guarding,
grimacing, restlessness, and other behavioral changes.
- Assign a pain scale number based on the FACES pain scale.
The FACES pain scale is appropriate to use in children ages 3 and up. The scale is intended
for clients to rate their own pain, not for others to rate the pain of the client.
A nurse is reviewing information for several clients on the unit. The nurse should recognize
that which of the following clients is at greatest risk for respiratory depression?
- A client who has chronic pain and recently started taking paroxetine
Any client could experience respiratory difficulties; however, paroxetine is not known to
directly cause respiratory depression. Therefore, there is another client the nurse should
identify as having the greatest risk.
- A client who has cancer and has taken oxycodone PRN for several months
Any client could experience respiratory difficulties; however, a client who has been taking an
opioid medication long term has a significantly lower risk of respiratory depression than a
,client who is newly taking the medication. Therefore, there is another client the nurse should
identify as having the greatest risk.
-A client who has been accidentally taking twice the amount of prednisone as prescribed
Any client could experience respiratory difficulties; however, prednisone is not known to
directly cause respiratory depression. Therefore, there is another client the nurse should
identify as having the greatest risk.
- A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN
Use of an opioid medication can decrease the respiratory rate, and the first 4 hr
postoperative are when the client is at highest risk for surgical complications. Therefore, the
nurse should identify that the client who had surgery 3 hr ago and is receiving IV
hydromorphone is at greatest risk for respiratory depression.
A nurse is caring for a client who has kidney stones. Which of the following manifestations is
an objective indicator of pain?
- The client is diaphoretic.
MY ANSWERThe nurse should identify that sweating is an objective manifestation of pain.
Objective data is information the nurse can gather by using their five senses. Sweating can
be visually noticed by the nurse.
- The client is experiencing stabbing pain.
This is a characteristic of pain, but the nurse would not be able to observe or measure this
type of pain. Anything the client reports to the nurse and cannot be measured or noted using
the five senses is a subjective finding.
- The client is nauseated.
The nurse would not be able to measure nausea. The client would need to tell the nurse they
are feeling nauseated. Therefore, this is a subjective finding of pain.
- The client states feeling dizzy.
The nurse could not measure dizziness. Anything the client reports to the nurse and cannot
be measured or noted using the five senses is a subjective finding.
A nurse is providing end-of-life care for a client who is unresponsive and near death. The
client's family asks the nurse about managing the client's pain. Which of the following
statements should the nurse make to the client's family?
- "Your family member will not require pain medication."
, According to the American Society for Pain Management Nursing and the Hospice and
Palliative Nurses Association position statement, end-of-life effective pain management is a
basic human right. Clients who are receiving end-of-life care should receive special
consideration for pain management.
- "Your family member can inform the provider about their decision for pain management."
The client is unresponsive and near death and will not be able to communicate their desires
to the provider. If the client were alert and responsive, they would be legally able to give
verbal consent and make decisions about pain management.
- "Your family member has the right to receive effective pain management."
According to the American Society for Pain Management Nursing and the Hospice and
Palliative Nurses Association position statement, end-of-life effective pain management is a
basic human right. Clients who are receiving end-of-life care should receive special
consideration for pain management.
- "Your family member will not be able to tolerate the effects of pain medications."
According to the American Society for Pain Management Nursing and the Hospice and
Palliative Nurses Association position statement, end-of-life effective pain management is a
basic human right. Clients who are receiving end-of-life care should receive special
consideration for pain management, and dosing will be based on the individual.
A nurse is assisting with a staff in-service regarding pain control. Which of the following
statements by a staff member indicates an understanding of the information? (Select all that
apply.)
- "A client's religious beliefs might affect the way they respond to pain" is correct. The nurse
should be aware of factors that could inhibit communication with the client and prevent pain
control, such as differences in ethnic backgrounds or religious beliefs.
- "Herbal therapies are not permitted for a client receiving prescription pain medication" is
incorrect. If a client chooses to use herbal medications, the nurse should advocate for the
client to be able to continue using them. The nurse should consult with the provider and
pharmacist to ensure there are no interactions or special precautions needed in order to
protect the client.
- "The client's past pain experiences are not related to their current pain and pain
management" is correct.
The client's past pain experiences are not related to their current pain and pain
management.
