1
HESI RN COMPREHENSIVE PREDICTOR EXAM.
1An oriented patient has recently had surgery. Which action is best for the
nurseto take to assess this
patient’s pain?
a. Assess the patient’s body language.
b. Ask the patient to rate the level of pain.
c. Observe the cardiac monitor for increased heart rate.
d. Have the patient describe the effect of pain on the ability to cope.
ANSWER : B
One of the most subjective and therefore most useful characteristics for
reporting pain is its severity.
Therefore, the best way to assess a patient’s painis to ask the patient to rate
the pain. Nonverbal communication, such as body language, is not as
effective in assessing pain, especially when the patient is oriented. Heart rate
sometimes increases when a patient is in pain, but this is not a symptom that
is specific to pain. Pain sometimes affects a patient’s ability to cope, but
assessing the effect of pain on coping assesses the patient’sability to cope; it
does not assess the patient’s pain.
2.A nurse is caring for a patient who recently had abdominal surgery and is
experiencing severe pain. The patient’s blood pressure is 110/60 mm Hg,
and heart rate is 60 beats/min. Additionally, the patient does not appear
tobe in any distress. Whichresponse by the nurse is most therapeutic?
“Your vitals do not show that you are having pain; can you describe
a. your pain?”
, 2
b. “OK, I will go get you some narcotic pain relievers
immediately.”
c. “What would you like to try to alleviate your pain?”
d. “You do not look like you are in pain.”
ANSWER : C
Be sure the patient is a partner in making decisions
about the best approaches for managing pain. A patient 20
knows the most about his or her pain and is an important 5 partner in selecting
successful pain therapies. The nurse must believe that a patient is in pain
whenever the
patient reports that he or she is in
, 5
3
pain, even if the patient does not appear to be in pain.
The nurse must be careful to not judge the patient based
on vital signs or nonverbal communication and must not assume that the
patient is seeking narcotics. Thepatient is a partner in pain management, so
going to get narcotics to treat the pain without consulting with the patient
first is not appropriate.
3.A nurse teaches the patient about the gate control theory. Which
statement made by a patient reflects a correct understanding about the
relationship
between the gate control theory of pain and the use of meditation to
relievepain?
“Meditation controls pain by blocking pain impulses from coming
a. through the gate.”
“Meditation alters the chemical composition of pain neuroregulators,
b. which closes the gate.”
“Meditation will help me sleep through the pain because it opens the
c. gate.”
d. “Meditation stops the occurrence of pain stimuli.”
ANSWER : A
According to this theory, gating mechanisms located along the central
nervoussystem regulate or block pain impulses. Pain impulses pass through
when a gate is open and are blocked when a gate is closed.
Nonpharmacologic pain-relief measures, such as meditation, work
byclosing the gates, which keeps pain impulses from coming through.
Meditation does not open pain gates or stop pain from occurring.
Meditationalso does not have an effect on pain neuroregulators.
, 6
4.A nurse is planning care for an older-adult patient who is experiencing pain.Which
statement made by the nurse indicates the supervising nurse needs to
follow up?
a. “As adults age, their ability to perceive pain decreases.” “Older patients may
have low serum albumin in their blood, causing
b. toxic effects of analgesic drugs.”
“Patients who have dementia probably experience pain, and their pain
c. s not always well controlled.”
20
“It is safe to administer
5
opioids to older adults as long as you
start with
small doses and frequently assess
thepatient’s response to the
d. medicati
on.”ANSWER:A
Aging does not affect the ability to perceive pain. This misconception must be
corrected by the supervising nurse. All the other statements are true and
require no follow-up. Opioids are safe to use in older adults as long as they
areslowly titrated and the nurse frequently monitors the patient.
Patients with dementia most likely experience unrelieved pain because their
pain is difficult to assess. Older adults frequently eat poorly, resulting in low
serum albumin levels. Many drugs are highly protein bound. In the presence
of low serum albumin, more free drug (active form) is available, thus
increasing the risk for side and/or toxic effects.
5. The nurse is caring for two patients; both are having a
hysterectomy.The first patient is having the hysterectomy after a
complicated birth. The
HESI RN COMPREHENSIVE PREDICTOR EXAM.
1An oriented patient has recently had surgery. Which action is best for the
nurseto take to assess this
patient’s pain?
a. Assess the patient’s body language.
b. Ask the patient to rate the level of pain.
c. Observe the cardiac monitor for increased heart rate.
d. Have the patient describe the effect of pain on the ability to cope.
ANSWER : B
One of the most subjective and therefore most useful characteristics for
reporting pain is its severity.
Therefore, the best way to assess a patient’s painis to ask the patient to rate
the pain. Nonverbal communication, such as body language, is not as
effective in assessing pain, especially when the patient is oriented. Heart rate
sometimes increases when a patient is in pain, but this is not a symptom that
is specific to pain. Pain sometimes affects a patient’s ability to cope, but
assessing the effect of pain on coping assesses the patient’sability to cope; it
does not assess the patient’s pain.
2.A nurse is caring for a patient who recently had abdominal surgery and is
experiencing severe pain. The patient’s blood pressure is 110/60 mm Hg,
and heart rate is 60 beats/min. Additionally, the patient does not appear
tobe in any distress. Whichresponse by the nurse is most therapeutic?
“Your vitals do not show that you are having pain; can you describe
a. your pain?”
, 2
b. “OK, I will go get you some narcotic pain relievers
immediately.”
c. “What would you like to try to alleviate your pain?”
d. “You do not look like you are in pain.”
ANSWER : C
Be sure the patient is a partner in making decisions
about the best approaches for managing pain. A patient 20
knows the most about his or her pain and is an important 5 partner in selecting
successful pain therapies. The nurse must believe that a patient is in pain
whenever the
patient reports that he or she is in
, 5
3
pain, even if the patient does not appear to be in pain.
The nurse must be careful to not judge the patient based
on vital signs or nonverbal communication and must not assume that the
patient is seeking narcotics. Thepatient is a partner in pain management, so
going to get narcotics to treat the pain without consulting with the patient
first is not appropriate.
3.A nurse teaches the patient about the gate control theory. Which
statement made by a patient reflects a correct understanding about the
relationship
between the gate control theory of pain and the use of meditation to
relievepain?
“Meditation controls pain by blocking pain impulses from coming
a. through the gate.”
“Meditation alters the chemical composition of pain neuroregulators,
b. which closes the gate.”
“Meditation will help me sleep through the pain because it opens the
c. gate.”
d. “Meditation stops the occurrence of pain stimuli.”
ANSWER : A
According to this theory, gating mechanisms located along the central
nervoussystem regulate or block pain impulses. Pain impulses pass through
when a gate is open and are blocked when a gate is closed.
Nonpharmacologic pain-relief measures, such as meditation, work
byclosing the gates, which keeps pain impulses from coming through.
Meditation does not open pain gates or stop pain from occurring.
Meditationalso does not have an effect on pain neuroregulators.
, 6
4.A nurse is planning care for an older-adult patient who is experiencing pain.Which
statement made by the nurse indicates the supervising nurse needs to
follow up?
a. “As adults age, their ability to perceive pain decreases.” “Older patients may
have low serum albumin in their blood, causing
b. toxic effects of analgesic drugs.”
“Patients who have dementia probably experience pain, and their pain
c. s not always well controlled.”
20
“It is safe to administer
5
opioids to older adults as long as you
start with
small doses and frequently assess
thepatient’s response to the
d. medicati
on.”ANSWER:A
Aging does not affect the ability to perceive pain. This misconception must be
corrected by the supervising nurse. All the other statements are true and
require no follow-up. Opioids are safe to use in older adults as long as they
areslowly titrated and the nurse frequently monitors the patient.
Patients with dementia most likely experience unrelieved pain because their
pain is difficult to assess. Older adults frequently eat poorly, resulting in low
serum albumin levels. Many drugs are highly protein bound. In the presence
of low serum albumin, more free drug (active form) is available, thus
increasing the risk for side and/or toxic effects.
5. The nurse is caring for two patients; both are having a
hysterectomy.The first patient is having the hysterectomy after a
complicated birth. The
