An oriented patient has recently had surgery. Which action is best for the nurse to 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 descri...
a nurse is caring for a patient who recently had a
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HESI RN (HESIRN)
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HESI RN COMPREHENSIVE PREDICTOR EXAM
HESI RN COMPREHENSIVE PREDICTOR EXAM
An oriented patient has recently had surgery. Which action is best for the
nurse to 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.
ANS: 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 pain
is 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’s
ability 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 to
be in any distress. Which response by the nurse is most therapeutic?
“Your vitals do not show that you are having pain; can you describe
a. your pain?”
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.”
ANS: C Be
su
,HESI RN COMPREHENSIVE PREDICTOR EXAM
re the patient is a partner in making decisions about the best approaches for
managing pain. A patient knows the most about his or her pain and is an
important partner in selecting successful pain therapies. The nurse must 205
believe that a patient is in pain whenever the patient reports that he or she is in
, HESI RN COMPREHENSIVE PREDICTOR EXAM.
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. The
patient 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 relieve
pain?
“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.”
ANS: A
According to this theory, gating mechanisms located along the central nervous
system 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 by
closing the gates, which keeps pain impulses from coming through.
Meditation does not open pain gates or stop pain from occurring. Meditation
also does not have an effect on pain neuroregulators.
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.”
“It is safe to administer opioids to 205
older adults as long as you start with
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