The nurse performing a focused assessment on pain will assess: (Select all that apply.).
Culture.
Psychological factors.
History of pain.
Contributing factors.
Assess verbal indicators
Correct Answer : A,B,C,D,E
Choice A rationale:
Culture can influence a person's perception and expression of pain. It's important to consider cultural factors when assessing and managing pain because beliefs and attitudes about pain can vary significantly among different cultural groups. This can affect how pain is experienced and communicated.
Choice B rationale:
Psychological factors, such as anxiety, depression, and coping mechanisms, play a significant role in the experience of pain. Assessing psychological factors is essential for a comprehensive understanding of the patient's pain experience and developing appropriate pain management strategies.
Choice C rationale:
Understanding the patient's history of pain is crucial for a focused pain assessment. Previous experiences with pain, including the cause, intensity, and effectiveness of previous pain management strategies, can provide valuable insights into the current pain situation.
Choice D rationale:
Assessing contributing factors, such as concurrent medical conditions, injuries, or environmental factors, is essential to determine the underlying causes of pain and develop an effective pain management plan.
Choice E rationale:
Verbal indicators are essential for assessing pain. Patients often describe their pain in words, and understanding their descriptions and expressions of pain is fundamental to evaluating its intensity, location, quality, and duration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse recommends that normal sleep and rest patterns can best be acquired by suggesting that the patient exercises in the mornings. Morning exercise can help regulate the circadian rhythm and improve sleep-wake patterns. It helps to reset the internal body clock, making it easier to fall asleep at night. However, exercise should not be too close to bedtime, as it may have a stimulating effect.
Choice B rationale:
Taking a nap during the day may provide a short-term boost in alertness but is not recommended as the primary method to acquire normal sleep and rest patterns. Daytime naps should be brief (20-30 minutes) and should not interfere with nighttime sleep. Excessive daytime napping can disrupt the regular sleep cycle.
Choice C rationale:
Drinking wine is not a recommended approach for acquiring normal sleep and rest patterns. Alcohol consumption, especially in the evening, can disrupt sleep cycles and negatively affect the quality of sleep. It may lead to frequent awakenings during the night and contribute to sleep disturbances.
Choice D rationale:
Smoking cigarettes is not a recommended approach for acquiring normal sleep and rest patterns. Nicotine is a stimulant that can interfere with sleep by increasing alertness and heart rate. Smoking can contribute to sleep difficulties and should be avoided, especially close to bedtime. .
Correct Answer is B
Explanation
Choice A rationale:
Constipation is not a common adverse effect of pain medication administered by the epidural route. Pain medication primarily affects the central nervous system and does not typically impact the gastrointestinal system in a way that would lead to constipation.
Choice B rationale:
Hypoventilation is the correct answer. When opioids or other potent pain medications are administered by the epidural route, they can depress the respiratory center in the brain, leading to hypoventilation (slow or inadequate breathing). This is a critical concern and the most important adverse effect to monitor because it can lead to respiratory compromise or even respiratory arrest.
Choice C rationale:
Nausea can be a side effect of some pain medications, but it is not the most important adverse effect to monitor in a patient receiving epidural pain medication. Nausea can often be managed with antiemetic medications.
Choice D rationale:
Headache is not a common adverse effect of epidural pain medication. The administration of pain medication into the epidural space is localized to the spinal area and does not typically lead to headaches.
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