Responses to Pain

Every question here, with the answer

1. A patient who is confused after surgery cannot clearly describe pain. The nurse notes an elevated heart rate and blood pressure before the patient says anything about discomfort. What is the nurse’s best interpretation?

   1. The findings are behavioral responses only and do not require pain assessment.
   2. The findings indicate adequate pain relief because the body is returning to normal functioning.
   3. The patient may be showing a sympathetic pain response, so the nurse should further assess for pain.
   4. The nurse should rely only on the patient’s verbal report because vital signs are not useful in pain assessment.

   Answer: The patient may be showing a sympathetic pain response, so the nurse should further assess for pain.

   Elevated heart rate and blood pressure can occur with a sympathetic response to pain, and this is especially important when a patient cannot communicate well. Vital signs should be used along with other pain assessment methods, not as the only measure.

2. The nurse reassesses a patient after a pain intervention. Which findings would support that the parasympathetic nervous system is taking over and the intervention may be effective? Select all that apply.

   1. The patient’s pupils are enlarged to improve vision.
   2. The patient’s heart rate and blood pressure are lower than before the intervention.
   3. The patient has more saliva and mucus to assist digestion and breathing.
   4. The patient’s blood pressure and heart rate increase to improve circulation.
   5. The patient’s digestion is supported as energy is directed toward breaking down food.

   Answer: The patient’s heart rate and blood pressure are lower than before the intervention., The patient has more saliva and mucus to assist digestion and breathing., The patient’s digestion is supported as energy is directed toward breaking down food.

   Parasympathetic responses occur during rest and relaxation and can indicate adequate pain relief. Enlarged pupils and increased heart rate and blood pressure are sympathetic responses associated with stress or pain, not parasympathetic recovery.

3. A patient reports pain, and the nurse wants to determine whether it is acute, chronic, or breakthrough pain. Which question is most appropriate?

   1. “Do you feel comfortable showing facial expressions of pain?”
   2. “Do you become quiet around other people when you are in pain?”
   3. “How long has the pain lasted?”
   4. “Are you worried that the pain will cause the worst possible outcome?”

   Answer: “How long has the pain lasted?”

   Asking how long the pain has lasted helps the nurse determine whether the pain is acute, chronic, or breakthrough. The other questions may address behavioral or affective responses, but they do not directly determine the pain category by duration.

4. The nurse is assessing an infant who is crying. Which nursing actions or interpretations are appropriate when evaluating possible pain? Select all that apply.

   1. Assume that all crying means the infant is in pain.
   2. Try comfort measures such as swaddling, feeding, and rocking.
   3. Use the FLACC scale to assess behavioral responses.
   4. Assess facial expressions, body posture, activity, crying, and ability to console.
   5. If comfort measures do not help, consider that the crying may be due to pain.

   Answer: Try comfort measures such as swaddling, feeding, and rocking., Use the FLACC scale to assess behavioral responses., Assess facial expressions, body posture, activity, crying, and ability to console., If comfort measures do not help, consider that the crying may be due to pain.

   The section emphasizes that infants primarily communicate through crying, but not all crying equals pain. The FLACC scale and comfort measures help the nurse assess whether crying may reflect pain.

5. A child with severe pain withdraws and resists when the nurse attempts to examine the painful area. What is the nurse’s best action?

   1. Use visual assessment and the child’s pain descriptors, and anticipate that pain relief may be needed before assessing the painful location.
   2. Delay all assessment until the child stops showing behavioral responses to pain.
   3. Tell the child that withdrawal from touch is not a typical pain response.
   4. Continue touching the painful area until the exact location is identified.

   Answer: Use visual assessment and the child’s pain descriptors, and anticipate that pain relief may be needed before assessing the painful location.

   Children may withdraw from touch because they fear that touching the area will worsen pain. Severe pain may require pain relief before assessing the painful location, and visual assessment and patient descriptors can support a comprehensive assessment without unnecessary touch.

6. A patient with chronic pain reports anxiety, fear, and increased stress related to the pain experience. Which interventions may help the patient adjust the affective response to pain? Select all that apply.

   1. Cognitive behavioral therapy
   2. Meditation
   3. Encouraging the patient to avoid any situation that could possibly cause pain
   4. Catastrophizing the pain to prepare for the worst outcome
   5. Guided imagery

   Answer: Cognitive behavioral therapy, Meditation, Guided imagery

   Cognitive behavioral therapy, guided imagery, and meditation can promote relaxation and decreased stress, helping with the emotional interpretation of pain. Avoidance and catastrophizing are described as problematic responses related to fear of pain, not therapeutic strategies.