Pain Assessment
Is pain subjective or objective?
Objective
Which of the following actions by the student nurse during an ear exam on a 10-year-old child requires intervention by the nurse?
a. The student pulls the pinna up and back
b. The student tilts the child's head away from them when looking in the child's ears
c. The student pushes on the tragus and palpates the mastoid process
d. The student pulls the pinna down and back
d. The student pulls the pinna down and back
What is the appropriate way to test the cervical muscles?
a. Have the client raise their eyelids, puff cheeks, and smile
b. Have the client turn their head to both sides as well as up and down
c. Have the client turn their head to both sides as well as up and down, and then against resistance
d. You don't test the cervical muscles
c. Have the client turn their head to both sides as well as up and down, and then against resistance
How many pounds in 1 kilogram?
2.2
Which of the following will make me scream if you do it? Select all that apply.
a. PULLING AN ALL NIGHTER
b. Reading each question carefully
c. TAKING THE TEST ON AN EMPTY STOMACH
d. GOING INTO THE TEST WITH A NEGATIVE ATTITUDE
e. Going into the test with a positive attitude
f. Using the highlighting tool
a. PULLING AN ALL NIGHTER
c. TAKING THE TEST ON AN EMPTY STOMACH
d. GOING INTO THE TEST WITH A NEGATIVE ATTITUDE
Which question will help you as the nurse assess the characteristics of a client's pain?
a. "Where is your pain?"
b. "When did your pain start?"
c. "What does your pain feel like?"
d. "How bad is your pain?"
c. "What does your pain feel like?"
Which of the following is not correct regarding normal aging?
a. An older adult experiencing presbycusis does not require medical intervention
b. Cilia in the ear become stiff and coarse
c. There is an increase in auditory reaction time
d. Arcus senilis in an older adult does not require medical intervention
c. There is an increase in auditory reaction time
Which lymph node is superficial to the mastoid process?
a. Preauricular
b. Submandibular
c. Posterior auricular
d. Posterior cervical
c. Posterior auricular
Your client is receiving digoxin 0.125mg IV at 10am. Available is digoxin ampule labeled 0.25mg/2mL. How many mL will you administer?
1mL
0.125mg / 0.25mg = 0.5mg
0.5mg x 2mL = 1mL
True or false: a bad test grade dictates your future as a nurse
FALSE
Your client complains of pain that is dull, deep, squeezing, and cramping. Where is this pain originating from?
a. Visceral
b. Cutaneous
c. Deep somatic
d. Referred
a. Visceral
Which of the following is correct regarding the eyes/is an expected finding during an eye assessment? Select all that apply.
a. Eye health is reflected by the visual acuity
b. The Snellen chart test is an accurate way to test visual acuity
c. Yellow-orange or pink optic disc
d. Pupils are 7mm
e. Brisk constriction when checking pupils
f. Eyebrows move symmetrically
b. The Snellen chart test is an accurate way to test visual acuity
c. Yellow-orange or pink optic disc
e. Brisk constriction when checking pupils
f. Eyebrows move symmetrically
Which of the following is NOT a normal change due to aging?
a. Increased elasticity of the skin
b. Concave curve of the spine
c. Facial bones being more distinctive
d. General decrease in body functions
a. Increased elasticity of the skin
The physician orders 40mg diphenhydramine hydrochloride IM. Available is 2g/5mL. How many mL will you administer?
40mg / 1,000 = 0.04g
0.04g / 2g = 0.002g
0.002g x 5mL = 0.1mL
You are taking the test and get to a question you absolutely do not know the answer to. Which action is most appropriate for you to do?
a. Give up, throw yourself on the ground, and cry
b. Picture dropping out and wondering what you're going to do for the rest of your life since you can't answer this one question
c. Take a deep breath, reread the question, eliminate at least 1 answer choice (or 2 if you can), reread the question AGAIN, reread the answer choices left, and make the most educated guess possible
d. Stand up on your desk and yell "FLORENCE NIGHTINGALE HELP ME"
c. Take a deep breath, reread the question, eliminate at least 1 answer choice (or 2 if you can), reread the question AGAIN, reread the answer choices left, and make the most educated guess possible
You are a preceptor to a student nurse on their long-term care clinical rotation. Which statement made by the student requires additional teaching about pain?
a. "Older adults tend to need more pain medicine due to their comorbidities."
b. "Pain is a normal process of aging so we should all expect to be in pain as we get older."
c. "Older adults often deny pain because they are afraid of becoming dependent on pain medicine like opioids."
d. "Dementia does not impact the ability to feel pain."
b. "Pain is a normal process of aging so we should all expect to be in pain as we get older."
When assessing the nose, which of the following findings are abnormal? Select all that apply.
a. Deviated septum
b. Sinus infection
c. Perforated septum
d. Red, smooth, moist surface of nasal cavity
e. Tender turbinates
f. Presence of polyps
a. Deviated septum
b. Sinus infection
c. Perforated septum
f. Presence of polyps
Which comment by a client requires additional education by the nurse?
a. "It is normal if my child's lymph nodes are soft and fixed."
b. "Lymphatic drainage helps to prevent potentially harmful substances from entering the circulation."
c. "It is normal if my child's lymph nodes are soft and moveable."
d. "I don't need to be worried about my mother's curved upper back."
a. "It is normal if my child's lymph nodes are soft and fixed."
The physician orders penicillin 200 mcg every day for 5 days. Available is penicillin 0.2mg/2mL. How many mL will you give in each dose?
2mL
200mcg / 1,000 = 0.2mg
0.2mg / 0.2mg = 1mg
1mg x 2mL = 2mL
a. A nursing student
b. Competent and knowledgable to answer the questions
c. A student who WILL NOT pull an all nighter or not eat before the test
d. Someone who has absolutely no idea what they are doing >:(
e. Someone who WILL make it through nursing school
f. A pirate (I ran out of ideas for an answer choice don't choose this one)
a. Nursing student
b. Competent and knowledgable to answer the questions
c. A student who WILL NOT pull an all nighter or not eat before the test
e. Someone who WILL make it through nursing school
A 78-year-old male is crying to the nurse because the pain "is unbearable and I can't function." Which statement by the nurse is most appropriate?
a. "You refused your PRN medicine so there isn't much I can do. You are old so pain is normal."
b. "Try turning the TV on or listening to music to distract yourself; distraction helps with pain management."
c. "I'll go get you your PRN pain medicine."
d. "Tell me about your pain."
d. "Tell me about your pain."
Which mouth/throat assessment finding requires immediate intervention by the nurse?
a. Receding gums in an elderly patient
b. Uvula is not mid-line
c. 4+ tonsils
d. White patches on the tongue
c. 4+ tonsils
Which of the following are expected findings when performing an assessment of the head and neck? Select all that apply.
a. Head is normocephalic
b. Midline trachea
c. Twitching of the eyes
d. Tender temporal artery
e. Crepitation of the temporomandibular joint
f. Color and texture appropritate for race
a. Head is normocephalic
b. Midline trachea
f. Color and texture appropriate for race
The physician orders 1,500mL D5W to infuse over 12 hours. Macrodrip tubing (10 gtt/mL) is available. What is the drip rate?
21gtt/min
12 hours x 60 minutes = 720 minutes
1,500mL x 10gtt/mL = 15,000gtt
15,000gtt / 720 minutes = 20.8gtt/min
If you happen to get a bad grade on the test/a lower grade than you wanted, what are the next steps?
a. Fight the person closet to you
b. Say "oh well" and don't change any of your study habits or test taking strategies
c. Drop out, adopt a pet raccoon, and try to become famous on TikTok
d. You schedule a test review with your professor, go over the questions you missed, recognize what went wrong this time and change your study habits/test taking strategies, and get a better grade on the next test
d. You schedule a test review with your professor, go over the questions you missed, recognize what went wrong this time and change your study habits/test taking strategies, and get a better grade on the next test