Test Bank For Health Assessment in
Har/Cdr edition: Janet R. Weber
Nursing, 3
To download the complete and accurate content document, go to: https://testbankbell.com/download/test-bank-for-health-assessment-in-nursing-3-har-c dr-edition-janet-r-weber/
1. The basis of pain is explained in what manner?
A) It has a psychologic basis.
B) It has a physiologic basis.
C) It has both a psychologic and physiologic basis.
D) It has a solely neurologic basis.
Ans: C
Difficulty: Moderate
Feedback:
Pain is seen as a combination of psychologic and physiologic phenomena.
2. A-delta primary afferent fibers transmit fast pain to the spinal cord within how many seconds?
A) 0.1 B) 0.5 C) 1 D) 1.5
Ans: A
Difficulty: Difficult
Feedback:
A-delta fibers transmit pain within 0.1 seconds.
3. The nurse should be aware that a client who has had major surgery and is experiencing depression also may likely be experiencing:
A) Less pain than reported
B) More pain than reported
C) About the same level of pain consistently
D) Minimal pain overall
Ans: B
Difficulty: Moderate
Feedback:
Emotional status issues such as depression and anxiety directly affect the level of pain reported. The nurse needs to be conscious of and able to react to the possibility that a client with depression is experiencing more pain than the client is reporting.
4. A client is diagnosed with chronic nonmalignant pain. The nurse understands that this client has experienced this pain for at least how many months?
A) 3 B) 6 C) 9 D) 12
Ans: B
Difficulty: Moderate
Feedback:
Chronic nonmalignant pain is described as a constant pain persisting more than 6 months.
5. What statement most accurately describes cancer pain?
A) Its basis is chronic neuropathy.
B) It is caused by a specific trauma.
C) It appears in the first month after cancer develops.
D) It is caused by compressed peripheral nerves.
Ans: D
Difficulty: Moderate
Feedback:
Cancer is often due to compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemotherapy radiation, or tumor growth.
6. What would the nurse use as the main assessment for a client's pain?
A) The client's spiritual aspect related to the pain
B) Current pain therapies used
C) The client's reporting of the pain
D) Psychosocial questions related to perceptions
Ans: C
Difficulty: Moderate Feedback:
Pain is subjective and the main assessment lies in the client's reporting of the pain.
7. The Verbal Descriptor Scale rates pain on what type of scale?
A) Facial expression scale
B) 0 to10 numeric scale
Ans: D
Difficulty: Moderate
Feedback:
C) 0 to 10 visual analog scale
D) Mild, moderate, and severe scale
The Visual Descriptor Scale rates pain on a scale between mild, moderate, and severe.
8. Which rating scale would be most appropriate for a 5-year-old client following a tonsillectomy?
A) Verbal Descriptor Scale
B) Wong-Baker Faces Scale
Ans: B
Difficulty: Moderate
Feedback:
C) Numeric Rating Scale
D) Visual Analog Scale
The Wong-Baker Faces Scale utilizes facial expressions shown on faces to describe pain intensity and would be appropriate for a 5-year-old child.
9. Which vital sign measurement might be an indicator of pain?
A) Respiratory rate of 18 breaths/min C) Temperature of 99.1 °F
B) Heart rate of 110 bpm D) Blood pressure of 130/75 mmHg
Ans: B
Difficulty: Easy
Feedback:
Pain can increase the heart rate; a rate of 110 bpm is above the normal range. The other vital signs noted are in normal range.
10. The nurse writes a wellness diagnosis. Which example represents this type of diagnosis?
A) Readiness for enhanced spiritual well-being related to coping with prolonged physical pain
B) Risk for activity intolerance related to chronic pain and immobility
C) Bathing/hygiene self-care deficit related to severe pain
D) Chronic pain related to chronic inflammatory process of rheumatoid arthritis
Ans: A
Difficulty: Moderate
Feedback:
A wellness diagnosis reflects a desire or willingness to do something that will enhance life.
11. What would be the best written example of a collaborative problem?
A) “Impaired physical mobility related to chronic pain”
B) “Risk for powerlessness related to chronic pain”
C) “Readiness for enhanced comfort level”
D) “PC: peripheral nerve compression”
Ans: D
Difficulty: Moderate
Feedback:
A collaborative problem is written as a “potential complication,” thus the letters “PC” appear before the problem.
12. When talking about the gate control theory, the nurse understands that the gating mechanism is generated from what area in the body?
A) Spinothalamic tract C) Substantia gelatinosa
B) Spinoreticular tract D) Neuropeptides
Ans: C
Difficulty: Difficult
Feedback:
Neurotransmitters are released and concentrated in the substantia gelatinosa and then bind to specific receptors.
13. The nurse is assessing a client who is experiencing a great deal of pain. Which assessment data would be considered normal under those circumstances?
A) Decreased heart rate
B) Increased urinary output
Ans: D
Difficulty: Difficult
Feedback:
C) Hypoglycemia
D) Decreased gastric motility
Pain can decrease gastric motility due to the body's compensation mechanism for pain.
14. What physiologic response would be expected in a client who rates a pain level of a 9 on a scale of 1 to 10?
A) Constricted pupils
B) Decreased blood pressure
Ans: C
Difficulty: Moderate
Feedback:
C) Increased serum glucose
D) Flaccid muscles
The stress response seen with pain will increase the serum glucose level.
15. Which question would be most appropriate to ask a client when the goal is to identify precipitating factors that might have exacerbated the pain?”
A) “What were you doing when the pain first stated?
B) “Do concurrent symptoms accompany the pain?”
C) “When did the pain start?”
D) “Is the pain continuous or intermittent?”
Ans: A
Difficulty: Moderate
Feedback:
Exacerbation means something that could make the pain more intense or worse than previously experienced. Asking when the client was doing when the pain started might identify that type of factor.
16. Which assessment data would indicate an abnormal finding when inspecting the abdomen during a pain assessment?
A) Smooth, raised old scar
B) Paler skin color than surrounding tissue
C) Dark, bluish-pink striae
D) Blood veins visible above umbilicus
Ans: C
Difficulty: Difficult
Feedback:
Dark, bluish-pink striae may indicate Cushing syndrome.
17. When performing a neurologic assessment for a client experiencing moderately severe pain, which piece of data would cause little concern?
A) Deep tendon reflexes measurement of 2+
B) Uncoordinated gait
C) Absent reflexes
D) Inability of the client to sense vibrations
Ans: A
Difficulty: Easy
Feedback:
Deep tendon reflexes are considered normal when assessed at 2+ on a 1+ to 4+ scale.
18. A client is in moderate pain. Which assessment finding would be considered abnormal during a musculoskeletal assessment?
A) Concave cervical spine C) Lumbar flexion of 80 degrees
B) Lateral thoracic curvature D) Lateral bending of 35 degrees
Ans: B
Difficulty: Moderate Feedback:
A lateral thoracic curvature may indicate scoliosis and is a cause of pain.
19. When percussing the abdomen, the nurse would consider what data as normal?
A) A 7-cm wide overall area of dullness near the left rib
B) Liver border dullness heard 4 cm below the costal margin
C) Hyperresonance heard over the abdomen
D) Dullness heard over the bladder
Ans: A
Difficulty: Moderate
Feedback:
Percussion of a 7-cm wide area of dullness near the left rib is normal and indicates the spleen.
20. When a client asks why the nurse is asking how the client's family experiences and tolerates pain, the best response by the nurse would include what explanation?
A) "It is just a way for me to more fully understand you and your upbringing."
B) "It helps me to direct interventions toward your cultural history."
C) "It helps to assess possible family-related perceptions of pain."
D) "It will allow me to see if you are more likely to react to pain in a negative manner."
Ans: C
Difficulty: Moderate
Feedback:
This line of questioning will help assess possible family-related perceptions of pain or any past experiences with persons in pain.