A 49-year-old patient who reports pain in the foot that moves up along the calf says, "My left foot feels like it is on fire." The patient reports that the pain started yesterday, and they have no prior history of injury or falls. Which components of pain assessment has the patient reported?

Aggravating and alleviating factors.

Exacerbation, with associated signs and symptoms.

Intensity, temporal characteristics, and functional impact.

Location, quality, and duration.

Answer and Explanation

The Correct Answer is D

A. Aggravating and alleviating factors: The patient has not identified any factors that worsen or relieve the pain.

B. Exacerbation, with associated signs and symptoms: There is no indication of exacerbating factors or associated symptoms in this description.

C. Intensity, temporal characteristics, and functional impact: The intensity (e.g., 1-10 scale), temporal characteristics (pattern over time), or functional impact on daily activities were not mentioned.

D. Location, quality, and duration. The patient described: Location: The foot and calf. Quality: "Feels like it is on fire" (neuropathic pain). Duration: Pain began yesterday.

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Correct Answer is C

Explanation

A. Encouraging client feedback about satisfaction with the facility experience: This reflects client-centered care but does not directly demonstrate autonomy.

B. Explaining unit rules and policies regarding unacceptable behaviors: This action involves setting expectations rather than promoting client autonomy.

C. Supporting the client's wish to refuse prescribed medications. Autonomy involves respecting a client's right to make their own decisions about their care, including the decision to refuse treatment, as long as they have the capacity to do so.

D. Making sure the client understands expectations for client participation: This is about ensuring clarity of expectations rather than honoring the client's right to self-determination.

A. Encourage visitors throughout the day. B. Provide the client with earplugs. C. Spread client care activities throughout the shift. D. Keep the door to the client's room open.

Correct Answer is B

Explanation

A. Encourage visitors throughout the day: Increased visitor interactions may worsen sensory overload by adding more stimuli.

B. Provide the client with earplugs. Earplugs help reduce environmental noise and sensory input, addressing the client's sensory overload and promoting rest and comfort.

C. Spread client care activities throughout the shift: Consolidating care activities, rather than spreading them out, minimizes interruptions and helps reduce sensory input.

D. Keep the door to the client's room open: Keeping the door open can increase noise and stimuli, exacerbating sensory overload.

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A 49-year-old patient who reports pain in the foot that moves up along the calf says, "My left foot feels like it is on fire." The patient reports that the pain started yesterday, and they have no prior history of injury or falls. Which components of pain assessment has the patient reported?

Nursing Test Bank

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