Med Surg 1, Exam 1: Ch. 8 - Pain

1. A patient with chronic pain who has been receiving morphine sulfate 20 mg IV over 24 hours is to be discharged home on oral sustained-release morphine (MS Contin) administered twice a day. What dosage of MS Contin will be needed for each dose to obtain an equianalgesic dose for the patient? (Morphine sulfate 10 mg IV is equianalgesic to morphine sulfate 30 mg orally.)

MS Contin 30 mg/dose Morphine sulfate 20 mg IV over 24 hours will be equianalgesic to MS Contin 60 mg in 24 hours. Because the total dose needs to be divided into two doses, each dose should be 30 mg.

5. A patient with chronic back pain has learned to control the pain with the use of imagery and hypnosis. The patient's spouse asks the nurse how these techniques work. Which response by the nurse is accurate? a. "The strategies work by affecting the perception of pain." b. "These techniques block the pain pathways of the nerves." c. "These strategies prevent transmission of stimuli from the back to the brain." d. "The therapies slow the release of chemicals in the spinal cord that cause pain."

a. "The strategies work by affecting the perception of pain." Cognitive therapies affect the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn.

18. A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic arthritic joint pain after a traumatic injury reports nausea and abdominal fullness. Which action should the nurse take initially? a. Administer the ordered antiemetic medication. b. Order the patient a clear liquid diet until the nausea decreases. c. Tell the patient that the nausea should subside in about a week. d. Consult with the health care provider about using a different opioid.

a. Administer the ordered antiemetic medication. Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics usually are prescribed to treat this expected side effect. The best choice would be to administer the antiemetic medication so the patient can eat

2. A nurse assesses a postoperative patient 2 days after chest surgery. What findings indicate that the patient requires better pain management? (Select all that apply) a. Confusion b. Hypoglycemia c. Poor cough effort d. Shallow breathing e. Elevated temperature

a. Confusion c. Poor cough effort d. Shallow breathing e. Elevated temperature Inadequate pain control can decrease tidal volume and cough effort, leading to complications such as pneumonia with increases in temperature. Poor pain control may lead to confusion through a variety of mechanism, including hypoventilation and poor sleep quality. Stressors such as pain cause increased release of corticosteroids that can result in hyperglycemia.

21. A patient who is using both a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? a. Remove the fentanyl patch. b. Obtain complete vital signs. c. Notify the health care provider. d. Administer prescribed PRN naloxone.

a. Remove the fentanyl patch. The assessment data indicate a possible overdose of opioid. The first action should be to remove the patch.

14. A patient with cancer asks the nurse to administer the prescribed hydrocodone tablets, but the patient who uses a fentanyl (Duragesic) patch for chronic abdominal pain caused by ovarian cancer, is asleep when the nurse returns with the medication. Which action is best for the nurse to take? a. Wake the patient and administer the hydrocodone. b. Suggest the use of nondrug therapies for pain relief. c. Wait until the patient wakes up and reassess the pain. d. Consult with the health care provider about the fentanyl dose.

a. Wake the patient and administer the hydrocodone. Because patients with chronic pain frequently use withdrawal and decreased activity as coping mechanisms for pain, sleep is not an indicator that the patient is pain free

1. Which question asked by the nurse will give the most information about the patient's metastatic bone cancer pain? a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How often do you take pain medication?" d. "How much medication do you take for the pain?"

b. "How would you describe your pain?"

13. The nurse is caring for a patient who has diabetes and reports chronic, burning leg pain even when taking oxycodone (OxyContin) twice daily. Which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain? a. Aspirin b. Amitriptyline c. Celecoxib (Celebrex) d. Acetaminophen (Tylenol)

b. Amitriptyline (Elavil) The patient's pain symptoms are consistent with neuropathic (nerve) pain and the tricyclic antidepressants are effective for treating this type of pain.

8. A patient with a deep partial thickness burn has been receiving hydromorphone through patient-controlled analgesia (PCA) for 1 week. The nurse caring for the patient during the previous shift reports that the patient wakes up frequently during the night reporting pain. What action by the nurse is appropriate? a. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. Consult with the health care provider about using a different treatment protocol to control the patient's pain. c. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

b. Consult with the health care provider about using a different treatment protocol to control the patient's pain. PCAs are best for controlling acute pain. This patient's history indicates a need for a pain management plan that will provide adequate analgesia while the patient is sleeping.

20. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? a. Check the skin under the heating pad. b. Count the respiratory rate every 2 hours. c. Ask the patient whether pain control is effective. d. Monitor sedation using the sedation assessment scale

b. Count the respiratory rate every 2 hours. Obtaining the respiratory rate is included in UAP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice.

1. The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids before. Which nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.) a. Assess for signs that the patient is becoming addicted to the opioid. b. Monitor for therapeutic and adverse effects of opioid administration. c. Emphasize that the risk of some opioid side effects increases over time. d. Teach the patient about how analgesics improve postoperative activity levels. e. Provide instructions on decreasing opioid doses by the second postoperative day.

b. Monitor for therapeutic and adverse effects of opioid administration. d. Teach the patient about how analgesics improve postoperative activity levels. Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain.

17. A patient who has fibromyalgia reports pain at level 7 (0 to 10 scale). The patient tells the nurse, "I feel depressed because I ache too much to play golf." Which patient goal has the highest priority when the nurse is developing the treatment plan? a. The patient will report pain at a level 2 of 10. b. The patient will be able to play a round of golf. c. The patient will exhibit fewer signs of depression. d. The patient will say that the aching has decreased.

b. The patient will be able to play a round of golf. For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment

10. The nurse assesses that a home hospice patient with terminal cancer who reports severe pain has a respiratory rate of 11 breaths/min. Which action should the nurse take? a. Tell the patient that increasing the morphine will cause the respiratory drive to fail. b. Titrate the prescribed morphine dose up until the patient indicates adequate pain relief. c. Inform the patient that more morphine can be given if the respiratory rate is at least 12. d. Administer a nonsteroidal antiinflammatory drug (NSAID) to improve patient pain control.

b. Titrate the prescribed morphine dose up until the patient indicates adequate pain relief. The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression.

4. A nurse assesses a patient with chronic cancer pain who is receiving imipramine (Tofranil) in addition to long-acting morphine (MS Contin). Which statement, if made by the patient, indicates to the nurse that the patient is receiving adequate pain control? a. "I'm not anxious during the day." b. "Every night I get 8 hours of sleep." c. "I can accomplish activities without much discomfort." d. "I feel less depressed since I've been taking the Tofranil."

c. "I can accomplish activities without much discomfort." Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication is also prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level

3. 1. The nurse teaches a student nurse about the action of ibuprofen. Which statement, if made by the student, indicates that teaching was effective? a. "The drug decreases pain impulses in the spinal cord." b. "The drug decreases sensitivity of the brain to painful stimuli." c. "The drug decreases production of pain-sensitizing chemicals." d. "The drug decreases the modulating effect of descending nerves."

c. "The drug decreases production of pain-sensitizing chemicals." NSAIDs provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury

22. The nurse reviews the medication orders for an older patient with arthritis in both hips who reports level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse offer as initial therapy? a. Naproxen 200 mg orally b. Oxycodone 5 mg orally c. Acetaminophen 650 mg orally d. Aspirin (acetylsalicylic acid) 650 mg orally

c. Acetaminophen 650 mg orally Acetaminophen is the best first-choice medication. The principle of "start low, go slow" is used to guide therapy when treating older adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased

19. A patient with terminal cancer-related pain and a history of opioid abuse reports breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? a. Use distraction by talking about things the patient enjoys. b. Suggest the use of alternative therapies such as heat or cold. c. Administer the prescribed PRN immediate-acting morphine. d. Consult with the doctor about increasing the MS Contin dose.

c. Administer the prescribed PRN immediate-acting morphine. The patient's pain requires rapid treatment, and the nurse should administer the immediate-acting morphine

9. A patient receiving epidural morphine has not voided for over 10 hours. What action should the nurse take first? a. Place an indwelling urinary catheter. b. Monitor for signs of narcotic overdose. c. Ask if the patient feels the need to void. d. Encourage the patient to drink more fluids.

c. Ask if the patient feels the need to void. Urinary retention is a common side effect of epidural opioids. Assess whether the patient feels the need to void.

16. A patient who had abdominal surgery yesterday is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority? a. Assessing for nausea b. Auscultating bowel sounds c. Checking the respiratory rate d. Evaluating for sacral redness

c. Checking the respiratory rate The patient's respiratory rate is the highest priority of care while using PCA medication because of the possible respiratory depression. The other areas also require assessment but do not reflect immediately life-threatening complications

12. Which medication should the nurse administer for a patient with cancer who describes the pain as "deep, aching and at a level 8 on a 0 to 10 scale"? a. Ketorolac tablets b. Fentanyl (Duragesic) patch c. Hydromorphone (Dilaudid) IV d. Acetaminophen (Tylenol) suppository

c. Hydromorphone (Dilaudid) IV The patient's pain level indicates that a rapidly acting medication such as an IV opioid is needed.

6. A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is appropriate for treating this change in assessment? a. Administer lorazepam (Ativan) 1 mg orally. b. Give ibuprofen 400 to 800 mg orally. c. Offer immediate-release morphine 30 mg orally. d. Suggest the patient take amitriptyline 10 mg orally.

c. Offer immediate-release morphine 30 mg orally. The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine.

23. The nurse on a surgical inpatient unit is caring for several patients. Which patient should the nurse assess first? a. Patient with postoperative pain who received morphine sulfate IV 15 minutes ago. b. Patient who received hydromorphone (Dilaudid) 1 hour ago and is currently asleep c. Patient who was treated for pain just prior to return from the postanesthesia care unit. d. Patient with neuropathic pain who is scheduled to receive a dose of hydrocodone (Lortab) now.

c. Patient who was treated for pain just prior to return from the postanesthesia care unit. The risk for oversedation is greatest in the first 4 hours after transfer from the postanesthesia care unit. Patients should be reassessed 30 minutes after receiving IV opioids for pain. A scheduled oral medication does not need to be administered exactly at the scheduled time. A patient who falls asleep after pain medication can be allowed to rest.

15. The health care provider has prescribed the following medications for a middle-aged patient who uses long-acting morphine (MS Contin) for chronic back pain but still has ongoing pain. Which medication should the nurse question? a. Morphine b. Dexamethasone c. Pentazocine (Talwin) d. Celecoxib (Celebrex)

c. Pentazocine (Talwin) Opioid agonist-antagonists can precipitate withdrawal if used in a patient who is physically dependent on mu agonist drugs such as morphine. The other medications are appropriate for chronic back pain.

7. A patient with chronic neck pain is seen in the clinic for follow-up. To evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Has there been a change in pain location?" b. "Can you describe the quality of your pain?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does pain keep you from activities that you enjoy?"

d. "Does pain keep you from activities that you enjoy?" The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions are also appropriate to ask, but information about patient function is more useful in evaluating effectiveness.

2. A patient who has had good control for chronic pain using a fentanyl (Duragesic) patch reports rapid onset pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." How will the nurse document the type of pain reported by this patient? a. Somatic pain b. Referred pain c. Neuropathic pain d. Breakthrough pain

d. Breakthrough pain Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain

11. The nurse is completing the medication reconciliation form for a patient admitted with chronic cancer pain. Which medication is of most concern to the nurse? a. Amitriptyline 50 mg at bedtime b. Ibuprofen 800 mg 3 times daily c. Oxycodone (OxyContin) 80 mg twice daily d. Meperidine (Demerol) 25 mg every 4 hours

d. Meperidine (Demerol) 25 mg every 4 hours Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods