MedSurg PrepU Chapter 13

A nurse is employed at a healthcare facility with a recent influx of many clients from a particular culture. The nurse is presenting information about the effect of one's culture on pain perception to a group of unlicensed assistive personnel (UAP). The nurse evaluates that the students need reteaching when one of them states

"A client from this culture always exaggerates his or her pain." Nurses should not stereotype clients based on culture by believing that those from a specific culture will exhibit more or less pain. Clients do learn from others how to respond to pain. Factors, such as age and gender, may explain differences about pain perception among cultural groups. The nurse needs to recognize that his or her values differ from those of other cultures.

A clinic nurse assesses a client with diabetes who reports taking naproxen (Aleve) and the herb bilberry for osteoarthtitis. To assess for an adverse reaction between naproxen and bilberry, the nurse asks the client

"Do you bleed easily?" Naproxen, a nonsteroidal anti-inflammatory drug, with the herb bilberry may enhance a client's risk for bleeding. Diarrhea, constipation, or both are frequent adverse reactions to naproxen but not bilberry. Bilberry may cause hypoglycemia. Naproxen does not. There should not be an increased level of pain as a result of the interaction of naproxen and bilberry.

When receiving epidural opioids, respiratory depression generally peaks within which time frame?

6 to 12 hours Respiratory depression generally peaks 6 to 12 hours after epidural opioids are administered, but it can occur earlier or up to 24 hours after the first injection

A patient has been prescribed a Fentanyl patch for pain control. The nurse understands that this patch should be replaced every:

72 hours. Fentanyl patches should be replaced every 72 hours. The other timeframes are incorrect.

When caring for a patient who is deaf, which of the following should be used to elicit information regarding the patient's level of pain?

An outside interpreter should be used. For people who are deaf of hard of hearing, outside interpreters (ie, not family members) should be used. For people with disabilities that result in communication impairment, computer-generated speech may be useful. For people who are blind and who know how to read Braille, pain assessment instruments can be obtained in Braille. The patient is deaf, so verbally asking to rate the pain on a scale would be inappropriate.

A client is recovering from abdominal surgery. The statement by the client that most indicates the nurse needs to educate the client about pain and pain control is

"I should expect to have pain." The nurse needs to educate the client about common concerns and misconceptions about pain and pain control. Clients may experience pain after surgery. However, medication is prescribed to control the pain, and there are interventions by the nurse to assist in alleviating the pain. This is what the nurse needs to educate the client about. The other options are positive statements by the client and true statements about pain and pain control.

A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the client

"Only you are to push the button for medication." With a PCA machine, clients control the administration of their pain medication within prescribed parameters. Family members or other visitors should not push the button on the PCA machine for the client; doing so overrides the safety features of the machine. Clients may become frustrated if pushing the button frequently does not result in pain relief. The nurse needs to instruct the client about time limits. Other instructions include not waiting until the pain is severe before pushing the button and that the PCA machine is used to control pain.

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. The best statement by the nurse is

"Please explain why you say you do not hurt when I see you grimacing during the dressing change." The nurse needs to explore the reason a client denies pain when pain is expected during a treatment, as with a dressing change to burns, and when the client grimaces during the dressing change. The nurse needs to educate clients about effects of pain on recovery. The nurse also cannot ignore that pain relief will hasten recovery. The nurse should not allow the client to associate pain with his dressing changes.

A client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies

"What do you mean by the word sick?" Nausea may occur with opiod use; however, before taking any other action, the nurse needs to clarify that this is what the client means by the word "sick."

A physician orders morphine sulfate 1 mg IV stat for chest pain. The drug is available in 2 mg per 1 mL syringe. How many mL does the nurse administer? Enter the correct number ONLY.

0.5 The dose ordered is 1 mg. The dose available is 2 mg. The quantity is 1 mL. 1 mg/2 mg x 1 mL = 0.5 mL.

A nurse is caring for a patient diagnosed with depression in the mental health unit. The nurse understands that therapeutic effects of tricyclic antidepressants occur at which timeframe?

3 weeks Patients need to know that a therapeutic effect may not take effect until they have taken the medication for 3 weeks. The other timeframes are incorrect.

Which of the following assessment tools will be most effective when assessing for pain in a two-year-old client?

A FACES scale FACES scales are best for assessing pain in very young clients because these scales use pictures and short descriptive phrases. Although a numeric scale, a word scale, or a linear scale may be used, a child may find them difficult to understand.

Which of the following is a disadvantage of using the transdermal route of opioid administration?

A delay in effect until the dermal layer is saturated A disadvantage of using the transdermal route of administration is that there is a delay in effect when the dermal layer is saturated. Advantages include a consistent opioid serum level, slightly less constipation than with oral opioids, and less cost as compared to the parenteral route

The nurse is assessing a client who has been taking up to 4 grams of acetaminophen (Tylenol) every day for undiagnosed pain. Upon questioning, the client reports he also takes kava-kava for pain. To check for a reaction due to ingestion of acetaminophen and kava-kava, the nurse asks the client about

Abrupt onset of rash and pruritus The use of acetaminophen and kava-kava increases the risk of hepatotoxicity. Initial signs and symptoms of a drug-induced hepatitis include an abrupt onset of a rash and pruritus. Initial effects would not include excessive clotting of blood, shortness of breath, or sensitivity to hot and cold temperatures.

Acute pain can be distinguished from chronic pain by assessing which characteristic?

Acute pain is specific and localized. Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury.

A patient is being treated in a substance abuse unit of a local hospital. The nurse understands that when a patient has compulsive behavior to use a drug for its psychic effect, the patient needs to be monitored for which of the following?

Addiction Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a person who has been taking opioids becomes less sensitive to their analgesic properties

A patient is being treated in a substance abuse unit of a local hospital. The nurse understands that when a patient has compulsive behavior to use a drug for its psychic effect, the patient needs to be monitored for which of the following?

Addiction Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a person who has been taking opioids becomes less sensitive to their analgesic properties.

A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain?

Administer analgesics around the clock. Because assessing pain medication needs in a client with end-stage dementia is difficult, analgesics should be administered around the clock. Clients at this stage of dementia typically can't request oral pain medications when needed. They're also unable to use patient-controlled analgesia devices. Transdermal patches are used to manage chronic pain; not postoperative pain.

A client who is prescribed morphine for undiagnosed abdominal pain reports that he is allergic to morphine. The nurse questions the client about his allegic reaction; the client responds that when he took it in the past, he experienced itching. The nurse plans to

Administer prescribed diphenhydramine (Benadryl). Pruritus or itching is a frequent side effect of morphine. It does not mean the client is allergic to morphine. Administering an antihistamine, such as diphenhydramine, may relieve the itching, and the client could still receive morphine. A skin cream would not be effective in minimizing the itching.

A client is postoperative and has not taken her pain medication. The nurse is performing an assessment at the beginning of her shift and determines that sensitization has occurred. The first nursing intervention is to

Administer the prescribed intravenous opioid. Sensitization occurs when the client waits too long to report pain and the pain is so intense that it is difficult to relieve. The first action of the nurse is to relieve the client's pain through administration of the prescribed intravenous opioid. Then the nurse can provide other alternative measures for pain relief. Once the pain is relieved, the nurse can educate the client about notifying the nurse when pain occurs. Naloxone is administered for opioid-induced respiratory depression. It is not needed in this client's situation.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?

Administering the analgesics every three hours Scheduling the administration of analgesics every three hours, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician.

Carbamazepine (Tegretol) is an example of which medication classification used in analgesia?

Anticonvulsant Tegretol is an anticonvulsant.

Which of the following should the nurse recommend to a client with a bruised ankle to initially relieve pain associated with the injury and reduce localized swelling?

Applications of heat and cold Pain associated with injury is best treated initially with applications of heat and cold. The cold reduces localized swelling and decreases vasodilation, which may alleviate minor or moderate pain. Although acupuncture may relieve the pain, it is not permanent and it may not reduce the swelling. PENS and TENS are used for managing acute and chronic pain such as pain caused by the spread of cancer to bones.

A female client with sickle-cell disease is hospitalized for pain management. The client's BUN is 24 mg/dL and creatinine is 1.6 mg/dL. To assist with management of the pain, the nurse

Applies warm soaks to the extremities Warm soaks may help to alleviate pain in the client with sickle-cell disease. Meperidine is not recommended in clients experiencing renal dysfunction. This client's renal studies show some dysfunction. Cold will cause the blood cells to lump even more and constrict blood vessels, increasing pain. Lowering the extremity to a dependent position will encourage blood to pool, particularly in the joints, increasing pain.

A client recovering from hip surgery is receiving morphine through a patient-controlled analgesia (PCA) machine with a set basal rate. It is most important for the nurse to

Assess the client's respiratory status. A basal rate is a continuous infusion of the medication. Assessment of the client's respiratory status is a major nursing responsibility and the most important one listed per Maslow's hierarchy of needs. The nurse will instruct the client about bolus doses for increased pain or painful activities and assess pain status. There is no information in the stem of the question to support the need for consent for PCA by proxy.

A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to

Assess the reason for the client's anxiety. Following the steps of the nursing process, the nurse needs to assess the reason for the client's anxiety. The client could be anxious about impending surgery, an unattended pet, a sick family member, etc. Then, the nurse intervenes appropriately by obtaining the assistance the client may need or administering anti-anxiety medication. The question is asking about treatment for anxiety. Pain medication should not be administered for anxiety. The nurse will not assist the client to a chair, because the client is on bedrest and in Buck's traction.

The client is prescribed 2 mg of intravenous morphine every 2 hours as needed for pain. The nurse administers the medication. Thirty minutes later, the client reports the pain level remains at a "6" on a pain intensity scale of 0 to 10. The nurse first

Assesses the client's mental status and vital signs The nurse is to reassess the client after administration of a medication for pain. Reassessment includes a pain rating scale, mental status, and vital signs. If the reassessment of the client demonstrates the client is alert, has satisfactory vital signs, and reports unrelieved pain, the nurse then consults with the physician. The listed statement of the nurse is nontherapeutic. It is not appropriate to teach the client about guided imagery or distraction when the client has pain. It should be done prior to pain onset.

The client takes naproxen (Aleve) for arthritic pain and is now prescribed warfarin (Coumadin) for persistent atrial fibrillation. Due to the interactions of the medications, the nurse

Assesses the client's stool for color Clients who take NSAIDs, such as naproxen, with warfarin may experience gastrointestinal bleeding. The nurse will need to monitor for this. Clients are to ingest a consistent level of vitamin K. Administering the medications with food does not increase absorption. Ingesting food with the medications may decrease gastrointestinal upset. Clients are instructed to not ingest alcohol.

A patient who has bone cancer has a new order for a Fentanyl patch. She has previously been receiving morphine for pain. When administering a Fentanyl patch, the last dose of sustained-release morphine should be administered:

At the same time the first patch is applied Because it takes 12 to 24 hours for the Fentanyl levels to gradually increase from the first patch, the last dose of sustained-release morphine should be administered at the same time the first patch is applied. The other time frames are incorrect.

The client, newly admitted to the hospital, has a list of home medications, which includes a transdermal fentanyl patch. It is most important for the nurse to

Check the dose. The dosage of any medication should be checked for correctness. This is basic medication administration to prevent error. The nurse will also perform the other options listed.

Which of the following is a misconception about pain and analgesia?

Chronic pain is due to a psychological disturbance. There is a misconception that chronic pain is due to a psychological disturbance. There is no evidence that stress causes pain. It is rare for chronic pain patients to misrepresent their symptoms. The stress of managing chronic pain may lead to depression.

An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client?

Collaborate with the client about his or her goal for a level of pain relief. The nurse should collaborate with each client about his or her goal for a level of pain relief; this helps implement interventions for achieving the goal. The client's description of pain or need for pain relief should never doubted or minimized. The client need not refrain from self-administering analgesics; providing a client with equipment to self-administer analgesics promotes a more consistent level of pain relief. The nurse should also inform the client of available pain management techniques and incorporate any preferences or objections to interventions for pain management that the client may have when establishing a plan of care; using all forms of available pain management techniques is not necessary.

Which of the following nursing interventions contributes to achieving a client's goal for pain relief?

Collaborate with the client about his or her goal for a level of pain relief. The nurse should collaborate with each client about his or her goal for a level of pain relief; this helps implement interventions for achieving the goal. The client's description of pain or need for pain relief should never doubted or minimized. The client need not refrain from self-administering analgesics; providing a client with equipment to self-administer analgesics promotes a more consistent level of pain relief. The nurse should also inform the client of available pain management techniques and incorporate any preferences or objections to interventions for pain management that the client may have when establishing a plan of care; using all forms of available pain management techniques is not necessary.

When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose?

Confusion Patients should be informed about signs and symptoms of fentanyl overdose such as shallow or difficulty breathing, extreme sleepiness, confusion, sedation. Hyperalertness, hyperventilation, and insomnia would not occur.

A client receives hydromorphone 2 mg intravenously for report of postoperative pain. Fifteen minutes later, the nurse notes respirations are 6 breaths/minute and the client is nonresponsive. The nurse administers prescribed naloxone (Narcan). The next time the client reports pain, the best nursing action is:

Consult with the healthcare provider to reduce the dose. The nurse consults with the healthcare provider about reducing the dose of an opioid temporarily, because doing so may prevent deep sedation. The nurse assesses the client and administers the prescribed dose of an opioid. The nurse does not withhold or change the prescribed dose of the medication unless client safety is immediately compromised. The nurse will ensure naloxone is available when an opioid is again administered to the client.

Which of the following nursing interventions should a nurse perform when caring for a patient who is prescribed opiate therapy for pain?

Do not administer if respirations are less than 12 per minute The nurse should not administer the prescribed opiate therapy if respirations are less than 12 per minute. The nurse should instruct a patient who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose level when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests

Which of the following is a required nursing intervention for a client receiving morphine sulfate?

Do not administer if respirations are less than 12/minute When respirations are less than 12/minute, the dose should be held as excessive opiate dosing can cause respiratory depression/suppression.

Reese Broderman, a 25-year-old male who is recovering from a motorcycle accident, is prescribed opiate pain medication to manage the pain from his accident and subsequent surgical repair. What nursing action should be taken when opiate analgesics are prescribed?

Do not administer if respirations are less than 12/minute When respirations are less than 12/minute, the dose should be held as excessive opiate dosing can cause respiratory depression/suppression.

The client is scheduled for surgery. The nurse is reviewing with the client about postoperative pain management. The client states her goal after receiving treatment is "0." The first action of the nurse is to

Educate the client that this goal may not be achievable. The client's goal of complete elimination of pain may be unrealistic. The nurse needs to first teach the client about setting an achievable goal. The nurse will plan to use a combination of pharmacologic and nonpharmacologic interventions for pain relief. The nurse may need to notify the surgeon of the client's goal of "0" for pain relief. The nurse does not ensure large doses of opioids are prescribed for the client. Many factors go into the prescription of medication for pain relief, including the client's response to the medication.

Which substance reduces the transmission of pain?

Endorphins Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike neurotransmitters that are endogenous. Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

A client is admitted to your trauma unit after being the victim of an industrial accident. As her nurse, you need to carefully monitor her traumatic injuries. How often should you assess and document her pain?

Every time Suzanna's vital signs are assessed The nurse should check and document the client's pain every time the client's temperature, pulse, respirations, and blood pressure is assessed. The American Pain Society (APS) has proposed that pain assessment should be considered the fifth vital sign.

The nurse needs to carefully monitor a patient with traumatic injuries. How often should the nurse check and document the patient's pain?

Every time the patient's vital signs are assessed The nurse should check and document the patient's pain every time the patient's temperature, pulse, respirations, and blood pressure are assessed. The American Pain Society (APS) has proposed that pain assessment should be considered the fifth vital sign. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the patient. Pain should not be assessed only on admission and discharge of the patient.

A client has been using nonnarcotic analgesics daily over an extended period. Which of the following effects should the nurse carefully monitor for in this client?

Gastrointestinal bleeding Some nonnarcotic analgesics when used daily over an extended period may cause undesirable side effects such as gastrointestinal bleeding and hemorrhagic disorders. Use of analgesics does not increase the risk for developing cardiac disorders, urinary tract infections, or hypothyroidism.

When taking a patient history, the nurse notes that the patient is taking herbal remedies in addition to acetaminophen. Which herb, when taken in conjunction with acetaminophen, enhances the risk of bleeding?

Gingko Gingko when taken with acetaminophen enhances the bleeding risk. Echinacea, willow, and kava when taken with acetaminophen increase the potential for hepatotoxicity and nephrotoxicity.

Prostaglandins are chemical substances with which of the following properties?

Increased sensitivity of pain receptors Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

The nurse understands that which of the following physiologic changes that influence the pain response occur in the gerontologic population?

Increased sensitivity to medications The older population experiences increased sensitivity to medication and increased risk for drug toxicity. They tend to have higher blood level of medications due to a slower metabolism. In this population, there is also an increased use of prescription and OTC medications.

About which of the following issues should the nurse inform patients who use pain medications on a regular basis?

Inform the primary health care provider about the use of salicylates before any procedure, and avoid OTC analgesics consistently without consulting a physician Patients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the patient to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Patients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

A client is recovering from abdominal surgery and sleeping. The client had received an opioid medication 3 hours ago. The client's son requests pain medication for the client, stating "I do not want her to wake up in pain." The first nursing action is

Instruct the son about lack of client consent. One of the client's rights is to participate in management of his or her own care. The nurse follows the nursing process by assessing the client's perception of pain but does not awaken the client to do this. The nurse can administer the pain medication only after assessment. The nurse does not administer the pain medication but does take the opportunity to educate the son.

A patient is being seen in the ER following a motor vehicle accident (MVA). He is having severe back pain. The preferred route of administration of medication in the most acute care situations is which of the following routes?

Intravenous The IV route is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and reliably. Epidural administration is used to control postoperative and chronic pain. Subcutaneous administration results in slow absorption of medication. Intramuscular administration of medication is absorbed more slowly than intravenously administered medication.

The preferred route of administration of medication in the most acute care situations is through which of the following routes?

Intravenous The IV route is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and reliably. Epidural administration is used to control postoperative and chronic pain. Subcutaneous administration results in slow absorption of medication. Intramuscular administration of medication is absorbed more slowly than intravenously administered medication.

A patient is complaining of a headache during epidural administration of an anesthetic agent. Which of the following nursing interventions should be completed?

Keep the head of the bed flat. If a headache develops, the patient should remain flat in bed, should be given large amounts of fluids (provided the medication condition allows), and the physician should be notified.

Which medication should be readily available for patients receiving epidural opioids who are experiencing respiratory depression?

Naloxone Opioid antagonist agents such as naloxone must be available for IV use if respiratory depression occurs. Diphenhydramine is used for opioid induced pruritus. Aspirin and ibuprofen would not be used.

An 82-year-old client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. He is without breakthrough pain at this point in time. How would his pain be classified?

Neuropathic and chronic When classified according to its source, pain can be categorized as either nociceptive or neuropathic. When classified according to its onset, intensity, and duration, pain can be categorized as either acute or chronic. Since he is without breakthrough pain at this time, he has no acute pain

Which of the following is important when addressing client pain?

Never doubt the need for pain relief. Healthcare workers should never doubt the client's need for pain relief. Scheduling the administration of analgesics every three hours, rather than on an as-needed basis, often affords a uniform level of pain relief. Providing a client with equipment to self-administer analgesics, as with the patient-controlled analgesia pump, also promotes a more consistent level of pain relief. Alternative therapies may be used.

Owen Li, a 59-year-old male, has returned from his hip repair surgery with a PCA to effectively control his post-op pain. What extra steps must you take to ensure he doesn't overdose on narcotic analgesia?

None Patient-controlled analgesia (PCA) allows clients to self-administer their own narcotic analgesic by means of an intravenous pump system. The client infuses the drug by pressing a hand-held button. The dose and time intervals between doses are programmed into the device to prevent accidental overdosage.

Which of the following pain assessment tools is most commonly used in adults?

Numeric scale A numeric scale is commonly used when assessing adults. Children as young as three years of age can use a FACES scale.

A client is reporting her pain as "8" on a 0-to-10 pain intensity scale. Then, the client states the pain is "3." Before the nurse leaves the room, the client states her pain is "6." The best action of the nurse is to

Obtain a pain scale with faces for the client to measure her pain. Various scales are helpful to clients trying to describe pain intensity. If the client cannot use one scale, such as the numeric pain intensity scale, the nurse uses another pain intensity scale that the client finds easy to understand and use. The nurse does not average the numbers, medicate based on the highest number, nor record each of the numbers the client stated.

Which intervention is appropriate for a nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?

Obtaining baseline vital signs before administering the first dose The nurse should obtain the client's baseline blood pressure and pulse and respiratory rates before administering the initial dose and then continue to monitor vital signs throughout therapy. A naloxone challenge test may be administered before using an opioid antagonist, not an opioid agonist. The nurse shouldn't discontinue an opioid agonist abruptly because withdrawal symptoms may occur. Morphine commonly is used as a continuous infusion in clients with severe pain regardless of the ability to tolerate fluids.

What term refers to the time the pain began?

Onset Onset is the time the pain began. Duration is the time span of the pain. Intensity is the magnitude of the pain. Quality is the sensory experience and the degree of suffering.

Which of the following is a physiologic response to pain?

Pallor Physiologic responses to pain include pallor, tachycardia, diaphoresis, and hypertension.

Which phase of pain transmission occurs when the brain experiences pain at a conscious level?

Perception Perception is the phase of impulse transmission during which the brain experiences pain at a conscious level, but many concomitant neural activities occur almost simultaneously. Transmission is the phase during which peripheral nerve fibers from synapses with neurons in the spinal cord. Modulation is the last phase of pain impulse transmission, during which the brain interacts with the spinal nerves in a downward fashion to alter the pain experience. Transduction is the conversion of chemical information in the cellular environment to electrical impulses that move toward the spinal cord

Which of the following is a true statement regarding placebos?

Placebos should never be used to test the person's truthfulness about pain. Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. The American Society for Pain Management Nurses (2009) contends that placebos should not be used to assess or manage pain in any patient, regardless of age or diagnosis. Reduction in pain as a response to placebo should never be interpreted as an indication that the person's pain is not real.

Which of the following, approved by the U.S. Food and Drug Administration, is the only use for lidocaine 5% (Lidoderm) patch?

Postherpetic neuralgia A lidocaine 5% (Lidoderm) patch has been shown to be effective in postherpetic neuralgia. Lidoderm has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.

Which of the following, approved by the United States Food and Drug Administration, is the only use for lidocaine 5% patch (Lidoderm)?

Postherpetic neuralgia A lidocaine 5% (Lidoderm) patch has been shown to be effective in postherpetic neuralgia. Lidoderm has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.

An older adult has been medicated with an oral opioid for postoperative pain. To make the pain medication more effective, the nurse first

Provides the client with a fresh gown and changes the bed linens Clients are usually more comfortable and pain relief measures are increased when physical needs are met. Nursing interventions would include providing a fresh gown, changing bed linens, placing the client in a more comfortable position, brushing teeth, and combing hair. Hydroxyzine may be given with opioid analgesics. However, elderly clients are more susceptible to adverse reactions of this medication, and other alternative measures should be tried first. A high Fowler's position in a chair may not be more comfortable. Ingesting food with an opioid medication does not make the medication more effective.

Which of the following is a gastrointestinal route of administration for analgesics?

Rectal A gastrointestinal route of administration of analgesics is the rectal route. The epidural space, oral mucosa, and subcutaneous sites are not related to the gastrointestinal route.

An elderly client has a fractured hip and is in Buck's traction. The client is disoriented and cannot express herself. At 0730 the client was calm. Now, at 0930, the client is restless and agitated. The nurse reviews the medication administration record. The last dose of opioid was at 0330. The nurse assesses the client's agitation may be from

Recurring pain Elderly clients may experience cognitive dysfunction, such as confusion and agitation, as a result of unrelieved pain. Once the pain is relieved, the cognitive dysfunction clears. The nurse needs to become astute in assessing the reason for agitation. Opioid medications are often incorrectly attributed as causing cognitive dysfunction in elderly clients. No strong evidence states that being elderly contributes to diminished pain perception.

As a standard practice within the pain management group where you practice nursing, opioid analgesics are effective tools in managing pain. A significant demographic within the practice are older adults who suffer from chronic pain. What impact does their age have on their initial dosing?

Reduced dose A reduced dose of analgesics, especially opioid analgesics, may be prescribed for the older adult initially; the initial dose may be one-half to two-thirds the usual adult dose. Older adults experience a higher peak effect and longer duration of pain relief from an opioid. The risk of increased accumulation of narcotics, also increases potential for falls from sedation and changes in cognitive functioning.

The nurse is visiting a client at home with intractable cancer pain. The client has a transdermal fentanyl patch on her right chest area. It is most important for the nurse to

Remove the heating pad present on the chest area. A heating pad over the transdermal patch will increase release of the medication, exposing the client to an overdose. The nurse will also perform the other options listed.

The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to:

Remove the patch after 12 hours. The lidocaine 5% patch is applied for 12 hours daily and is approved for use with postherpetic neuralgia. The patch may be applied in various areas on the body

A new surgical patient has been prescribed an opioid analgesic intravenously for pain control. The nurse should be aware of which most serious adverse effect of this medication?

Respiratory depression Respiratory depression is the most serious adverse effect of opioid analgesic agents administered by IV, subcutaneous, or epidural routes. The other side effects can occur with administration of opioids but are not the most serious.

Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?

Risk for impaired gas exchange Problems that may develop with opioid and opiate therapy include risk for impaired gas exchange related to respiratory depression, constipation related to slowed peristalsis, and risk for injury related to drowsiness and unsteady gait.

Which of the following is a heightened response seen after exposure to a noxious stimulus?

Sensitization Sensitization is a heightened response seen after exposure to a noxious stimulus. Pain tolerance is the maximum intensity or duration of pain that a person is willing to endure. Pain threshold is the point at which a stimulus is perceived as painful. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when opioids are discontinued

Which of the following is the appropriate intervention to avoid physical dependence on drugs in a client?

Short duration Disadvantages of using the IV route for analgesic administration include short duration, the occurrence of possible respiratory depression, and that careful dosage calculations are needed. Intramuscular analgesics have a slower entry into the bloodstream.

Which of the following is a true statement with regards to the preventative approach to the use of analgesics?

Smaller doses of medication are needed. Smaller doses of medication are needed with the preventative approach, because the pain does not escalate to a level of severe intensity. A preventative approach may result in the administration of less medication over a 24-hour period, helping prevent tolerance to analgesic agents and decreasing the severity of side effects. The preventative approach reduces the peaks and troughs in the serum level and provides more pain relief with fewer side effects.

Your grandmother suffers from osteoarthritis and is prescribed a scheduled dose of analgesics to manage her chronic pain. As she lives on a limited income, she frequently skips doses or takes half-doses to "make her medicine last longer". What client teaching would you perform to assure uniform pain management for your grandmother?

Take medication doses when ordered Pain management cannot be effective if medication is not consistently used. While nondrug interventions can be suggested, other resources can be utilized to assure your grandmother has an adequate supply of pain medication. Especially in chronic pain, medication doses should never be skipped or reduced without physician input.

A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client

That medication will be prescribed for pain relief Pain is expected postoperatively, and the client should be reassured that medication will be prescribed to relieve pain. The client may have less pain knowing that measures will be taken to reduce it. Diversional activities may be used in addition to analgesics. Anxiety about pain could increase the client's perception of pain. Another nursing activity is being an advocate for the client and notifying his surgeon of the client's fear.

A client reports abdominal pain as "8" on a pain intensity scale of 0-10 30 minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses

That the client's past experiences with pain may influence her perception of current pain Clients who have had previous experiences with pain are usually more frightened about subsequent painful events, as in the client who experienced partial-thickness burns to more than 60% of her body. The clients in these situations are less able to tolerate pain. Insufficient data in the stem support that the client is dependent on drugs or that this current pain is related to the client's previous burn injuries.

Which of the following is the only reliable source for quantifying pain?

The client The client is the only responsible source for quantifying pain. The nurse, the pain assessment tool, and the physician are not reliable sources to quantify pain

Which of the following is a reliable source for quantifying pain?

The client's description of the pain The client's description of the pain is the only reliable source for quantifying pain. Physiologic data such as vital signs or the extent or nature of the injury do not indicate the amount of pain

When completing a teaching plan for a patient receiving patient-controlled analgesia (PCA), which component would be importance to stress?

The pump will deliver a preset amount of medication. A patient experiencing pain can administer small amounts of medication directly into the IV, subcutaneous, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The patient should not wait until the pain is severe to push the button. Even if the patient pushes the button multiple times in rapid succession, no additional doses are released because of the preset lock-out time. Sedation can occur with the use of the PCA pump. Assessment of respiratory status remains a major nursing role.

Which of the following is a true statement with regards to the nursing process of pain control?

The use of physiologic signs to indicate pain is unreliable. Use of physiologic signs to indicate pain is unreliable. Although it is important to observe for any and all pain behaviors, the absence of these behaviors does not indicate an absence of pain. It is unwise to make judgments and formulate treatment plans based on behaviors that may or may not indicate pain. Not all patients exhibit the same behaviors, and there may be different meanings associated with the same behavior. Nonverbal and behavioral expressions of pain are not consistent or reliable indicators of the quality or intensity of pain, and they should not be used to determine the presence or severity of pain experienced

A 39-year-old client has been taking opioid analgesics for more than 2 weeks to control his post-surgical pain. While the surgeon is pleased with Louis's healing progress, he wants to change the analgesic to a non-opioid drug. He prescribes a gradually lower opioid dose and increasingly larger non-opioid drug doses. Why is the surgeon changing medications in this manner?

To avoid withdrawal symptoms To avoid withdrawal symptoms, drugs that are known to cause physical dependence are discontinued gradually. The dosage or the frequency of their administration is lowered over 1 week or longer.

A 34-year-old client who has undergone extensive fracture repair continues to request opioid pain medication with increasing frequency. Her initial surgeries occurred more than 1 month ago and you are concerned with her increasing requests. What would you expect to be the cause of her frequent appeals for pain medication?

Tolerance Tolerance is a condition in which a client needs larger doses of a drug to achieve the same effect as when first administered and may not develop until an opioid drug is used regularly for 4 weeks or more. The development of tolerance is not an indication of addiction; rather, the client's request for pain-relieving drugs more often is a consequence of poor pain control. The most appropriate nursing action is to consult with the physician regarding a need for an increased dose of the drug (by 25% - 50%), not reducing its dosage or frequency of administration.

The client is postoperative for a total hip arthroplasty and denies pain when asked by the nurse. The client remains still in the bed and refuses to move. She finally reports feeling pressure at the site upon continued questioning by the nurse. The best nursing intervention is to

Use the term "pressure" when asking the client about pain. It is best for the nurse to use the client's terminology when assessing pain. Though the nurse may want to medicate this client, the nurse can only choose from the options present, and medicating is not there. The nurse does not wait for the client to use the word pain. Information in the stem of the question indicates that the client is experiencing pain. The client may have difficulty using a pain scale, because the client denies pain. The nurse does not re-educate the client to use the word pain instead of pressure.

A client who speaks Korean only had emergency surgery. No pain scale was established prior to surgery. To assess the client's pain postoperatively, the nurse

Uses a language translation phone line If a client does not speak English, an interpreter should be consulted. Many healthcare facilities now contract to foreign language interpreting services via telephone. Family members should not be used for interpretation, because relatives may have difficulty translating accurately. These clients would most likely have difficulty using a numeric pain intensity scale or a visual analogues scale unless the words were written in the client's language.

In which case it is most likely that pain management may not be readily forthcoming to an adult patient who is in pain?

When the patient's expressions of pain are incongruent with the nurse's expectations If a patient's expressions of pain are incongruent with the nurse's expectations, pain management may not be readily forthcoming. A numeric scale is used when assessing adults and is not inappropriate. If analgesics are contraindicated for the patient's condition, several nondrug interventions can be used. The risk for improper management of pain does not increase specifically in the case of chronic pain.

Regarding tolerance and addiction, the nurse understands that

although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare. Addiction is rare and should never be the primary concern for a patient in pain.

The client experienced abdominal surgery the previous day and has just received an opioid medication for report of pain. The client is sitting in a chair next to the bed. An additional activity that the nurse uses to relieve pain is

encourage the client to watch television Distraction, such as watching television, helps relieve pain. Ice may be applied for 15 to 20 minutes at a time but may be uncomfortable when applied to the abdomen. Ambulating has other benefits for the client but may not relieve pain. The client should concentrate on breathing slowly in and out, not hold the breath.

The client is taking oxycodone (Oxycontin) for chronic back pain and reports decreased pain relief when he began taking a herb to improve his physical stamina. The nurse asks if the herb is

ginseng Ginseng may inhibit the analgesic effects of an opioid, such as oxycodone. The other herbs listed (valerian, kava-kava, and chamomile) may increase central nervous system depression.

A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends

increasing the amount of bran and fresh fruits and vegetables Constipation is a common problem with the use of opioid medications, such as methadone. Activities to prevent constipation include increasing bran and fresh fruits and vegetables in the diet. The client should ingest 8 to 10 glasses of fluids per day. Milk of magnesia may be used if no bowel movement is produced in 3 days. Milk of magnesia is not to be used daily. A glycerin suppository, not bisacodyl, may be used to make the bowel movement less painful.

When a person who has been taking opioids becomes less sensitive to the drug's analgesic properties, that person is said to have developed a (an)

tolerance. Tolerance is characterized by the need for increasing dose requirements to maintain the same level of pain relief. Addiction refers to a behavioral pattern of substance use characterized by a compulsion to take the drug primarily to experience its psychic effects. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Balanced analgesia occurs when the patient is using more than one form of analgesia concurrently to obtain more pain relief with fewer side effects.

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply

• "How long have you experienced this pain?" • "Please point to where you are experiencing pain." • "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." • "What aggravates your chest pain?" The nurse needs to assess pain as to intensity, timing, location, and aggravating factors. Assessing frequency is important, but the statement "You've never had this pain before, have you" is leading and nontherapeutic.

The nurse administered an analgesic to a client who was reporting pain. The medication is ordered as needed every 3 hours. Forty minutes later the client states he has had little relief. The nurse does all of the following:

• evaluates the pain level using the established pain scale • assesses respirations, pulse, and blood pressure • consults with the healthcare provider about the client's report The dose of the pain medication is ineffective in relieving the client's pain. The nurse evaluates client response using the same pain scale and vital signs. The nurse may need to consult with the healthcare provider and inform of the ineffectiveness of the medication. The nurse places the client in a position of comfort to enhance effectiveness of the medication now, not later. The nurse's statement delays appropriate treatment for the client.

The client has suffered an injury to his right leg and is reporting pain at the level of "5" on a scale of 0 to 10. The client has a history of peripheral arterial disease. The client requests nonpharmacologic interventions. The nurse does all of the following

• massages the client's back and shoulders • teaches the client to perform slow, rhythmic breathing • turns on the television to a show the client asks to watch Nonpharmacological interventions that promote comfort include a massage even to an unaffected area, relaxation techniques as in counted breathing, and distraction as in watching the television. Ice is not applied to an area with impaired circulation. Macrobiotic diet is an alternative therapy that may be harmful.