Pain Management PrepU - Ch. 35
A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing? A - somatic pain B - cutaneous pain C - referred pain D - visceral pain
D (Explanation: Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial. Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix.)
The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data? A - How would you rate the pain on a scale of 0 to 10? B - How would you describe your pain? C - How does the pain develop and progress? D - What do you do to alleviate your pain and how well does it work?
C (Explanation: When assessing the chronology of the client's pain, the nurse could ask the client how the pain develops and progresses. To assess the quality of the client's pain, the nurse could ask for the client to describe the pain. To assess the quantity of the pain, the client could be asked to rate the pain on a scale of 0 to 10. To assess the alleviating factor of the pain, the nurse could ask what the client does to alleviate the pain and how well it works.)
The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? A - confused to time and place B - right shoulder immobilizer in place C - rates pain an 8 on a 0 to 10 scale D - B/P 178/92 and pulse 118
A (Explanation: Clients must be cognitively and physically capable of using the PCA equipment safely. Confusion in a client would lead the nurse to question the client's ability to correctly use the PCA.)
The nurse is caring for four clients. Which client does the nurse identify as the most likely to have undertreated pain? Select all that apply. A - 34-year-old with schizophrenia B - 53-year-old with recurrent pancreatitis C - 29-year-old who has a speech impediment D - 60-year-old with early onset dementia E - 41-year-old who is from a different country F - 18-year-old with a broken ulna
A C D E (Explanation: Clients who are most likely to have underassessed and undertreated pain include infants; children younger than 7; culturally diverse clients; clients with mental challenges, dementia, hearing, or speech impairment; or those who experience psychological disturbances. The client with a broken ulna and the client with recurrent pancreatitis are not as likely to have undertreated pain.)
The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit? A - Lisinopril B - Furosemide C - Naloxone D - Digoxin
C (Explanation: The nurse should ensure that naloxone is readily available on the unit, as it can reverse the respiratory depressant effects of opioids. Naloxone is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids. Furosemide is a loop diuretic and used to treat hypertension (high blood pressure) and edema. Lisinopril is an angiotensin converting enzyme (ACE) inhibitor used for treating high blood pressure, heart failure and for preventing kidney failure due to high blood pressure and diabetes. Digoxin is used to treat congestive heart failure.)
The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment? A - Respiratory status, oxygen saturation, pain, and sedation level B - Temperature, pedal pulses, and assessment of cranial nerves C - Gastrointestinal status, bowel movements, and urine output D - Heart rate, capillary refill, bowel sounds and pedal pulses
A (Explanation: Respiratory status, oxygen saturation, pain, and sedation level are the best description of the priority of the hourly assessments for this client. The priority concern for this client is the risk of respiratory depression because of the use of analgesia; therefore, the priority assessments during the first 12 hours of epidural therapy include assessing the client's vital signs, respiratory status, pain status, sedation level, oxygen saturation at least once per hour during the first 12 hours of therapy. If there are no complications after 12 hours, the assessments should continue every 2 hours and then decrease per facility policy. Airway, breathing, and circulation are the top priorities in the care of any client, and in this client, breathing is a concern because of the risk of respiratory depression from the epidural analgesia. Although important, the other options do not best describe the priority assessments because the main concern, the risk of respiratory depression, is not the focus of the other options.)
A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client: A - in the postoperative stage with occasional pain. B - experiencing acute pain. C - experiencing chronic pain. D - in the early postoperative period.
A (Explanation: A PRN (as needed) medication would be most appropriate for a client in the postoperative stage with occasional pain. A client in the early postoperative period would benefit from the dosage of pain medication with around the clock dosing. A client experiencing chronic pain would benefit from the dosage of pain medication with around the clock dosing. A client experiencing acute pain would benefit from the dosage of pain medication with around the clock dosing.)
Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy? A - A chronic opioid therapy plan B - A walking aid C - Physical therapy referral D - Acupuncture
A (Explanation: Opioids are not contraindicated in older adults but are rarely used in chronic pain prior to nonpharmacologic measures.)
You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so? A - When obtaining patient vital signs B - Before the patient is discharged C - The first question you ask the patient D - At several points throughout your history-taking
A (Explanation: Pain should be addressed during your first encounter with the patient. However, you will probably want to start a professional conversation prior to addressing pain. Vital signs are often collected in the beginning of the patient visit. This would be the most appropriate time to address pain.)
The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data? A - How does the pain develop and progress? B - How would you describe your pain? C - How would you rate the pain on a scale of 0 to 10? D - What do you do to alleviate your pain and how well does it work?
A (Explanation: When assessing the chronology of the client's pain, the nurse could ask the client how the pain develops and progresses. To assess the quality of the client's pain, the nurse could ask for the client to describe the pain. To assess the quantity of the pain, the client could be asked to rate the pain on a scale of 0 to 10. To assess the alleviating factor of the pain, the nurse could ask what the client does to alleviate the pain and how well it works.)
A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse? A - "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." B - "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to prevent accidental dislodgement of the catheter." C - "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to decrease the risk of severe migraine headaches." D - "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to increase the effectiveness of the spinal analgesia."
A (Explanation: The rationale for keeping the head of the bed elevated 30 degrees is that this position helps to minimize the upward migration of the opioid in the spinal cord, thereby minimizing the risk of respiratory depression. The nurse does not keep the head of the bed elevated to decrease the risk of migraines as migraines are not a common problem with epidural analgesia. Positioning of the client does not increase the effectiveness of the medication. Positioning also does not prevent accidental dislodgement of the catheter; this is accomplished by a secure dressing and taping the tubing so that it is not pulled.)
A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory? A - administering backrub when client's head hurts B - asking client how sensory stimuli produces pain C - requesting health care provider to order the client's opioid medication D - removing items from the room that remind client of former spouse
A (Explanation: Administering a backrub reflects the Gate Control Theory. Asking the client how sensory stimuli produces pain reflects the Pattern Theory. Removing items that remind the client of a former spouse reflects the Neuromatrix Theory. Having the health care provide order the client's opioid medication reflects the endogenous opioid theory.)
When performing an assessment on a client with chronic pain, the nurse notes that the client frequently shifts conversational topics. What does the nurse determine this may indicate? A - anxiety B - boredom C - moodiness D - depression
A (Explanation: Clients in pain may experience anxiety, and the anxiety may also increase the perception of pain. Signs of anxiety include decreased attention span or ability to follow directions, asking frequent questions, shifting topics of conversation, and avoidance of discussion of feelings. Depression can elicit symptoms of insomnia or sleepiness. Boredom is a verbal expression of feeling unsatisfied by an activity or being uninterested in it. Moodiness describes minor daily mood changes that can elicit emotions of happiness and then sadness or vice versa.)
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort? A - Endorphins B - Serotonin C - Dopamine D - Melatonin
A (Explanation: Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that certain measures, such as skin stimulation and relaxation techniques, release endorphins. Serotonin is an important chemical and neurotransmitter in the human body. It is believed that serotonin helps regulate mood and social behavior, appetite and digestion, sleep, memory, and sexual desire and function. Melatonin is a hormone that is produced by the pineal gland in humans and animals and regulates sleep and wakefulness. Dopamine is a neurotransmitter that helps control the brain's reward and pleasure centers.)
A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action? A - Avoid massaging this area and report the finding to the health care provider. B - Massage the area in an attempt to restore adequate circulation. C - Gently massage the region, document the finding, and verbally report it to the health care provider. D - Avoid massaging the area and apply a thin layer of a topical antibiotic ointment.
A (Explanation: Nonblanching reddened areas should not be massaged and should be documented and reported to the client's health care provider. Antibiotic ointments are not applied to areas of possible skin breakdown.)
A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing: A - visceral pain. B - cutaneous pain. C - somatic pain. D - neuropathic pain.
A (Explanation: The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.)
The wife of a client with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the client is likely showing the effects of: A - tolerance. B - physical dependence. C - drug interactions. D - addiction.
A (Explanation: This client is likely developing drug tolerance, which occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief. This is not a pathologic finding and does not necessarily indicate physical dependence. Addiction is the fact or condition of being addicted to a particular substance, thing, or activity. A drug interaction is a reaction between two (or more) drugs or between a drug and a food or beverage. Tolerance does not indicate addiction or a heightened risk of addiction.)
The client is a new admission who reports lower right quadrant abdominal pain. The client is scheduled for an emergency appendectomy. What question(s) will the nurse ask the client in relation to the pain? Select all that apply. A - How would you describe the pain? B - How do you rate your pain on a scale of 0 to 10? C - What medication have you taken to relieve the pain? D - Does anything make the pain worse? E - When did your pain begin?
A B C D E (Explanation: All of these questions are appropriate for a pain assessment. They are part of a comprehensive pain assessment, which is to be performed on the client's admission to a clinical facility. The nurse wants to quantify the client's pain as well as wants to qualify the client's pain by asking for a description of the pain in the client's own words. The nurse asks about the onset, which is when the pain began. It is important to know what medications the client has taken for pain relief. For this client, it is extremely important, because the client is going for emergency surgery. These medications could affect the client's outcome for the surgery.)
A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? A - Increased respiratory rate B - Guarding of the chest area C - High blood pressure D - Decreased heart rate
B (Explanation: A person's behavioral response to pain can be demonstrated by protecting or guarding the painful area, grimacing, crying, or moaning. Increased blood pressure and respiratory rate are typical physiologic (sympathetic) responses to moderate pain. Decreased heart rate is a typical physiologic (parasympathetic) response to severe pain.)
A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action? A - Turn on the unit shortly before applying the electrodes to the client's skin. B - Start with the lowest intensity and gradually increase it to the appropriate level. C - Administer analgesia 30 minutes before beginning a TENS session. D - Disinfect with chlorhexidine the areas where the electrodes will be applied
B (Explanation: After applying the electrodes, the nurse should turn on the unit and adjust the intensity setting to the lowest intensity and determine if the client can feel a tingling, burning, or buzzing sensation. The nurse should then adjust the intensity to the prescribed amount or the setting most comfortable for the client. Skin should be clean before applying the electrodes, but it is unnecessary to use disinfectant. Analgesia may or may not be necessary before a TENS session.)
The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client? A - Administer opioid analgesics B - Use massage and heat application to the lower back C - Have the client perform active exercises to stretch the back muscles D - Encourage the client to have an epidural steroid injection
B (Explanation: The gate theory appears to explain why mechanical and electrical interventions or heat and pressure may provide effective pain relief. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Teaching self-management techniques that activate closing the gate may also minimize the experience of pain. Pain medication and epidural anesthesia are not a part of gate theory interventions. Stretches and active exercises may cause further injury to the client.)
A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action? A - Turn on the unit shortly before applying the electrodes to the client's skin. B - Start with the lowest intensity and gradually increase it to the appropriate level. C - Disinfect with chlorhexidine the areas where the electrodes will be applied D - Administer analgesia 30 minutes before beginning a TENS session.
B (Explanation: After applying the electrodes, the nurse should turn on the unit and adjust the intensity setting to the lowest intensity and determine if the client can feel a tingling, burning, or buzzing sensation. The nurse should then adjust the intensity to the prescribed amount or the setting most comfortable for the client. Skin should be clean before applying the electrodes, but it is unnecessary to use disinfectant. Analgesia may or may not be necessary before a TENS session.)
A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique? A - A nurse uses deep-breathing exercises to distract a client from his pain. B - A nurse applies intermittent heat and cold to a client's leg. C - A nurse guides a client to use imagery. D - A nurse distracts the client by playing his favorite music.
B (Explanation: Cutaneous stimulation is the intermittent application of heat or cold, or both. Heat accelerates the inflammatory response to promote healing, reduces muscle tension to promote relaxation, and helps to relieve muscle spasms and joint stiffness. Cold reduces muscle spasm, alters tissue sensitivity, and promotes comfort by slowing the transmission of pain stimuli. Distraction such as playing a client's favorite music, deep breathing exercises, and imagery are diversional activities that assist coping with the pain.)
A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? A - Epinephrine B - Naloxone C - Atropine D - Diphenhydramine
B (Explanation: Naloxone is an opioid antagonist that reverses the respiratory-depressant effect of an opioid. Diphenhydramine is an antihistamine mainly used to treat allergies. Atropine is a medication to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate and to decrease saliva production during surgery. It is typically given intravenously or by injection into a muscle. Epinephrine injection is used for emergency treatment of severe allergic reactions (including anaphylaxis) to insect bites or stings, medicines, foods, and other options but not for opioids.)
When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: A - ask the client's family if he ever uses pain medicines. B - actively solicit information about the client's pain level. C - assume the client does not need medication. D - document the client's lack of medication.
B (Explanation: Some cultures see pain tolerance as a virtue; often men are expected to tolerate pain more stoically than women do. Health care providers need to recognize the client's cultural beliefs and not impose their own judgments.)
The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care? A - Assessing for impaired urinary elimination B - Preventing constipation C - Observing for diarrhea D - Observing for bowel incontinence
B (Explanation: The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use. Urinary elimination and bowel incontinence are not affected by opioid use.)
The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention? A - Document what the client states. B - Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. C - Tell the healthcare provider that the client is unsure of the pain medication taken. D - Call the pharmacy to attempt to identify the pill.
B (Explanation: The priority nursing intervention is to ask the client for the original bottle that the drug was dispensed into from the pharmacy. This will provide the most accurate identification of the medication. Other interventions can subsequently be implemented.)
A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse? A - Tell the client he or she will have to wait for 1 hour. B - Assess for medication prescription for breakthrough pain. C - Assess the client for signs of opioid addiction. D - Administer the next dose of the pain medication.
B (Explanation: Breakthrough pain is a temporary flare-up of moderate to severe pain that occurs even when the client is taking pain medication around the clock. It can occur before the next dose of analgesic is due (end of dose pain). It is treated most effectively with supplemental doses of a short-acting opioid taken on an "as needed basis." Therefore, the nurse should check for a prescription for breakthrough pain medication. Telling the client that he or she has to wait is not a therapeutic action by the nurse. Administering the next dose of pain medication is a violation of nursing practice and does not follow the standard of care. The nurse needs to assess for the therapeutic effects of the pain medication and not opioid addiction.)
You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so? A - The first question you ask the patient B - When obtaining patient vital signs C - Before the patient is discharged D - At several points throughout your history-taking
B (Explanation: Pain should be addressed during your first encounter with the patient. However, you will probably want to start a professional conversation prior to addressing pain. Vital signs are often collected in the beginning of the patient visit. This would be the most appropriate time to address pain.)
The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply. A - Client is allowed to have one drink of alcohol each day. B - Keep a diary to record level of pain and time medication is taken. C - You must check with your primary care provider before breast-feeding your infant. D - You may smoke cigarettes during the day but not at night. E - For better absorption, take your pain medication on an empty stomach. F - Do not drive a vehicle while taking this medication.
B C F (Explanation: The nurse will provide instructions about the medication prescribed for pain relief. This medication is an opioid, and extra precautions are required. The client is not to drive a vehicle while taking an opioid due to slowed reflexes and decreased cognitive thinking. The client is not to breast-feed her infant without checking with her primary care provider. The opioid may be absorbed into the breast milk and fed to the infant, which may adversely affect the infant. The client is to keep a diary about her pain experiences, which includes level of pain and time the medication was taken. This provides a more accurate documentation of the pain experience and prevents overdosage from taking the medication too frequently. The client is not to drink alcohol. Alcohol will depress the central nervous system when taken with an opioid and may lead to respiratory failure. The client may smoke, but someone will need to be present (for safety reasons) since the client may fall asleep due to the opioid. It does not matter whether it is day or night. The medication is not better absorbed when taken on an empty stomach. The client takes the pain medication with food, since nausea is a frequent side effect when the opioid is taken on an empty stomach.)
The nurse is assessing the pain of a preschooler. Which pain scales would be appropriate for the nurse to utilize? (Select all that apply.) A - 0-10 Numeric Rating Scale B - COMFORT scale C - CRIES Pain Scale D - Wong-Baker Faces Scale E - FLACC Scale
B D E (Explanation: When assessing the pain of a preschooler, the nurse could choose from the following pain scales: COMFORT, FLACC, and Wong-Baker Faces. The CRIES pain scale is for neonates, and the 0-10 Numeric scale is for adults and children over 9 years old.)
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain? A - "How long have you experienced this pain?" B - "Could you please rate your pain on a 1-10 scale?" C - "Can you describe the type of pain you are having?" D - "When did your pain begin?"
C (Explanation: Asking the client to describe the pain establishes quality. Asking the client to rate pain on a 1-10 scale reflects intensity. Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset.)
While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant? A - FACES scale B - Apgar score C - FLACC scale D - Braden scale
C (Explanation: The FLACC scale (face, legs, activity, cry, and consolability) is used to measure pain for children between the ages of 2 months and 7 years. The Braden scale is used to predict pressure sore risk. The FACES scale is used to assess pain in older children using a series of faces, ranging from a happy face to a crying face. Apgar score is done at birth to assess how well the baby tolerated the birthing process.)
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse? A - Place the client in the supine position B - Begin CPR C - Administration of 0.4 mg of naloxone D - Administer a lower dose of the analgesic for the next dose
C (Explanation: The client is experiencing impending respiratory arrest due to the effect of the medication and this should be reversed immediately prior to arrest. This is the priority action and will correct the respiratory depression immediately. CPR is not indicated at this time, because the client is not in full arrest. Placing the client in the supine position may decrease respirations further.)
The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment? A - Gastrointestinal status, bowel movements, and urine output B - Heart rate, capillary refill, bowel sounds and pedal pulses C - Respiratory status, oxygen saturation, pain, and sedation level D - Temperature, pedal pulses, and assessment of cranial nerves
C (Explanation: Respiratory status, oxygen saturation, pain, and sedation level are the best description of the priority of the hourly assessments for this client. The priority concern for this client is the risk of respiratory depression because of the use of analgesia; therefore, the priority assessments during the first 12 hours of epidural therapy include assessing the client's vital signs, respiratory status, pain status, sedation level, oxygen saturation at least once per hour during the first 12 hours of therapy. If there are no complications after 12 hours, the assessments should continue every 2 hours and then decrease per facility policy. Airway, breathing, and circulation are the top priorities in the care of any client, and in this client, breathing is a concern because of the risk of respiratory depression from the epidural analgesia. Although important, the other options do not best describe the priority assessments because the main concern, the risk of respiratory depression, is not the focus of the other options.)
The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point? A - judging whether the client is in pain or is just depressed B - beginning pain medications before the pain is too severe C - reviewing and revising the pain management treatment plan D - administering a placebo and performing a reassessment of the pain
C (Explanation: The nurse's focal point should be on reviewing and revising the pain management treatment plan presently in place. The client is status-post bowel resection, so administering a placebo is not the correction option, and could be ethically wrong. The nurse would possibly do a depression assessment, but if the client is reporting constant pain, the pain management plan must be reviewed and revised. The question does not address if the client is taking pain medications, so the option addressing beginning pain medications before the pain is too severe is not correct.)
The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) A - Encourage the use of a sitter. B - Encourage increased protein. C - Encourage deep breathing. D - Play the client's favorite music. E - Promote a restful environment.
C D E (Explanation: Anxiety, lack of sleep, and muscle tension may all increase the client's perceived intensity of pain. Therefore, the client's plan of care should include measures to promote sleep and decrease anxiety and muscle tension. These include relaxation techniques, such as deep breathing, favorite music, and restful environment. Use of a sitter, someone to be paid to stay with the client in the room at all times, is not indicated and may cause the client's anxiety level to increase. Encouraging increased protein does not aid in the client's perceived intensity of pain.)
The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate? A - The nurse should expect slight resistance during the removal of the epidural catheter. B - If the client develops a headache, an opioid analgesic may be administered along with the epidural analgesia. C - If a client is experiencing adverse effects, a peripheral IV line should be inserted to allow immediate administration of emergency drugs, if warranted. D - The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.
D (Explanation: The anesthesiologist/pain management team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min or has unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache. No other medications should be administered; a peripheral IV line should already be in place. Resistance should not be felt when removing an epidural catheter.)
When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response? A - Psychosomatic B - Physiologic C - Affective D - Behavioral
D (Explanation: Behavioral (voluntary) responses would include moving away from painful stimuli, grimacing, moaning, crying, restlessness, protecting the painful area, and refusing to move the limb. Physiologic (involuntary) responses would include increased blood pressure, increased pulse and respiratory rates, pupil dilation, muscle tension and rigidity, pallor (due to peripheral vasoconstriction), increased adrenaline output, and increased blood glucose. Psychological responses would include exaggerated weeping and restlessness, withdrawal, stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, and powerlessness.)
The nurse is reviewing relaxation techniques with the client who has chronic back pain that radiates to the legs. What information does the nurse include? A - Tighten and relax muscles starting with the upper body. B - Sit in a wood chair with a straight back. C - Take shallow abdominal breaths. D - Close your eyes while practicing the relaxation exercises.
D (Explanation: Closing the eyes will help the client focus on relaxation and not be distracted by visual cues. The client should assume a comfortable position. This may be in a chair or a bed. A straight back wood chair is unlikely to allow the client to assume a comfortable position that would promote relaxation. The client takes deep abdominal breaths, not shallow breaths; this promotes relaxation. The client would tighten and relax muscles, starting with the toes and working up towards the head.)
A client is postoperative day 1 and the nurse's assessment reveals signs of pain, such as grimacing and guarding. Which is the most reliable method for assessing the client's pain? A - Compare the client's presentation to expected outcomes at this point in recovery. B - Assess and document the client's behaviors over a period of hours. C - Correlate the client's vital signs with his or her symptoms. D - Ask the client to describe and rate his or her pain.
D (Explanation: Pain is whatever the experiencing person says it is, existing whenever he or she says it does. This definition rests on the belief that the only one who can be a real authority on whether, and how, a person is experiencing pain is that individual. Because pain is subjective, self-report is generally considered the most reliable way to assess pain and should be used whenever possible. It is superior to objective assessments, even though these may inform the nurse's decision making.)
After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client? A - 2 B - 1 C - 4 D - 3
D (Explanation: The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows:1 = awake and alert; no action necessary2 = occasionally drowsy but easy to arouse; requires no action3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.)
The nurse is caring for a client who frequently comes to the emergency department (ED) reporting a headache that is an 8 or 9 on a pain scale of 1 to 10. The client is noted to be laughing while on the phone and chatting with staff after reporting a headache that is a 10. Which action will the nurse perform prior to initiating treatment? A - Discuss observations with the client B - Contact the pain clinic for further assessment C - Request a lower dose of medication from the health care provider D - Assess for nonverbal cues to pain
D (Explanation: The nurse must not make assumptions about how a client experiences or interprets pain; the nurse should acknowledge the pain as the client reports it. At the same time, the nurse will fully assess the client and document any nonverbal clues to pain observed. Contacting the pain clinic should be an intervention at the time of discharge. Requesting a lower dose of pain medication is not appropriate. Discussing the observations with the client may allow for communication regarding the client's care, but the nurse should acknowledge the pain level as the client reports it, as pain is subjective.)
How should the nurse position the head of the bed for a client receiving epidural opioids? A - Reverse Trendelenburg B - Flat C - Trendelenburg D - Elevated 30 degrees
D (Explanation: The nurse should position the head of the bed so that it is elevated 30 degrees unless contraindicated. Elevation of the client's head minimizes upward migration of the opioid in the spinal cord, thereby decreasing the risk for respiratory depression. The Trendelenburg position is when the feet are higher than the head. Reverse Trendelenburg position or supine position is when the head is higher than the feet.)
A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure? A - Biofeedback mechanism B - Guided imagery C - Patient-controlled analgesia (PCA) D - Cutaneous stimulation
D (Explanation: Cutaneous stimulation techniques include acupressure, massage, application of heat and cold, and transcutaneous electrical nerve stimulation (TENS).)
When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: A - assume the client does not need medication. B - ask the client's family if he ever uses pain medicines. C - document the client's lack of medication. D - actively solicit information about the client's pain level.
D (Explanation: Some cultures see pain tolerance as a virtue; often men are expected to tolerate pain more stoically than women do. Health care providers need to recognize the client's cultural beliefs and not impose their own judgments.)
A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain? A - PAINAD Scale B - Wong-Baker C - FLACC Scale D - CRIES Pain Scale
D (Explanation: The CRIES scale is appropriate for neonates (0 to 6 months). The Wong-Baker Faces Pain Rating scale requires children to be at least 3 years old. The FLACC scale is used for infants and children (2 months to 7 years) unable to validate the presence of or quantify pain severity; and the PAINAD scale is specific to the needs of clients with dementia.)
A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client? A - Nonopioid analgesics B - Corticosteroids C - NSAIDs D - Opioid analgesics
D (Explanation: The nurse would expect to administer opioid analgesics to a client with severe pain following a mastectomy. Nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are usually the drugs of choice for both acute and persistent moderate chronic pain. Corticosteroids would be used to address inflammation and swelling.)