PrepU i hateU: Chapter 34 Comfort and Pain

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? "When did your pain begin?" "How long have you experienced this pain?" "Could you please rate your pain on a 1-10 scale?" "Can you describe the type of pain you are having?"

"Can you describe the type of pain you are having?" 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.

A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation; however, he can be aroused. What would be the sedation score for this client? 4 2 3 1

3 Explanation: The sedation score for this client is 3. -1 is given to a client who is awake and alert, -2 is given to a client who is slightly drowsy but easily aroused, -3 is sedation - drowsy and drifting off during conversation; however, he can be aroused -4 describes a client who is *somnolent*, with minimal or no response to physical stimulation.

The nurse is caring for a client who has a long history of using opioid pain medication. When the client reports back pain of "10" on a 1-10 scale, what is the appropriate nursing action? -Reassure the client that the pain is not excruciating, since they takes opioids. -Recognize that clients who take opioids have less pain than clients who do not. -Acknowledge the pain as the client reports it. ----------Document that pain is "5" on 1-10 scale.

Acknowledge the pain as the client reports it. Explanation: Nurses must acknowledge pain as the patient reports it, because there is no other way to accurately measure pain. The other answer choices are incorrect nursing actions.

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse? Hold the pain medication. Administer the pain medication. Contact the client's health care provider. Reassess the client's pain in 30 minutes.

Administer the pain medication. Explanation: Pain is considered to be present whenever the client states it is. Therefore, the nurse should administer the client's pain medication. It is important that the nurse understand that clients have different ways to manage their pain. It would be inappropriate to delay administration or to hold the medication. There is no indication that the client's health care provider needs to be notified at this time.

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) Encourage deep breathing. Play the client's favorite music. Encourage the use of a sitter. Promote a restful environment. Encourage increased protein.

Encourage deep breathing. Play the client's favorite music. Promote a restful environment. 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.

Which of the following is considered to be the most potent neuromodulators? Endorphins Afferent Efferent Enkephalins

Endorphins Explanation: Endorphins and enkephalins are opioid neuromodulators. Endorphins are powerful pain blocking chemicals with prolonged analgesic effects. Enkephalins are considered less potent. There are no neuromodulators called efferent or afferent.

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.) Percocet Heat Massage Cold Acetaminophen

Heat Massage Cold Explanation: The *gate theory supports that the signals at the gate in the spinal cord determine which impulses eventually reach the brain*. A limited amount of sensory information can be processed by the nervous system at any given moment. When there is too much information sent through, certain cells in the spinal column interrupt the signal as if closing a gate*. The theory appears to explain why mechanical and electrical interventions such as *heat, cold, pressure, and massage* provide effective pain relief. Percocet and acetaminophen are medications that can be used for 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? Furosemide Digoxin Lisinopril Naloxone

Naloxone -Furosemide: Diuretic -Digoxin: Blood pressure support and antiarrhythmic (via Sodium and potassium inside heart cells) -Lisinopril: ACE inhibitors (angiotensin II-renin) dilates blood vessels -*Naloxone: Narcan* - opioid antagonist 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 identifies the pain described by a client whose back discomfort began after an automobile accident and has persisted for 8 months as: acute. malignant. chronic. recurrent.

chronic. Explanation: Chronic pain lasts for a prolonged period, and its cause is not amenable to specific treatment.

The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? rates pain an 8 on a 0 to 10 scale confused to time and place B/P 178/92 and pulse 118 right shoulder immobilizer in place

confused to time and place 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.

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain? referred pain chronic pain acute pain limited pain

referred pain Explanation: *Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage*. Acute pain is distinct from chronic pain and is relatively more sharp and severe and lasts from 3 to 6 months. Chronic pain is often defined as any pain lasting more than 12 weeks. Limited pain is not usually a term used.

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? -administering a placebo and performing a reassessment of the pain -judging whether the client is in pain or is just depressed -beginning pain medications before the pain is too severe -reviewing and revising the pain management treatment plan

reviewing and revising the pain management treatment plan 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 administering medications to a client with neuropathic pain. The client asks why he is getting an antidepressant medication since he is not depressed. What is the best response by the nurse? -"The doctor thinks it will help with your pain." -"Treating your depression, even if you don't think you have it, will help control your pain." -"All clients with pain have at least some depression." -"Antidepressants have been shown to have pain-relieving qualities in clients with neuropathic pain."

"Antidepressants have been shown to have pain-relieving qualities in clients with neuropathic pain." Explanation: Antidepressants are helpful in treating neuropathic and persistent pain. All clients with pain don't necessarily have depression. Somatosensory function is the ability to interpret bodily sensation. Sensation takes a number of forms, including touch, pressure, vibration, temperature, itch, tickle, and pain.

The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain? "How long have you experienced this pain?" "Have you had this pain before?" "When did your pain begin?" "Could you please rate your pain on a 1-10 scale?"

"How long have you experienced this pain?" Explanation: Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset. Asking if the client has had this pain before reflects patterns. Asking the client to rate pain on a 1-10 scale reflects intensity.

The nurse has completed a preoperative teaching session with a client who will receive morphine via a patient-controlled analgesia (PCA) pump after surgery. Which statement by the client indicates the need for further teaching? "I can push the button whenever I feel pain." "I will remind my family member to push the PCA pump button for me if I doze off during the day." "I will use the PCA pump until oral pain medication controls my pain." "I will let my nurse know if the pain medication is not effective enough to help me move after surgery."

"I will remind my family member to push the PCA pump button for me if I doze off during the day." Explanation: *Sedation occurs before clinically significant respiratory depression*. Thus, if the client is too sleepy to push the button (or ask that it be pushed), the button should not be pushed. The other answers are all correct.

The nurse is caring for a client utilizing a Patient Controlled Analgesia (PCA) pump that is programmed to allow a bolus dose every 10 minutes. The client is sleeping with visitors at the bedside. Which of the following instructions should the nurse give the client's visitors? "Remind the client to push the button more often than every 10 minutes." "Only the client should push the pump button." "Push the pump button when you think the client is in pain." "Push the button on the pump every 10 minutes."

"Only the client should push the pump button." Explanation: The nurse should instruct the visitors that only the client should push the button on the pump to administer the bolus pain medication. Unauthorized family members or caregivers (instead of the client) who administer PCA by pushing the dosage button can cause serious analgesic overdoses resulting in oversedation, respiratory depression, and death. The client should push the pump's button only when feeling the sensation of pain.

A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse? Administer the medication if respiratory rate is > 9. Administer the medication when the client's heart rate is < 90. Administer the medication when the client's heart rate is > 80. Administer the medication when the client's blood pressure is > 140/90.

Administer the medication if respiratory rate is > 9. Explanation: The nurse can *safely administer the new pain medication when the client's respiratory rate is greater than 9*. Opioids can cause respiratory depression. Therefore, this is important to monitor before administering the opioid. Blood pressure and heart rate are slightly elevated due to the client experiencing pain. These vital signs are stable to administer the opioid.

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply. Assess for pain control 30 minutes after administering an analgesic. Provide pain medication before activity that may increase pain. Delegate pain assessment to the UAP. Infer that the client who does not complain has no pain. Consider cultural implications of the perception of pain.

Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain. Explanation: Pain assessment should never be delegated to a UAP. Pain medication should be given in advance of an activity that may increase pain. The nurse should consider cultural implications associated with pain and assess for pain control after medication is given. Assumptions should not be made about pain.

The nurse is preparing to administer an NSAID to a client for pain relief. The nurse notices that the client is diagnosed with a bleeding disorder. What should the nurse do? Administer the medication with food. Ask the client if the medication is desired. Administer the medication. Contact the health care provider.

Contact the health care provider. Explanation: *The nurse should contact the health care provider regarding the diagnosis of a bleeding disorder and the prescription for the NSAID.* NSAIDs are contraindicated in clients with bleeding disorders, because the action of the NSAID can interfere with the client's platelet function. Administering the medication is not warranted because the nurse has identified a problem that can affect the safety of the client. Asking the client if the medication is desired will not change the risk. Administering the medication with food can affect the safety of the client.

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? Apgar score FACES scale Braden scale FLACC scale

FLACC scale 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. Apgar score - Look at the babies! FACES scale - baker-wong Braden scale - braden's skin The Face, Legs, Activity, Cry, Consolability scale or FLACC scale

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? Increased respiratory rate Decreased heart rate Guarding of the chest area High blood pressure

Guarding of the chest area 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 nurse is working with a 12-year-old boy who was involved in an MVA. He has several broken bones and contusions. He rates his pain as a 7/10. The nurse plans to administer intravenous hydromorphone to relieve the pain. What side effect is the nurse most worried about? Cardiac arrest Itching Respiratory depression Addiction

Respiratory depression Explanation: Respiratory depression is always a major concern in an opioid-naïve patient.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? The client obtains pain relief slowly and steadily. The client is actively involved in pain management. The client is able to have long hours of rest. The client requires less nursing care.

The client is actively involved in pain management. Explanation: Patient-controlled analgesia (PCA) gives the client the advantage of playing an active role in pain management, as the client is allowed to self-administer medication. Pain relief is rapid, not slow and steady, because the drug is delivered intravenously. PCA does not replace nursing care or reduce the amount of care that the client requires.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? -Thorough client education is necessary to prevent overdoses. -An antidote is automatically delivered if the client exceeds the recommended dose. -Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. -The dose that is delivered when the client activates the machine is preset.

The dose that is delivered when the client activates the machine is preset. Explanation: PCAs are designed to make it impossible for the client to exceed the client-specific dosing parameters programmed into the machine. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics. The client does not need to be educated about overdoses.

A client asks the nurse which vitamins should be taken daily for feelings of fatigue, anxiety, and depression 1 week before menses. Which of the following is the correct response by the nurse? Vitamin A Vitamin B6 Vitamin D Vitamin C

Vitamin B6 Explanation: The nurse should encourage taking Vitamin B6 daily, as it may be effective at relieving symptoms of irritability, fatigue, and depression related to the premenstrual period. *Vitamin A supports growth and bone development, vision, reproduction, and development and maintenance of skin tissue.* Vitamin C protects against immune system deficiencies, cardiovascular disease, prenatal health problems, eye disease, and even skin wrinkling.

The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use? visual analog scale Wong-Baker FACES® scale word scale numeric scale

Wong-Baker FACES® scale Explanation: Children as young as 3 years of age can use the Wong-Baker FACES® scale. A word, numeric, or visual analog scale is more appropriate for adults.

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? Serotonin Dopamine Endorphins Melatonin

endorphins 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 client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention? -frequent turns and application of skin emollients ------supplementary oxygen and chest physiotherapy ------calorie restriction and dietary supplements -stool softeners and increased fluid intake

stool softeners and increased fluid intake Explanation: *The most common side effect of opioid use is constipation.* Consequently, stool softeners and increased fluid intake may be indicated. Opioids may cause respiratory depression, but this fact in and of itself does not create a need for oxygen supplementation or chest physiotherapy. The use of opioids does not create a need for calorie restriction, supplements, frequent turns, or the use of skin emollients.

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: somatic pain. neuropathic pain. cutaneous pain. visceral pain.

visceral pain. 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.