skills: chap. 44 EAQ pain management

Acetaminophen Rationale A physician may first recommend acetaminophen to this patient because the pain is mild, and acetaminophen is relatively safe and widely available over the counter for musculoskeletal pain. The physician may prescribe aspirin, naproxen, or ibuprofen, but these may be second-choice drugs because they are nonsteroidal antiinflammatory drugs which carry a risk for bleeding, especially in older adults, and may not be necessary if the pain is mild. p. 1035

A 65-year-old patient is experiencing mild musculoskeletal pain. Which drug is the primary health care provider most likely to prescribe? Aspirin Naproxen Ibuprofen Acetaminophen

Diabetic neuropathy Trigeminal neuralgia Nerve root compression Rationale Neuropathic pain arises when there is abnormal processing of sensory input by the peripheral or central nervous system. Pain felt along the distribution of many peripheral nerves as in diabetic neuropathy is a neuropathic pain. Pain felt partly along the distribution of a damaged nerve such as in nerve root compression is also an example of neuropathic pain. Pain associated with trigeminal neuralgia is also a neuropathic pain. Aching muscles and a throbbing pain at the knee joint are examples of nociceptive pain. Test-Taking Tip: Be aware of Latin and Greek word roots! The question asks for neuropathic pain, which you know contains the word root, neur, meaning nerve. The correct answers all contain the word nerve or the word root neur. All questions may not be this clear, but it is certainly a clue worth remembering. p. 1018

A group of nursing students is learning about nociceptive and neuropathic pain. What are examples of neuropathic pain? Select all that apply. Aching muscles Diabetic neuropathy Trigeminal neuralgia Nerve root compression Throbbing pain at knee joint

Naloxone Rationale Naloxone is prescribed for respiratory depression as a result of opioid overdose. Administering too much too quickly may cause severe pain and other serious complications. Capsaicin is effective for relief from minor aches and muscle and joint pain, not respiratory distress. A Lidoderm patch is effective for relieving cutaneous neuropathic pain, not respiratory distress. Acetaminophen is effective for treating musculoskeletal pain, not respiratory distress. pp. 1036

A primary health care provider prescribes medication for a patient in respiratory distress. Shortly after, the patient complains of severe pain. Which medication did the patient likely receive? Naloxone Capsaicin Lidoderm patch Acetaminophen

"Guided imagery provides effective pain relief for a patient who has acute appendicitis." Rationale Acute pain cannot be effectively managed by nonpharmacological pain management interventions alone, so the nursing student requires further teaching to understand that guided imagery alone will be inadequate for a patient experiencing acute appendicitis. The remaining statements indicate understanding. Cognitive-behavioral interventions like biofeedback can change a patient's perception of pain. Any nonpharmacological intervention like music therapy can be used in combination with pharmacological interventions to provide pain relief. Therapeutic touch is a complementary and alternative pain relief method. p. 1031

A registered nurse is teaching a nursing student about various nonpharmacological pain management interventions. Which of the nursing student's statements indicates a need for further teaching? "Biofeedback can help change a patient's perception of pain." "Music therapy can be used in combination with pharmacological measures." "Guided imagery provides effective pain relief for a patient who has acute appendicitis." "Therapeutic touch is a complementary and alternative medicine pain relief method."

Prostaglandin Rationale Prostaglandins are generated from the breakdown of phospholipids of the cell membrane and are known to increase pain sensitivity. NSAIDs act by decreasing the levels of such compounds in the blood. Renin is involved in balancing water and electrolytes in the body. Neurotransmitters such as serotonin inhibit the transmission of pain. Diclofenac sodium is a painkiller that reduces pain sensitivity. p. 1015

A student nurse is reading about the mode of action of nonsteroidal anti-inflammatory drugs (NSAIDS). The NSAID drug decreases the level of a chemical that is known to increase pain sensitivity. With which chemical does the NSAID react? Renin Serotonin Prostaglandin Diclofenac sodium

Hematoma Rationale Because anticoagulants reduce the action of the blood's platelets, hematoma is a possible complication when epidural anesthesia is administered to a patient on anticoagulants. Anticoagulants and anesthesia have different actions, so a synergistic effect is not a concern. Anticoagulants do not predispose a patient to an allergic reaction to epidural anesthesia. Respiratory depression is an adverse effect of opioids, but anticoagulants do not make it more likely. p. 1041

During a preoperative assessment, a patient reports history of a heart attack and use of anticoagulant medications. If epidural anesthesia is administered to the patient for the surgery, for which possible complication should the nurse look? Synergistic effects Hematoma Allergic reaction Respiratory depression

Psychogenic pain is not real. Administering analgesics regularly leads to drug addiction. Patients who abuse substances overreact to discomfort. Rationale Psychogenic pain is real and requires intervention. Regular administration of analgesics does not lead to drug addiction. However, some analgesics such as morphine should not be overused. The patients who abuse substances do not overreact to discomfort; their discomfort may be real. Chronic pain is not psychological; it may be real and can have an impact on daily activities. Patients who do not speak can still feel pain and need intervention. p. 1019

The nurse works in a postsurgical ward. Which statements by the nurse indicate common misconceptions about pain? Select all that apply. Psychogenic pain is not real. Chronic pain is not psychological. Patients who cannot speak can feel pain. Administering analgesics regularly leads to drug addiction. Patients who abuse substances overreact to discomfort.

Acetaminophen Rationale Acetaminophen is safe to use in combination with opioids like oxycodone for pain relief. A health care provider may do so to lower the opioid dose. Fentanyl, morphine, and codeine are also opioids, so combining them with another opioid would have potentially dangerous synergistic effects. p. 1035

The physician tells the nurse to administer a second drug to a patient already on oxycodone. Which drug would be safe for this patient? Fentanyl Morphine Codeine Acetaminophen

"I will place ice between my thumb and index finger if I have shoulder pain." Rationale Cold is effective for tooth or mouth pain, not shoulder pain, when the ice is placed on the web of the hand between the thumb and index finger. This is an acupressure point that influences nerve pathways to the face and head. The remaining statements indicate understanding: Ice can be applied two to five times a day with firm pressure to the skin, covered with a lightweight cloth. Ice should also be applied within a 6-inch circular area near the site of pain. p. 1033

The registered nurse is teaching a patient about the use of cold therapy in acute pain management. Which of the patient's statements indicates a need for further teaching? "I will apply ice two to five times a day." "I will apply ice with a lightweight cover, with firm pressure to my skin." "I will apply ice within a 6-inch circular area near where I have pain." "I will place ice between my thumb and index finger if I have shoulder pain."

Administering 0.4 mg of naloxone Rationale Respiratory depression is a serious side effect of opioid administration. Naloxone counters the effects of opioids, so this drug would be used to treat respiratory depression resulting from morphine administration. Acetylcysteine is used to counter acetaminophen, not opioid, overdose. Oxycodone is also an opioid that can result in further respiratory depression. The patient should be immediately treated with naloxone as airway and breathing are top priorities of care over pain or less severe side effects. p. 1036

What is the immediate intervention if a patient on morphine 10 mg/mL infusion therapy experiences severe respiratory depression? Administering acetylcysteine Change morphine infusion to oral oxycodone Decreasing the rate of infusion Administering 0.4 mg of naloxone

Legs Neck Back Reddened skin Rationale The nurse should avoid massaging any postsurgical patient's legs because recent surgery increases a patient's risk for blood clots, and massaging the legs may dislodge a clot, resulting in pulmonary embolism. The nurse should not provide neck or back massage to a patient recovering from spinal surgery without a physician's orders. The nurse should avoid massaging reddened skin, because this may aggravate already irritated or infected skin. The nurse may safely massage a spinal patient's hands. pp. 1034

When providing massage for pain relief in a patient recovering from spinal surgery, which areas of the body should the nurse avoid? Select all that apply. Hands Legs Neck Back Reddened skin

Corticosteroids Rationale Corticosteroids relieve pain caused by inflammation and bone metastasis. Antidepressants relieve neuropathic pain. Opioid analgesics and nonsteroidal antiinflammatory drugs are used in acute and chronic pain management and are not adjuvant drugs. p. 1038

Which adjuvant drug relieves pain caused by inflammation and bone metastasis? Corticosteroids Antidepressants Opioid analgesics Nonsteroidal antiinflammatory drugs

Anticonvulsants Tricyclic antidepressants Rationale Anticonvulsants and tricyclic antidepressants can be effective for treating chronic pain, especially neuropathic pain. Corticosteroids are typically used to relieve pain from inflammation and bone metastasis. Opioid and nonopioid analgesics are not adjuvant drugs. p. 1038

Which adjuvant drugs are preferred for treating neuropathic pain? Select all that apply. Corticosteroids Anticonvulsants Opioid analgesics Nonopioid analgesics Tricyclic antidepressants

Epidural analgesia Rationale Epidural analgesia is preferred for relieving chronic cancer pain. Local anesthesia is used to numb specific areas in acute pain. Topical analgesics are used to treat neuropathic and musculoskeletal pain. Perineural local anesthetic infusion is used to relieve pain during surgical procedures. p. 1039

Which type of pain management therapy is preferred for relieving chronic cancer pain? Local anesthesia Topical analgesic Epidural analgesia Perineural local anesthetic infusion

Naproxen Ibuprofen Rationale Some patients who have asthma or an allergy to aspirin are also allergic to other nonsteroidal antiinflammatory drugs (NSAIDs). Naproxen and ibuprofen are NSAIDs, so the physician may avoid prescribing these medicines to the patient for pain management. Tramadol, oxycodone, and hydromorphone are opioid analgesics, which may be less risky for allergic reaction in this patient. p. 1035

While taking a patient's medical history, a nurse records that the patient has asthma. Which medications for pain management might the physician avoid prescribing? Select all that apply. Tramadol Naproxen Ibuprofen Oxycodone Hydromorphone

Overdose of acetaminophen Rationale Dangerous hepatotoxic overdoses of acetaminophen are treated with acetylcysteine. Antiulcer drugs may be prescribed to treat gastric bleeding caused by overdose of aspirin. Overdoses of fentanyl and morphine may be treated with naloxone. p. 1035

Why would a primary health care provider prescribe acetylcysteine to a patient who is on pharmacological pain management therapy? Overdose of aspirin Overdose of fentanyl Overdose of morphine Overdose of acetaminophen

Notifying the health care provider if the patient develops pain at the epidural insertion site Rationale The nurse should notify the health care provider if the patient develops pain at the epidural insertion site, because it may indicate development of an epidural hematoma. Administering supplemental opioids could lead to dangerous additive central nervous system adverse effects. The nurse should monitor vital signs and respiratory rate once every 15 minutes after the administration of epidural anesthesia to ensure stable vitals; once every hour is not enough. Anticoagulants and antiplatelet drugs should not be administered to the patient, because they may increase the risk of hematoma formation. p. 1041

A nurse administers epidural anesthesia to a patient in the terminal stages of cancer for pain relief. Which nursing intervention is then necessary? Administering supplemental doses of opioid Assessing vitals once every hour after administering the first dose Administering anticoagulant medications with the epidural Notifying the health care provider if the patient develops pain at the epidural insertion site

PCA allows self-administration of analgesics. Rationale PCA allows the patient to self-administer analgesic medication whenever needed. There is no risk of overdosage due to the programming. Opioids can be safely administered using PCA. It allows intravenous or subcutaneous administration of medications. p. 1039

A patient has had arthritic pain for 8 years and has surgery to remove a buildup of septic fluid. Postoperative, the patient received morphine through a patient-controlled analgesia (PCA) device for the management of pain. What is the advantage of PCA that the nurse should teach the patient? PCA allows self-administration of analgesics. PCA is associated with a risk of overdose. PCA does not allow administration of opioids. PCA allows intramuscular administration of medications.

"Which factors relieve your pain?" "How would you describe the pain?" "On a scale of 0 to10, how high would you rate the pain?" Rationale To assess the pain completely and accurately, the nurse needs to assess its onset, palliative factors, quality, radiation, severity, and time factors related to the pain. Asking about palliative factors helps to determine the factors that influence the pain. A description of the pain helps to understand the nature and location of the pain. Asking a patient to rate the pain on a pain scale helps to assess the intensity of the pain. Asking questions regarding elimination and allergies does not help in pain assessment. STUDY TIP: Use the "OPQRST" mnemonic to recall what should be assessed about pain. Each letter stands for a pain characteristic and follows the sequence in the alphabet. A description of the pain is implied by the Q for quality. R can stand for radiation as well as rating. p. 1023

A patient has had arthritic pain for 8 years. Which questions should the nurse ask to assess the patient's pain? Select all that apply. "Which factors relieve your pain?" "How would you describe the pain?" "Are you having any trouble passing stools?" "Are you allergic to any food item or medication?" "On a scale of 0 to10, how high would you rate the pain?"

Naproxen Ibuprofen Rationale Some patients who are allergic to aspirin may have a higher risk of allergy to other nonsteroidal antiinflammatory drugs (NSAIDs). Naproxen and ibuprofen are NSAIDs, so the health care team may avoid them to prevent the risk of allergic reaction. Fentanyl, morphine, and oxycodone are opioids, and an allergy to aspirin is not indicative of an allergy to opioids, so the health care team may use them for this patient. p. 1035

A patient in pain mentions a history of allergy to aspirin. Which drugs might the health care team avoid for this patient? Select all that apply. Fentanyl Morphine Naproxen Ibuprofen Oxycodone

A: Ask regularly about the pain. B: Believe the patient about the pain. C: Choose pain control options appropriate to the patient. Rationale The ABCDE approach helps in accurately assessing pain and its management. A stands for "Ask regularly about the pain." B stands for "Believe the patient and family in the report of pain." C stands for "Choose pain control options appropriate for the patient." D stands for "Deliver interventions in an orderly and coordinated fashion." E stands for "Empower patients and their families." p. 1023

A patient is in the first postoperative day following a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. The nurse decides to use the ABCDE approach while assessing and managing pain for this patient. What are the correct components of the ABCDE approach? Select all that apply. A: Ask regularly about the pain. A: Assess the pain once a week. B: Believe the patient about the pain. C: Choose pain control options appropriate to the patient. D: Deny the use of painkillers and encourage the patient to bear the pain naturally.

It is a pain that is sensed at a site away from its actual origin or pathology. Rationale A pain that is sensed at a site away from its actual origin or pathology is known as referred pain. A pain that occurs sporadically over time is known as chronic episodic pain. A moderate pain that occurs constantly for more than 6 months is known as chronic or persistent noncancerous pain. A cancer pain is neuropathic pain that is caused generally after cancer or a tumor. STUDY TIP: To help you remember the definition of referred pain, draw two outlines of a body, one front and one back. Using several sources, circumscribe (circle) areas where referred pain is perceived, then write what organs send pain to those areas in the circles. For instance, circle the left anterior chest and left arm and write heart within those circles. Circle the upper right back and write gall bladder. Use different colors for each organ. The drawing and colors will help you visually recall the meaning of referred pain. It may seem like a bit of work to do so, but the number of times this information will be important to you as a nurse will make it worth it! p. 1018

A patient is in the first postoperative day following a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. The patient complains of pain in the shoulders. The nurse understands that it is a referred pain. What explanation should the nurse give to the patient regarding the referred pain? It is a pain that occurs sporadically over time. It is a moderate pain that occurs for more than 6 months constantly. It is a pain that is sensed at a site away from its actual origin or pathology. It is neuropathic pain that is caused generally after cancer or a tumor.

Opioids can be used safely in cases of moderate to severe pain. Slow titration prevents potentially dangerous opioid-induced side effects. In case of any adverse effects, opioid antagonist drugs can be given to reverse the effects. Rationale There are many misconceptions about the use of opioid drugs. Opioids can be safely given to people for management of moderate to severe pain. Opioids are given in slow titration to prevent the appearance or development of any side effects. In rare cases, there may be respiratory depression as an adverse effect of opioid drugs. In such cases, an opioid antagonist drug can be administered to the patient to reverse the effects of opioids. It is not mandatory to give opioids only after surgery. They can be administered to relieve pain of any origin. The action of opioids can be reversed with the proper antagonist drug. p

A patient is in the first postoperative day following a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. The patient is apprehensive about being given opioid drugs and is afraid of becoming addicted to the drug. The patient is also afraid of chronic side effects. What explanation should the nurse give the patient? Select all that apply. Opioids can be used safely in cases of moderate to severe pain. Opioids can be given only after surgery or for postsurgical pain. Slow titration prevents potentially dangerous opioid-induced side effects. The drug is administered carefully, because its action cannot be reversed. In case of any adverse effects, opioid antagonist drugs can be given to reverse the effects.

Acetylcysteine Rationale Overdose of acetaminophen may lead to hepatotoxicity, which is treated with acetylcysteine. Naloxone is used to reverse the adverse effects of opioids, not acetaminophen. Tramadol and oxycodone are used to manage pain, not to treat acetaminophen overdose. p. 1035

A patient took more than the prescribed amount of acetaminophen and is experiencing hepatotoxicity. Which drug might the nurse anticipate the health care provider to use to treat this patient? Naloxone Tramadol Oxycodone Acetylcysteine

Helping the patient walk Increasing the patient's fluid intake Rationale Helping the patient ambulate can provide relief from constipation because the movement of abdominal muscles decreases abdominal distention, promoting bowel movement. Increasing the patient's fluid intake promotes bowel movement, which will reduce abdominal cramping. Administering stool softeners is a pharmacological intervention. Sleep therapy can help a patient experiencing fatigue, and raising a toilet seat could help a patient with limited mobility due to pain, but these interventions will not relieve constipation and cramping. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. pp. 1033-1034

A patient who underwent abdominal surgery experiences constipation and severe cramping. Which nonpharmacological nursing interventions may provide relief to this patient? Select all that apply. Helping the patient walk Increasing the patient's fluid intake Providing stool softeners to the patient Planning sleep therapies for the patient Providing an elevated toilet seat to the patient

Collaborating with an occupational therapist to provide assistive devices for grooming Rationale The nurse may collaborate with an occupational therapist to provide assistive devices to the patient for grooming, but this is not done to relieve pain; rather, this is an intervention to help the patient dress and prepare for the day if the joint pain is making this difficult. The remaining interventions are appropriate for pain relief. Music and television can help relieve pain by taking the patient's attention away from it. Analgesic administration is a pharmacological therapy method to provide pain relief. Cool compresses may also help soothe the pain caused by rheumatoid arthritis. p. 1032

A patient with rheumatoid arthritis reports acute joint pain in the hand. Which intervention is inappropriate for providing pain relief? Encouraging the patient to listen to music or watch television Collaborating with an occupational therapist to provide assistive devices for grooming Administering ordered analgesics around the clock for 24 to 48 hours Applying cool compresses to the patient's joints with the prescriber's approval

5 mg codeine every 4 hours Rationale Because codeine is short-acting, relief is likely only attainable with administration every 4 hours. If 5 mg is not enough, or the side effects remain, the patient may require a different opioid. Even at every 8 hours, 10-mg and 20-mg doses are too much for the patient to tolerate without adverse side effects. A 5-mg dose every 12 hours is probably too long of an interval for this patient to obtain relief from the pain. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. p. 1035

A primary health care provider prescribes 10 mg of codeine every 4 hours to a patient who has chronic pain from cancer. However, after taking a second dose of the prescribed drug, the nurse notices that the patient is very drowsy and nauseous. Which dose alteration may provide effective pain relief while improving the drowsiness and nausea? 5 mg codeine every 4 hours 10 mg codeine every 8 hours 20 mg codeine every 8 hours 5 mg codeine every 12 hours

It acts by inhibiting the synthesis of prostaglandins. One of its serious side effects is gastrointestinal bleeding. Rationale Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, act by inhibiting prostaglandin synthesis, thereby inhibiting cellular response to inflammation and thus reducing pain. Gastrointestinal bleeding is a major adverse effect of NSAIDs. The remaining statements are incorrect. Opiates, not NSAIDs, depress the central nervous system to relieve pain. Because of the risk for gastrointestinal bleeding, ibuprofen and other NSAIDs are not frequently the first choice for treating pain in older adults. Ibuprofen is not a prescription drug; it is widely available over the counter. p

A primary health care provider recommends ibuprofen to a patient in pain. Which statements about this medication are correct? Select all that apply. It depresses the central nervous system in order to relieve pain. It acts by inhibiting the synthesis of prostaglandins. It is highly recommended for older adults experiencing pain. It is the most effective prescription drug available for pain relief. One of its serious side effects is gastrointestinal bleeding.

"NSAIDs work by depressing the central nervous system." Rationale Opioids, not nonsteroidal antiinflammatory drugs (NSAIDs), depress the central nervous system. The other statements indicate effective teaching: NSAIDs inhibit prostaglandin synthesis, which inhibits cellular responses to inflammation; this helps relieve pain. An allergy to aspirin may be indicative of an allergy to other NSAIDs, and NSAIDs may put older adults at an increased risk for gastrointestinal bleeding. p. 1035

A registered nurse is teaching a nursing student about using nonsteroidal antiinflammatory drugs (NSAIDs) for pain management. Which of the nursing student's statements indicates a need for further teaching? "NSAIDs work by depressing the central nervous system." "NSAIDs act by inhibiting the synthesis of prostaglandins." "Patients allergic to aspirin are more likely to be allergic to other NSAIDs." "Use of NSAIDS in older adults may result in increased risk of adverse events."

Serotonin Norepinephrine Gamma aminobutyric acid Rationale During the process of pain modulation, endogenous opioids, serotonin, norepinephrine, and gamma aminobutyric acid (GABA) are some of the inhibitory neurotransmitters released to inhibit the pain impulse. This happens in the fourth and final phase of the nociceptive process. Histamine and substance P have no role in pain modulation. Histamine is released by mast cells and plays a major role in the inflammatory process. Substance P transmits pain impulses from the periphery to higher brain centers. p. 1016

The human body has a mechanism to reduce pain perception by inhibitory neurotransmitters. What are the inhibitory neurotransmitters of pain in the brain? Select all that apply. Serotonin Histamine Substance P Norepinephrine Gamma aminobutyric acid

To decrease the dose of opioid required for pain control Rationale Administration of acetaminophen will reduce the dose of opioid drug required to achieve maximum pain relief. Acetaminophen overdose leads to hepatotoxicity; it does not prevent it. Oversedation and respiratory depression can be adverse side effects of opioid administration, but acetaminophen treats only pain. p. 1035

The nurse administers 250 mg of acetaminophen along with 5 mg of hydrocodone to a patient in pain. Why is acetaminophen part of this protocol? To reduce the risk of hepatotoxicity To prevent the risk of oversedation To prevent the occurrence of respiratory depression To decrease the dose of opioid required for pain control

Patients who repeatedly seek multiple medical opinions for chronic pain relief Rationale When a patient with chronic pain seeks pain medication from multiple primary health care providers, the patient is called a drug seeker but not an illicit drug abuser. This kind of addiction is called pseudoaddiction. Such drug seekers should be referred to pain specialists. Pseudoaddiction is not related to a history of taking over-the-counter medicines or the history of drinking coffee for more than 5 years. The patients who say that heroin increases concentration do not have pseudoaddiction. p. 1043

The nurse has conducted an informative session on discouraging pseudoaddiction to a group of people in a community. Which group of patients should be the main target for the nurse's teachings? Patients with a history of taking over-the-counter medicines Patients with a history of drinking coffee for more than 5 years Patients who say that heroin increases concentration Patients who repeatedly seek multiple medical opinions for chronic pain relief

"Two months ago, I was diagnosed with hepatitis B." Rationale Because acetaminophen can cause hepatotoxicity, and a patient who has hepatitis B has a compromised liver, the nurse may expect the physician to avoid recommending acetaminophen to this patient. Acetaminophen is safe for a patient who consumes alcohol occasionally, but it should be used with caution for a patient who frequently drinks alcohol. Occasional alcohol intake might not affect the administration of acetaminophen. Nonsteroidal antiinflammatory drugs, not acetaminophen, may aggravate constipation. An allergy to penicillin will not necessarily predispose a patient to an allergy to acetaminophen. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 1039

The nurse is assessing a patient who complains of back pain. After taking the patient's history, the nurse does not expect the physician to recommend acetaminophen. Which of the patient's statements led the nurse to this conclusion? "I drink alcohol occasionally." "I have been constipated for 3 days." "I am allergic to penicillin." "Two months ago, I was diagnosed with hepatitis B."

Decrease in blood pressure Rationale Superficial pain or mild-to-moderate pain stimulates the sympathetic nervous system. The parasympathetic nervous system is stimulated by continuous, deep, or severe pain involving visceral organs. Stimulation of the parasympathetic nervous system has an inhibitory effect on the body systems and causes a decrease in blood pressure. The sympathetic nervous system prepares the body for a fight-or-flight response. Diaphoresis, dilation of pupils, and increased heart rate are caused by the stimulation of the sympathetic system. Test-Taking Tip: On questions about the parasympathetic or sympathetic nervous system, remind yourself that the parasympathetic system is the rest-and-digest system, and the sympathetic nervous system is the fight-or-flight system. Then consider which system the question is asking about and match up the choice with that system accordingly. For this question, only the parasympathetic symptom would cause a decrease in blood pressure. p. 1017

The nurse is assessing a patient who has sustained severe injuries in a motor vehicle accident. The patient is in severe pain and is diaphoretic. On assessment, the patient's heart rate is increased, pupils are dilated, and blood pressure is decreased. Which finding is caused by the stimulation of the parasympathetic nervous system? Diaphoresis Dilation of pupils Increased heart rate Decrease in blood pressure

Acute pain has an identifiable cause. Acute pain has limited tissue damage. Acute pain results in prolonged hospitalization. Rationale Acute pain has an identifiable cause, limited tissue damage, and an emotional response. Acute pain results in prolonged hospitalization as it seriously threatens a patient's recovery, so the health team members treat it aggressively. Acute pain is protective, unlike chronic pain, which is not protective. A patient with chronic pain may seek numerous health care providers because of its unknown cause. Test-Taking Tip: Have confidence in your initial responses to a question; they are more than likely the correct answers. p. 1017

The nurse is assessing a patient with acute pain. Which statements are true about acute pain? Select all that apply. Acute pain is not protective. Acute pain has an identifiable cause. Acute pain has limited tissue damage. Acute pain results in prolonged hospitalization. Patients with acute pain seek numerous health care providers.

Massage Cold application Transcutaneous electrical nerve stimulation (TENS) Rationale Cutaneous stimulation releases endorphins, which block the transmission of painful stimuli. Massage, cold application, or transcutaneous electrical nerve stimulation (TENS) all stimulate the skin, which may be helpful in reducing pain perception via endorphin release. Opioid analgesics reduce pain by binding with opiate receptors to modify pain perception, not by releasing endorphins. Nonsteroidal antiinflammatory drugs (NSAIDs) reduce pain by inhibiting prostaglandin synthesis, which inhibits the body's cellular response to inflammation. p. 1033

The nurse is caring for a patient on pain management therapy. Which types of therapy cause a release of endorphins that can block the transmission of painful stimuli? Select all that apply Massage Opioid analgesics Cold application Nonsteroidal antiinflammatory drugs (NSAIDs) Transcutaneous electrical nerve stimulation (TENS)

Decreased pulse rate Decreased blood pressure Peripheral edema Rationale Potential adverse effects of opioids include bradycardia (decreased pulse rate), hypotension (decreased blood pressure), and peripheral edema due to the accumulation of fluids. Decreased, not increased, respiratory rate may occur with opioid administration. Pupil constriction may occur with the use of opioids, but pupil dilatation is an effect of opioid withdrawal. p. 1036

The nurse is caring for a patient who is on opioid therapy. For which findings is the nurse carefully observing the patient? Select all that apply. Decreased pulse rate Increased respiratory rate Decreased blood pressure Pupil dilatation Peripheral edema

Increased heart rate Increased glucose level Decreased gastrointestinal motility Rationale The stimulation of the sympathetic branch of the autonomous nervous system causes an increased heart rate, an increased glucose level, and decreased gastrointestinal motility. Stimulation of the parasympathetic branch results in rapid, irregular breathing and decreased blood pressure. Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes. p. 1017

The nurse is learning about the effects of pain on the sympathetic system. What are the manifestations of sympathetic stimulation in response to the pain? Select all that apply. Increased heart rate Rapid, irregular breathing Increased glucose level Decreased blood pressure Decreased gastrointestinal motility

Patient B Rationale Renal insufficiency is a common side effect of nonsteroidal antiinflammatory drugs (NSAIDs). Ibuprofen is a NSAID, so Patient B is at the highest risk for renal insufficiency. Patients A and D, on fentanyl and hydromorphone respectively, are at risk of experiencing the wide range of side effects caused by opioids, including hallucinations, bradypnea, and hypotension. Patient C on acetaminophen is at risk for hepatotoxicity. p. 1035

The nurse is reviewing the clinical data of four patients who are on pain management therapy. Which patient is at the highest risk for renal insufficiency? Patient A Patient B Patient C Patient D

Older patients underreport pain. Opioids are safe to use in older patients. Older adults with cognitive impairment do not experience less pain. Rationale Older patients underreport pain with the fear of losing their independence, and do not want to alarm loved ones. Opioids are safe to use with proper monitoring of the patient to note any side effects. There is no evidence that cognitively impaired older adults experience less pain compared to individuals with intact cognitive function. Sleeping does not indicate pain relief. It indicates exhaustion, and in fact, pain may prevent the patient from having a good sleep. Age does not dull the sensitivity to pain. Older adults perceive pain as much as young adults. p. 1020

The nurse is teaching a group of caregivers about the concept of pain in older adults. What should the nurse include in the teachings? Select all that apply. Older patients underreport pain. Sleeping indicates pain relief. Opioids are safe to use in older patients. Older adults tend to perceive more pain. Older adults with cognitive impairment do not experience less pain.

Absorption of drugs is faster than expected. Preterm neonates have greater sensitivity to pain than older children do. Assessment of pain involves behavioral cues and physiological indicators. Rationale Absorption of drugs in infants is faster than expected. The drugs that are excreted by the kidneys should be administered in a lower dosage. Preterm neonates have greater sensitivity than term neonates or older children. Using behavioral cues such as facial expression and physiological indicators such as changes in vital signs provide proper assessment of pain. Infants cannot verbalize pain but respond with behavioral changes. Term neonates have the same sensitivity to pain as older children. p. 1020

The nurse is teaching a group of nursing students about concepts of pain in infants. Which information should the nurse include in the teaching? Select all that apply. Infants cannot express pain. Absorption of drugs is faster than expected. Infants are less sensitive to pain than adults are. Preterm neonates have greater sensitivity to pain than older children do. Assessment of pain involves behavioral cues and physiological indicators.

Infants learn to perceive pain by experiencing the first unpleasant stimulus. Rationale Some common misconceptions about pain sensation in infants exist, of which the nurse should be aware. Infants immediately respond to pain on experiencing the first noxious stimulus. Infants feel pain from birth; a functional processing of pain is developed by mid to late gestation. Nurses can use behavioral changes and alterations in vital signs to assess pain in infants. Although infants cannot verbalize pain, they can express pain by crying. p. 1020

The nurse is teaching a group of nursing students about pain sensations in infants. Which information should be included in the teaching about pain sensation in infants? Infants do not perceive pain sensation immediately after birth. Nurses cannot accurately assess pain in infants. Infants cannot express pain sensation in the first month of life. Infants learn to perceive pain by experiencing the first unpleasant stimulus.

Regular administration of analgesics will not lead to addiction. Patients with minor illnesses may also experience severe pain. Rationale Misconceptions about pain often lead to poor nursing care. Therefore, it is important to know these misconceptions in order to promote appropriate pain management in patients. Regular administration of analgesics does not lead to addiction. Therefore, analgesics should be administered whenever the need arises. Although a patient may suffer from minor illness, he or she may experience severe pain that should not be ignored. A common misconception is that chronic pain is often psychological. However, chronic pain may have a pathological origin. Another misconception is that only hospitalized patients experience pain. Patients who are not hospitalized may also experience pain that needs to be addressed. Another misconception is that psychogenic pain is not real. STUDY TIP: Write out true statements and common misconceptions about pain on separate pieces of paper or note cards. Hold a true-or-false study session where members read one statement and discuss why it is either true or false. Have your text handy to confirm the answers! p. 1019

The nurse is teaching pain management to a group of caregivers. Which information should be included? Select all that apply. Chronic pain is often psychological. Only hospitalized patients experience severe pain. Psychogenic pain is not real. Regular administration of analgesics will not lead to addiction. Patients with minor illnesses may also experience severe pain.

"The A fibers are myelinated and the C fibers are unmyelinated." Rationale The A fibers are myelinated, whereas the B fibers are unmyelinated. The A fibers are larger in diameter, whereas the B fibers are smaller in diameter. Because A fibers are larger in diameter, they transmit signals to the central nervous system (CNS) more rapidly than the smaller C fibers. The sensations caused by the stimulation of the A fibers are localized, whereas the sensations caused by the stimulation of the B fibers are diffuse. p. 1016

The nursing instructor asks the student nurse to differentiate between A and C peripheral nerve fibers. Which statement made by the student nurse indicates effective learning? "The A fibers are myelinated and the C fibers are unmyelinated." "The A fibers are smaller in diameter and the C fibers are larger in diameter." "The A fibers transmit signals slowly and the C fibers transmit signals rapidly." "The A fibers cause diffuse sensation and the C fibers cause localized sensations."

"The infusion rate of an intravenous push of naloxone should be 0.5 mL for 1 minute." "0.4 mg of naloxone should be diluted with 15 mL saline." Rationale Naloxone (Narcan) is used to reverse the effects of opioids, especially in cases of overdose. While administering naloxone, the intravenous (IV) push should be at a rate of 0.5 mL every 2 minutes, not for 1 minute, until the respiratory rate is greater than eight breaths/min. Generally, 0.4 mg of naloxone is diluted with 9 mL, not 15 mL, saline. The remaining statements are correct. Opioid-naïve patients should be closely monitored for sedation, which occurs before respiratory depression. If naloxone is administered too quickly, the patient may experience severe pain and other serious complications. If an adult patient who is on pain management therapy with opioid analgesics experiences respiratory depression, naloxone should be administered. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1036

The registered nurse and a nursing student are discussing opioid pain management therapy and naloxone (Narcan). Which of the nursing student's statements indicate a need for further teaching? Select all that apply. "The infusion rate of an intravenous push of naloxone should be 0.5 mL for 1 minute." "0.4 mg of naloxone should be diluted with 15 mL saline." "Opioid-naïve patients should be closely monitored for sedation." "Administering naloxone faster than the recommended rate may cause severe pain." "If an adult patient experiences respiratory depression, naloxone should be administered."

"I should use TENS on patients who have chronic cancer pain." "I should apply hair or skin preparations before placing TENS electrodes." "I should remove TENS electrodes if the patient feels a buzzing or tingling sensation." Rationale Transcutaneous electrical nerve stimulation (TENS) is effective in treating acute, emergent, and postsurgical and procedural pain control, but not chronic conditions, like cancer pain. The nurse should not apply any hair or skin preparations before attaching the TENS electrodes. Buzzing or tingling sensations are normal, and do not require the nurse to remove electrodes. The other statements indicate understanding. The range of frequency of TENS is 10 Hz to 50 Hz. The TENS electrodes should be placed directly over or near the site of pain. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1033

The registered nurse is teaching a nursing student about applying transcutaneous electrical nerve stimulation (TENS) to a patient. Which of the nursing student's statements indicate a need for further teaching? Select all that apply. "I should set the frequency to no more than 50 Hz." "I should use TENS on patients who have chronic cancer pain." "I should place TENS electrodes directly over or near the site of pain." "I should apply hair or skin preparations before placing TENS electrodes." "I should remove TENS electrodes if the patient feels a buzzing or tingling sensation."

Oxycodone Rationale Because opioid analgesics like oxycodone depress the central nervous system, they are not safe in combination with epidural anesthesia because of possible additive central nervous system adverse effects. Aspirin, naproxen, and ibuprofen are nonsteroidal antiinflammatory drugs (NSAIDs) which do not affect the central nervous system. p. 1041

Which drug is unsafe for the central nervous system as a supplement to epidural anesthesia? Aspirin Naproxen Ibuprofen Oxycodone

Calcitonin Bisphosphonates Rationale Calcitonin and biphosphates are effective in relieving bone pain. Gabapentin, nortriptyline, and infusional lidocaine are typically used to treat neuropathic pain, not bone pain. p. 1038

Which drugs may provide relief from bone pain? Select all that apply. Calcitonin Gabapentin Nortriptyline Bisphosphonates Infusional lidocaine

Hot bath Cold application Rationale A patient who has diabetic neuropathy may not be able to adequately monitor temperature in areas affected by nerve damage, so application of any heat or cold may place this patient at a higher risk for injury. If done safely and properly, yoga, massage, and relaxation exercises should not place a patient with diabetic neuropathy at a higher risk for injury than any other patient. p. 1033

Which nonpharmacological techniques pose a risk of injury to the patient if the patient has a history of diabetic neuropathy? Select all that apply. Yoga Massage Hot bath Cold application Relaxation exercises

Therapeutic touch Rationale Therapeutic touch is a nonpharmacological complementary and alternate pain management intervention. Distraction, biofeedback, and guided imagery, music are nonpharmacological, but considered cognitive-behavioral, not alternative and complementary, interventions. p. 1031

Which pain management method is considered a nonpharmacological complementary and alternative intervention? Distraction Biofeedback Guided imagery Therapeutic touch

Hydromorphone is available for both oral and intravenous administration. Rationale Hydromorphone is available for both oral and intravenous administration. The remaining statements are false. Morphine is also available both orally and intravenously. Hydrocodone and oxycodone are available only for oral administration. p. 1035

Which statement is true regarding opioiates for pain management? Morphine is available only for oral administration. Hydrocodone is only available intravenously. Oxycodone is available for both oral and intravenous administration. Hydromorphone is available for both oral and intravenous administration.

Opioid analgesics act on higher centers of the brain. The short-acting forms of opioids provide pain relief for approximately 4 hours. Rationale Opioid analgesics act on higher centers of the brain and spinal cord by binding with opiate receptors. The short-acting forms of opioid analgesics provide pain relief for approximately 4 hours. Opioid analgesics will decrease the testosterone levels in male patients, decreasing, not increasing, libido. Opioid analgesics are prescribed to relieve moderate to severe levels of pain; other drugs are more appropriate for mild pain. Prolonged use of opioid analgesics will increase patient tolerance to most opioid side effects except central nervous system depression. p. 1035

Which statements about opioid analgesics for pain management are correct? Select all that apply. Opioid analgesics act on higher centers of the brain. Use of opioid analgesics will increase libido in male patients. Opioid analgesics are prescribed for relieving mild forms of pain. The short-acting forms of opioids provide pain relief for approximately 4 hours. Prolonged use of opioid analgesics will increase patient tolerance to depression of the central nervous system.

Lidoderm patch Rationale The Lidoderm patch is effective for treating postherpetic neuralgia, a cutaneous neuropathic pain. Capsaicin is more appropriate for relieving minor aches and pains of the muscles and joints. ELA-Max/LMX and a eutectic mixture of local anesthetics (EMLA) are more often used to treat children. p. 1039

Which topical analgesic is effective for relieving postherpetic neuralgia in adults? Capsaicin ELA-Max/LMX Lidoderm patch Eutectic mixture of local anesthetics (EMLA)

Cutaneous stimulation Rationale Cold application stimulates the skin, which helps reduce pain perception, perhaps by releasing endorphins or activating large, fast-transmitting A-beta sensory nerve fibers. Relaxation techniques include meditation, yoga, guided imagery, and progressive relaxation exercises. Distraction works by diverting the patient's attention to something other than pain, thus reducing awareness of it. Acupressure involves the application of pressure, not cold. p. 1033

Which type of pain management is cold application? Relaxation Distraction Cutaneous stimulation Acupressure