Content area: Pain
The nurse is discussing pain management with a student who is caring for a 1-day postoperative abdominal surgery client who is a known opioid substance abuser. What comment by the student indicates a need for further education? 1."Opioid substance abusers are less tolerant to opioids and require decreased doses." 2."These clients should be allowed to choose their pain medications and dosing regimen." 3."Nonopioid therapies such as cutaneous stimulation are generally effective if used alone." 4."These clients are at an increased risk for abrupt physiological withdrawal when opioid agonists are abruptly withdrawn."
"Opioid substance abusers are less tolerant to opioids and require decreased doses." Rationale: Opioid substance abusers have developed a tolerance to opioids and require higher, not decreased, doses for a therapeutic effect. The other statements are appropriate comments.
The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed? 1.Older adults tend to report pain less often than do younger adults. 2.Clients in this age group are less sensitive to pain and have a greater pain tolerance. 3.Mental images of pain are a less effective means to assess pain in this group than visual representations. 4.Pain in the cognitively impaired older adult may require more frequent assessments than in clients who are not impaired.
Clients in this age group are less sensitive to pain and have a greater pain tolerance. Rationale: Cognitive impairment in the older adult acts as a barrier to pain assessment, and pain may be more accurately reported at the moment when it occurs than when prompted by the nurse. Clients in this age group are not less sensitive to pain and do not necessarily have a greater pain tolerance. The other options are correct statements
A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1."I will be sure to ask my client what his pain level is on a scale of 0 to 10." 2."I know that I should follow up after giving medication to make sure it is effective." 3."I know that pain in the older client might manifest as sleep disturbances or depression." 4."I will be sure to cue in to any indicators that the client may be exaggerating their pain."
"I will be sure to cue in to any indicators that the client may be exaggerating their pain." Rationale: Pain is a highly individual experience, and the new graduate nurse should not assume that the client is exaggerating his pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by members of other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute in this population.
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client? 1. "Where is the pain located?" 2. "Does pain medication help?" 3. "What does the pain feel like?" 4. "How does the pain affect you?" 5. "Do you have the pain when you sleep?" 6. "What makes your pain better or worse?"
1. "Where is the pain located?" 3. "What does the pain feel like?" 4. "How does the pain affect you?" 6. "What makes your pain better or worse?" Rationale: The PQRSTU method is one method of assessing pain. With this method, the nurse asks about the following: Provocative/palliative (option 6); Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain (continuous or intermittent); and How the pain affects yoU (option 4). Options 2 and 5 may be questions that would be asked; however, these are not a part of the PQRSTU method.
A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy? 1.Constipation because of the location of the epidural catheter 2.Dislodgment of the epidural catheter because the catheter is not sutured in place 3.Permanent lower motor weakness because of the proximity of the catheter to the sciatic nerve 4.Chronic addiction to the epidural medication because epidural analgesia is a more powerful means of pain relief than patient-controlled analgesia therapy
2.Dislodgment of the epidural catheter because the catheter is not sutured in place Rationale: Epidural analgesia (also known as peridural or extradural analgesia) refers to the instillation of a pain-blocking agent into the epidural space. Complications that occur with epidural analgesia are directly related to catheter placement, catheter maintenance, and the type of analgesia. Epidural catheters are not sutured in position and must be taped in place to help prevent dislodgment. Low concentrations of medications are used to avoid any sensory and motor deficits that can accompany epidural analgesia. Constipation and chronic addiction are not specific complications of epidural analgesia.
A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child? 1.Assess the child's physical status. 2.Ask the child how the injury occurred. 3.Report the case as suspected child abuse. 4.Observe the interactions between the child and his friends.
Assess the child's physical status. Rationale: The initial intervention is to assess the child's physical status. The child should be initially assessed for injury to the right arm and for bruises, burns, scars, and any other signs of abuse. The nurse would next report the case as suspected child abuse to the appropriate authorities. Option 2 may or may not be appropriate, depending on the situation because the child may be fearful of telling the truth about how the injury occurred. Option 4, although appropriate for some situations, is not appropriate as the initial intervention.
The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? 1.Document the findings. 2.Attempt to arouse the client. 3.Contact the health care provider (HCP) immediately. 4.Check the medication administration history on the PCA pump.
Attempt to arouse the client. Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump, and should continue to monitor the client closely to determine if further action is needed. The nurse should contact the HCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client.
The nurse is caring for a client with a back injury sustained 1 year ago. To obtain the most complete assessment data about the client's chronic pain pattern, what should the nurse ask the client? 1."Can you describe what makes your pain worse?" 2."What is the intensity of your pain on a scale of 0 to 10?" 3."Can you describe your daily activities in relation to your pain?" 4."Would you describe your pain as aching, throbbing, or stabbing?"
Can you describe your daily activities in relation to your pain? Rationale: The client has chronic pain, which is pain lasting greater than 6 months. This affects quality of life and is disruptive to even the simplest of tasks such as eating, bathing, or shopping. Therefore, the priority for the nurse is to ask the client about these issues. Option 1 addresses aggravating factors of the pain. Although options 2 and 4 are important, they are not specific to what the question is asking: assessment data about chronic pain pattern. These questions would be most helpful with planning of pain management.
To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what should the nurse do first? 1.Request a cardiopulmonary consult. 2.Teach the client to splint the incision. 3.Teach the proper technique for huff coughing. 4.Ensure that the client is experiencing adequate pain control.
Ensure that the client is experiencing adequate pain control. Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways and prevent atelectasis. The client with an abdominal incision is hesitant to cough unless pain control is adequate. The incision in an open cholecystectomy is just under the diaphragm in the right upper quadrant of the abdomen, making coughing and deep breathing painful. The nurse should first ensure that pain control is adequate so that pulmonary hygiene measures are maximally effective. A cardiopulmonary consult is requested for clients with preexisting risk caused by lung pathology or for clients already experiencing postoperative respiratory complications. Splinting the incision is an effective postoperative strategy for assisting with effective coughing and deep breathing, but it should follow pain control. Huff coughing, although it can be used in the postoperative client, is an effective coughing strategy that is most often recommended for clients with chronic obstructive airway disorders.
The health care provider (HCP) writes a prescription for acetylsalicylic acid, or aspirin, for a client who was admitted to the hospital with joint pain from rheumatoid arthritis. The nurse contacts the HCP to verify the prescription if which finding is noted in the assessment data? 1.Renal colic 2.Hypertension 3.Diabetes mellitus 4.Gastric ulceration
Gastric Ulceration Rationale: Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. Contraindications to the medication include gastrointestinal bleeding or ulceration, bleeding disorders, history of hypersensitivity to aspirin or other nonsteroidal antiinflammatory medications, impaired hepatic function, and chickenpox or flu in children or teenagers. The items noted in options 1, 2, and 3 are not contraindications to this medication.
The clinic nurse is caring for a client who has been prescribed fentanyl, a potent opioid, for chronic pain. In what forms is it available for chronic pain administration in the at-home setting? Select all that apply. 1.Intranasal spray 2.Intravenous push 3.Fentanyl via a patient-controlled analgesia pump 4.Oral transmucosal lozenge 5.72-hour transdermal patch 6.Effervescent buccal oralets
Intranasal spray Oral transmucosal lozenge 72-hour transdermal patch Effervescent buccal oralets Rationale: There are four ways to administer fentanyl for chronic pain. They are as follows: 72-hour transdermal patches, oral transmucosal lozenges, effervescent buccal oralets, and intranasal sprays. Fentanyl administered either intravenous (IV) push or with a patient-controlled analgesia (PCA) pump is given for acute, not chronic, pain.
The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the health care provider at standard doses and frequencies would the nurse question? 1.Ibuprofen by oral route 2.Morphine sulfate by intravenous route 3.Tramadol hydrochloride by oral route 4.Meperidine hydrochloride by intramuscular route
Meperidine hydrochloride by intramuscular route Rationale: Ibuprofen, morphine sulfate, tramadol, and meperidine are all analgesics. Ibuprofen is a nonsteroidal antiinflammatory medication and is acceptable for use in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate and meperidine hydrochloride are both opioid analgesics, and both are effective in treating acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it should be used only short term and is not recommended for use in older clients.
The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate? 1.Naloxone 2.Promethazine 3.Atropine sulfate 4.Protamine sulfate
Naloxone (Narcan) Rationale: Naloxone is an opioid antagonist that is used to treat opioid overdose. Atropine sulfate is an anticholinergic. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin.
The nurse is assessing the status of pain in an alert elderly client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain? Select all that apply. 1.Pain is something that must be lived with. 2.Nurses are too busy to listen to reports of pain. 3.Pain signifies a serious illness or impending death. 4.Reporting pain will result in being labeled as a "bad" client. 5.Expressing pain is only done by people who want attention. 6.Nurses and other caregivers often give too much medication to older clients.
Pain is something that must be lived with. Nurses are too busy to listen to reports or pain Pain signifies a serious illness or impending death Reporting pain will result in being labeled as a "bad" client Rationale: Some beliefs and concerns of older adults about pain include the following: pain is something that must be lived with, nurses are too busy to listen to reports of pain, pain signifies a serious illness or impending death, and reporting pain will result in being labeled as a "bad" client. The options "Expressing pain is only done by people who want attention" and "Nurses and other caregivers often give too much medication to older clients" are not beliefs held by older clients.
A client with a fractured femur who has had an open reduction-internal fixation is receiving ketorolac. Which assessment measurement will assist the nurse in determining the effectiveness of this medication? 1.Pain rating 2.Temperature 3.Serum calcium level 4.White blood cell count
Pain rating Rationale: Ketorolac is a nonopioid analgesic and nonsteroidal antiinflammatory agent. It acts by inhibiting prostaglandin synthesis and produces analgesia that is peripherally mediated. The nurse evaluates the effectiveness of this medication by using the pain rating scale with the client. Options 2, 3, and 4 are unrelated to the use of this medication.
The nurse is caring for a client who had a cholecystectomy 1 day ago. The nurse plans pain-management techniques, knowing that the severity of the client's pain can be related to which factor? 1.Positioning of the client during surgery 2.How long the client had pain before surgery 3.The type of general anesthesia used during surgery 4.The use of nonsteroidal antiinflammatory medications before surgery
Positioning of the client during surgery Rationale: The duration of the operation, the degree of tissue trauma, and the positioning of the client during surgery all may contribute to the presence and severity of postoperative pain. How long the client had pain before surgery, the type of general anesthesia, and nonsteroidal antiinflammatory medications used before surgery are unrelated to the severity of pain in the postoperative period.
The nurse works in a long-term care facility, caring for older clients. The nurse should make which interpretation when an older client complains of pain? 1.Pain is a natural and expected outcome of aging. 2.Something is wrong, and an assessment should be made. 3.Nonpharmacological relief measures are not effective in older clients. 4.It is best to treat the symptom of pain immediately rather than focus on identifying the cause.
Something is wrong, and an assessment should be made. Rationale: A complaint of pain by an older client should be addressed promptly because the pain indicates a physiological problem. Options 1, 3, and 4 are incorrect. Pain is not a natural and expected outcome of aging. Nonpharmacological relief measures such as massages and warm soaks may be effective. The cause of the pain is always assessed before the pain is treated.
The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action should the nurse take first? 1.Stop the IV infusion. 2.Apply ice to the catheter site. 3.Contact the health care provider. 4.Readjust the rate of IV administration.
Stop the IV infusion. Rationale: The IV must be stopped immediately because it has infiltrated. The remaining options allow the IV solution to continue to flow and further exacerbate the infiltration rather than intervene to stop it.
A client is being started on tramadol therapy for pain management after a back injury. When educating this client on tramadol therapy, what is the priority? 1.The client cannot drink alcohol while taking tramadol. 2.The client cannot smoke cigarettes while taking tramadol. 3.The client should increase the intake of calcium-rich foods. 4.The client should avoid additional over-the-counter cough syrups.
The client cannot drink alcohol while taking tramadol. Rationale: The client taking tramadol should not consume alcoholic beverages while taking this medication because it further depresses the central nervous system (CNS). Cigarette smoking does not adversely affect tramadol; however, the client should be discouraged from smoking and encouraged to join a smoking-cessation program for general healthy reasons. The client may need increased calcium, but this is not because of tramadol. The client can take cough syrup with this medication.
The nurse is setting up a transcutaneous electrical nerve stimulation unit on a client with chronic pain. As the nurse turns up the level of stimulation, the client complains of discomfort. Based on this finding, the nurse should make which interpretation? 1.The maximal stimulation has been reached, and it should be decreased slightly. 2.This is a temporary effect, and the stimulation should continue to be increased. 3.The maximal stimulation has been far exceeded, and it should be decreased by half. 4.This is a complication of the device's use, and it should be discontinued immediately.
The maximal stimulation has been reached, and it should be decreased slightly. Rationale: Use of a transcutaneous electrical nerve stimulation (TENS) unit involves applying two electrodes from the machine to the skin and adjusting the level of stimulation to one lead at a time. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximal stimulation necessary to block pain stimuli has been reached. The volume is then reduced by a small amount until no further muscle discomfort or contractions occur. The other options are incorrect.
The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications, that are contraindicated for use with ibuprofen? Select all that apply. 1.Warfarin 2.Glimepiride 3.Amlodipine 4.Simvastatin 5.Hydrochlorothiazide
Warfarin Glimepiride Amlodipine Rationale: Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen can amplify the effects of anticoagulants such as warfarin; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as Glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as Amlodipine; therefore, this combination is contraindicated. Although concurrent use of NSAIDs can result in an antagonistic effect with antihypertensives, it is not a contraindication and the medications can still be taken together; it may be advisable to closely monitor the blood pressure while NSAIDs are being taken, especially in elderly clients. There is no known interaction between ibuprofen and simvastatin.