Pain/Mobility

The pharmacist is teaching a group of staff nurses about multimodal analgesia. When explaining the risks and benefits of multimodal analgesia, which information will the pharmacist include in the teaching? Select all that apply. 1. Prevention of analgesic 2. Reduction in medication doses 3. Increased episodes of uncontrolled pain 4. Increased risk for medication side effects 5. Increased incidence of persistent post surgical pain

1, 2 Rationale Goals of multimodal analgesia include carefully combining analgesics to maximize relief and prevent analgesic gaps that may lead to worsening pain. This approach may allow for a reduction in doses of each of the drugs in the treatment plan. Prevention of analgesic gaps has the potential to decrease, not increase, episodes of uncontrolled pain. A reduction in medication doses has the potential to decrease, not increase, the risk for medication side effects. This approach also offers the promise of reducing, not increasing, the incidence of prolonged or persistent postsurgical 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. 54

Which conditions produce visceral pain? Select all that apply. 1. Colitis 2. Pancreatitis 3. Osteoarthritis 4. Bone metastasis 5. Peripheral vascular disease

1, 2 Rationale Pancreatitis and colitis are associated with visceral pain. Sources of somatic pain include osteoarthritis, bone metastases, and peripheral vascular diseases. p. 48, Table 4-3

The nurse preceptor is evaluating a novice nurse's understanding of pain management for patients with cancer pain. Which statements by the novice nurse are correct? Select all that apply. 1. "Cancer treatments are associated with acute pain" 2. "The majority of cancer pain is the result of tumor growth" 3. Cancer pain usually is present in two or more areas of the body" 4. "Very few patients with cancer report pain at the time of their diagnosis" 5. "Opioid medications are not effective for use in the management of cancer pain"

1, 2, 3 Rationale Cancer treatments can cause acute pain (e.g., from repetitive blood draws and other procedures, surgery, and toxicities from chemotherapy and radiation therapy). Most cancer pain is the result of tumor growth, including nerve compression, invasion of tissue, and/or bone metastasis. Patients with cancer pain generally have pain in two or more areas of the body but usually talk about only the primary area. Many patients with cancer report pain at the time of diagnosis, which increases in advanced stages of the disease. Most cancer pain can be successfully managed by giving adequate amounts of oral opioids around the clock. pp. 46-47

A patient reports increasing pain during dressing changes. Which interventions are recommended for the patient? Select all that apply. 1. Distraction 2. Music therapy 3. Premedication 4. Epidural analgesic 5. Assistance by the patient with the dressing change 6. Transcutaneous electrical nerve stimulation (TENS)

1, 2, 3 Rationale Distraction stimulates efferent nerve fibers and reduces the patient's perception of painful experiences. Music therapy provides a distraction and can reduce the patient's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment. Involving the patient in an uncomfortable dressing change would tend to increase the patient's perception of pain; it is a better tactic to distract the patient. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain such as incisional pain; its use during a dressing change would not be feasible. pp. 65-66

The nurse educator is teaching the nursing student about nociception. When identifying chemicals that are responsible for activating nociceptors during the transduction process, which substances are correct for the nurse educator to include in the discussion? Select all that apply. 1. Serotonin 2. Bradykinin 3. Substance P 4. prostaglandins 5. Endogenous opioids

1, 2, 3, 4 Rationale During transduction, a number of excitatory compounds (e.g., serotonin, bradykinin, histamine, substance P, and prostaglandins) are released that further activate more nociceptors. Endogenous opioids (endorphins) affect pain modulation. p. 47

Which components are included in McCaffery and Pasero's Hierarchy of Pain Measures? Select all that apply. 1. Observing patient behaviors 2. Conducting an analgesic trial 3. Attempting to obtain self-report 4. Using nonpharmocologic interventions 5. Evaluating physiologic indicators of pain

1, 2, 3, 5 Rationale Key components of McCaffery and Pasero's Hierarchy of Pain Measures include requiring the nurse to (1) attempt to obtain a self-report; (2) consider underlying pathology or conditions and procedures that might be painful (e.g., surgery); (3) observe behaviors; (4) evaluate physiologic indicators; and (5) conduct an analgesic trial. Using nonpharmacologic measures is not a component of McCaffery and Pasero's Hierarchy of Pain Measures. p. 53

Why is the oral route preferred for administration of analgesics? Select all that apply. 1. Lease expensive route 2. Well tolerated by most patients 3. Best route to control postoperative pain 4. Can be administered at home or in the hospital 5. Easiest way to control around-the-clock (ART) administration

1, 2, 4 Rationale The oral route is generally the preferred route of administration of analgesics. This is because oral administration is the least expensive, best tolerated, and easiest to administer whether at home or in the hospital. IV administration is preferred for postoperative pain. Any administration route can be effective for ART pain control. p. 54

The nursing student is designing a poster about nociception. Which substances should be included when listing excitatory compounds that activate nociceptors? Select all that apply. 1. Histamine 2. Bradykinin 3. Endorphins 4. Substance P 5. Prostaglandins

1, 2, 4, 5 Rationale Direct stimulation of nociceptors triggers the release of a number of excitatory compounds, including bradykinin, histamine, substance P, and prostaglandins. These excitatory compounds activate additional nociceptors. Endorphins are not excitatory compounds; these chemicals modulate pain and inhibit neuronal activity by binding to opioid receptors. pp. 47, 49, 56

Which are commonly used nonpharmacologic interventions for pain management? Select all that apply. 1. Distraction 2. Acupuncture 3. Magnet therapy 4. Guided imagery 5. Cryotherapy gels 6. Therapeutic touch

1, 2, 4, 6 Rationale Guided imagery, therapeutic touch, distraction, and acupuncture are nonpharmacologic therapies used for pain management. No pharmacologic product or drug is used with these interventions. Cryotherapy gels are pharmacologic interventions consisting of local short-acting gels which are pharmacologic formulations. Magnet therapy uses a pharmacologic product (the magnet) to achieve pain management. pp. 65-66

The nurse is planning nonpharmacologic strategies to alter the patient's pain perception. Which interventions are appropriate for the nurse to include in the patient's plan of care? Select all that apply. 1. Imagery 2 Distraction 3. Antiemetics 4. Hydromorphone PCA 5. Cognitive behavioral therapy

1, 2, 5 Rationale Cognitive behavioral therapy and specific approaches such as imagery and distraction have been developed based on evidence that brain processes can strongly influence pain perception. Pharmacologic interventions for managing pain include administration of antiemetics for treatment of nausea and opioid administration such as hydromorphone via patient-controlled analgesia (PCA). p. 48

A patient who received shoulder arthroscopy for rotator cuff repair a week ago reports severe pain at the surgical site that "travels down the arm." Which responses by the nurse are appropriate? Select all that apply. 1 "Please describe the pain in your shoulders" 2. "Can you rate your pain on a scale from 0-10, with 10 being the worst?" 3. "The surfer should have corrected the pain in your shoulder" 4. "Does the pain hurt less than it did a week ago, before the surgery" 5. "Are there any positions that make your shoulder hurt worse or feel better?"

1, 2, 5 Rationale When assessing the patient for pain, the nurse must accept the patient's subjective report of the pain, as well as look for physical signs or symptoms of the pain. It is appropriate to ask the patient to describe the pain, rate the pain, and discuss whether there are times when the pain goes away or gets worse based on positioning. These can all help the nurse better understand the patient's level of pain, possibly why there is pain, and how to proceed in the patient's care plan. It is not appropriate to tell the patient that the surgery should have corrected this pain; if the patient reports pain, it must be explored. It is inappropriate to ask the patient to compare the pain to before the surgery, as this is not a helpful indicator for why the patient has pain now since it may be unrelated to the presurgical problem. p. 136

Which conditions produce visceral pain? Select all that apply. 1. Bladder spasms 2. Rheumatoid arthritis 3. Intestinal distention 4. Wound complications 5. Nerve compression

1, 3 Rationale Sources of visceral pain include bladder spasms and intestinal distention. Wound complications and rheumatoid arthritis produce somatic pain. Nerve compression causes neuropathic pain. p. 48, Table 4-3

The nurse is preparing a patient for an appendectomy in the emergency department. How does the nurse classify the patient's pain? Select all that apply. 1. Acute 2. Chronic 3. Visceral 4. Somatic 5. Neuropathic

1, 3 Rationale The patient's pain is classified as acute and visceral pain. Acute pain is a sudden pain caused by acute inflammation. Visceral pain arises from the organs and linings of body cavities. Chronic pain is a gradual pain that recurs for indefinite periods, usually for more than 3 months. Somatic pain arises from the skin and musculoskeletal structures. Neuropathic pain arises from nerve fibers, spinal cord, and central nervous system. pp. 46, 48

Which assessment data is most consistent with chronic pain? Select all that apply. 1. Depression 2. Increased heart rate 3. Elevated blood pressure 4. Gradual onset of discomfort 5. Pain that has lasted for 1 month

1, 4 Rationale Effects of chronic pain can include depression and hopelessness for patients and their families. The onset of chronic pain is gradual. Vital signs are not reliable indicators of pain. In particular, because the body adapts to persistent pain, pulse and blood pressure may actually be lower than normal in people with chronic pain. Chronic pain is often defined as pain that lasts or recurs for an indefinite period, usually for more than 3 months. pp. 46-47

What are the advantages of acetaminophen? Select all that apply. 1. It is available in liquid form 2. It has no effect on liver function 3. It has no effect on renal function 4. It can be taken on an empty stomach 5. It is preferred in postoperative patients 6. It has no effect on platelet aggregation

1, 4, 5, 6 Rationale Acetaminophen is available in liquid form. It causes no adverse gastrointestinal effects and can be taken on an empty stomach. It is preferred in postoperative patients because it does not increase the risk of bleeding. It has no effect on platelet aggregation unlike most other non-opioid analgesics. Acetaminophen can impair renal function and liver function as well as cause serious side effects such as nephrotoxicity and hepatotoxicity. pp. 55-56

The primary health care provider instructs the nurse to obtain the patient's pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply. 1. Use a standard pain assessment tool 2. Ask the patient about past pain history 3. Ask the patient to respond immediately 4. Increase features of the scale, such as the font size 5. Repeat the instructions and questions more than once

1, 4. 5 Rationale Using a standard pain assessment tool will help in the correct assessment of the levels of pain. Increased font size and other features of the scale helps provide clarity as the patient responds to the nurse's questions. It is important for the nurse to repeat the instructions and questions more than once. The nurse should allow ample time for the patient to respond. Asking the patient about their present level of pain rather than pain history will help in establishing a line of treatment. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. pp. 48-54

Epidural analgesia is used for acute pain management that includes postoperative pain and chronic cancer pain. What precautions are needed when administering epidural analgesia? Select all that apply. 1. An antiemetic receives the associated nausea and vomiting 2. A high concentration of bupicacaine is used for significant pain relief 3. Lower motor weakness is less with bupivacaine 4. Diphenhydramine relieves the itching side effect of epidural analgesia 5. The patient's respiration and sedation levels are monitored at frequent intervals

1, 5 Rationale An antiemetic may relieve the associated nausea and vomiting of epidural analgesia, which are common side effects of epidural opioids. The patient's respiration and sedation levels are monitored at frequent intervals. Patients who receive epidural opioids are also at risk for respiratory depression resulting from high plasma or cerebrospinal fluid concentrations of the instilled drug. A high concentration of bupivacaine is not used for significant pain relief; rather, low concentrations of local anesthetics are used to prevent significant sensory and motor deficits. Lower motor weakness is less with ropivacaine as compared to bupivacaine. Diphenhydramine, which is an antihistaminic drug, does not relieve the itching side effect of epidural analgesia because epidural-induced pruritus does not appear to be caused by histamine release. pp. 61-63

Gabapentin is an adjuvant analgesic effective in treating fibromyalgia. What statements are correct about gabapentin? Select all that apply. 1. Primary side effects are sedation and dizziness 2. It is helpful in treating pain associated with cancer 3. It is contraindicated in patients who have diabetes 4. It causes serious side effects at doses above 1200 mg daily 5. It is an anticonvulsant drug given for persistent neuropathic pain

1, 5 Rationale Gabapentin is used in treating persistent neuropathic pain. Primary side effects are sedation and dizziness, which are usually transient and most notable during the titration phase of treatment. Gabapentin is an anticonvulsant drug, not a tricyclic antidepressant. It is not contraindicated in diabetes; in fact, it is useful in diabetic neuropathy. Gabapentin can be administered at doses of up to 3600 mg daily with few side effects as compared to other anticonvulsants. pp. 63-64

The nursing student is giving a classroom presentation about neuropathic pain. Which information is appropriate for the nursing student to include in the presentation? Select all that apply. 1. Neuropathic pain involves the abnormal recessing of stimuli 2. Subcategories of neuropathic pain include somatic and visceral pain 3. Neuropathic pain arises from the skin and musculoskeletal structures 4. Examples of neuropathic pain include pain-associated trauma and surgery 5. Neuropathic pain may occur in the absence of tissue damage or inflammation

1, 5 Rationale Neuropathic pain is sustained by the abnormal processing of stimuli. Neuropathic pain may occur in the absence of tissue damage or inflammation. In contrast, nociceptive pain is the result of actual or potential tissue damage or inflammation. Nociceptive pain, not neuropathic pain, is often categorized as being somatic or visceral. Somatic pain arises from the skin and musculoskeletal structures, and visceral pain arises from organs. Examples of somatic pain include pain-associated trauma and surgery. p. 48

Which is a characteristic of nociceptive deep somatic pain? 1. Aching 2. Shooting 3. Stabbing 4. Throbbing

1. Aching Rationale A characteristic of nociceptive deep somatic pain is aching. Throbbing occurs in cutaneous, superficial, or subcutaneous tissues. Shooting pain is associated with neuropathic pain. Stabbing pain occurs with nociceptive visceral pain. p. 48

The nurse is caring for a patient who is receiving intravenous hydromorphone. Prior to administration of the medication, the patient's respiratory rate was 18 breaths per minute. Ten minutes after receiving a dose of hydromorphone, the patient is unarousable and her respiratory rate is 8 breaths per minute. Which action will the nurse implement immediately? 1. Administer naloxone 2. Assess blood pressure 3. Notify the primary health care provider 4. Decrease the next mediation dose by half

1. Administer naloxone Rationale Naloxone, which is an opioid antagonist, is indicated for reversal of opioid-induced respiratory depression and excess sedation. Notification of the primary health care provider may be appropriate, but this is not the priority intervention for treatment of opioid-induced respiratory depression and excess sedation. Blood pressure assessment is not an immediate priority; treatment of respiratory depression is the priority. Administration of any additional opioid medication, including a reduced dose, is contraindicated. p. 57

The nurse suspects that an older patient who is unable to talk is experiencing pain as indicated by grimacing. Which pain assessment tool should the nurse use to rate the patient's pain? 1. Checklist of Nonverbal Pain Indicators 2. Pain Assessment in Advanced Dementia Scale 3. Faces, Legs, Activity, Crying and Consolability Tool 4. Discomfort in Dementia of the Alzheimer's Type Scale

1. Checklist of Nonverbal Pain Indicators Rationale The Checklist of Nonverbal Pain Indicators is based on the work of The American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons. The panel found six common pain indicators that can be observed and documented to indicate pain, including facial grimacing. The Pain Assessment in Advanced Dementia Scale is used to assess pain in patients with dementia. The Faces, Legs, Activity, Crying and Consolability Tool is used to assess pain in children between the ages of 12 months and 7 years or in individuals who are unable to communicate pain. Discomfort in Dementia of the Alzheimer's Type Scale is used to assess pain in older patients with dementia and Alzheimer's disease. With this tool, the nurse observes breathing, negative vocalization, and lack of relaxed body language to assess the patient's pain. p. 54

Which is a nonpharmacological cognitive-behavioral technique that may relieve anxiety in a patient experiencing chronic pain? 1. Distraction 2. Acupuncture 3. Therapeutic touch 4. Diaphragm breathing

1. Distraction Rationale Distraction is an example of a nonpharmacological cognitive-behavioral technique that can relieve anxiety in a patient experiencing chronic pain. Acupuncture, diaphragmatic breathing, and therapeutic touch are nonpharmacological techniques that may help relieve anxiety, but they are physical, not cognitive-behavioral. p. 66

When using McCaffery and Pasero's Hierarchy of Pain Measures, which assessment data corresponds with behavioral signs? 1. Frowning or grimacing during repositioning 2. Ensuring hearing aids are functioning properly 3. Nodding the head to signal the presence of pain 4. Squeezing the eyelids tightly to indicate pain intensity

1. Frowning or grimacing during repositioning Rationale McCaffery and Pasero's Hierarchy of Pain Measures includes behavioral signs such as facial expressions. Head nodding and eye blinking or squeezing the eyelids tightly can be used to signal presence of pain and sometimes used to rate intensity, in which cases these actions represent self-reports of pain. Ensuring that hearing aids are functioning properly is a strategy for ensuring effective use of a self-report tool. p. 53 Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A nurse is guiding a patient with chronic pain through visualizing being on a peaceful beach. This is an example of which type of nonpharmocological anxiety management? 1. Imagery 2. Distraction 3. Relaxation breathing 4. Therapeutic massage

1. Imagery Rationale A patient experiencing chronic pain is also prone to experiencing anxiety. Imagining the sights, sounds, and smells of being on a peaceful beach is an example of using imagery to reduce anxiety. Reading a book or watching television are examples of distraction. The nurse may use relaxation breathing and therapeutic massage in tandem with imagery, but this scenario only illustrates the use of imagery. Test-Taking Tip: Multiple choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Read carefully so that you will answer exactly what the question is asking of you. p. 67

A hospitalized patient anticipates a daily painful dressing change. Which complementary and alternative medicine therapy might the nurse offer before the procedure? 1. Imagery 2. Acupuncture 3. Hydrotherapy 4. Animal-assisted therapy

1. Imagery Rationale Changing dressings or performing other procedures may produce pain for the patient. Imagery can be used to calm and distract the patient from pain. Animal-assisted therapy would be difficult because the nurse will be performing a dressing change, and the animal could get in the way, contaminate the wound, or cause the patient to move around too much. Hydrotherapy may be contraindicated for this patient. Acupuncture is not something that the nurse can easily offer during a dressing change. p. 67

The nurse is caring for a patient who is on opioid therapy. If observed in the patient, which behavior is most important for the nurse to report to the primary health care provider? 1. Impaired control over use 2. Use lasting three or less days 3. Use lasting seen or more days 4. Requests for more doses before he prescribed interval has elapsed

1. Impaired control over use Rationale Impaired control over use of the opioid is the behavior most indicative of addiction. Use lasting three or less days indicates the patient is opioid-naïve, not addicted. Use lasting seven or more days indicates the patient is opioid-tolerant, but not necessarily addicted. Requests for more doses ahead of schedule could potentially indicate addiction, but it might just indicate that the patient's pain is not well controlled or that the patient is anxious about having medication continuously available so that pain does not go unmanaged. p. 57

During which process of pain transmission does an opioid analgesic medication inhibit pain by affecting central mechanisms? 1. Modulation 2. Transmission 3. Perception 4. Transduction

1. Modulation Rationale Nociception means "normal" pain transmission and is generally discussed in terms of four processes: transduction, transmission, perception, and modulation. The inhibition of pain by central and peripheral mechanisms occurs during the modulation process. The initial stimulation of nociceptors occurs during transduction. During transmission, action potentials are transmitted from the periphery toward the CNS. Perception involves the conscious awareness of pain. p. 48

The nurse administers acetaminophen to a patient for treatment of a headache. Which process of nociception is affected by the medication's inhibition of peripheral pain mechanisms? 1. Modulation 2. Transmission 3. Perception 4. Transduction

1. Modulation Rationale Nociception means "normal" pain transmission and is generally discussed in terms of four processes: transduction, transmission, perception, and modulation. The inhibition of pain by central and peripheral mechanisms occurs during the modulation process. The initial stimulation of nociceptors occurs during transduction. Perception involves the conscious awareness of pain. During transmission, action potentials are transmitted from the periphery toward the CNS. pp. 47-48

Which statement is true about assessing pain in an older adult patient? 1. Older adults are at great risk for undertreated pain 2. The nurse should assess for present and past pain 3. Older adults usually believe that pain signifies a minor illness 4. Older adults typically believe that expressing pain is acceptable

1. Older adults are at great risk for undertreated pan Rationale Older adults are at great risk for undertreated pain because of outdated beliefs by some health care providers about older adults' pain sensitivity, tolerance, and ability to take opioids. The nurse should assess only for present pain. Older adults often believe that expressing pain is unacceptable. Pain usually signifies a major illness. p. 59, Chart 4-1

Which statement about opioid addiction is correct? 1. Opioid addiction is a chronic disease that is treatable disease 2. Use of clonidine may increase the distressing symptoms of withdrawal 3. Physical dependence occurs only in older and immunologically compromised patients 4. The opioid-dependent patient's skin may become hot and dry during the withdrawal phase

1. Opioid addiction is a chronic disease that is treatable disease Rationale Opioid addiction is a chronic neurologic and biologic disease. The disease of addiction is a treatable disease and the patient should be referred to an expert for diagnosis and treatment. Physical dependence is observed in all patients who take opioids over a period of time, not only in older and immunologically compromised patients. During the withdrawal phase, the patient's skin feels wet due to excessive perspiration, not hot and dry. Clonidine acts by central inhibition of the hyper-noradrenergic state that occurs during opioid withdrawal. It thus alleviates the distressing symptoms of withdrawal and does not increase them. p. 58

Which class of medications includes nalaxone? 1. Opioid antagonists 2. Opioid analgesics 3. Adjuvant analgesics 4. Nonopioid analgesics

1. Opioid antagonists Rationale Naloxone, which is an opioid antagonist, is indicated for reversal of opioid-induced respiratory depression and excess sedation. Opioid analgesics include fentanyl and morphine. Nonopioid analgesics include acetaminophen and the NSAIDs. Adjuvant analgesics include a variety of agents with unique and widely differing mechanisms of action, such as local anesthetics and some anticonvulsants and antidepressants. p. 57

What is the preferred route of administration of analgesics? 1. Oral 2. Topical 3. Intramuscular 4. Subcutaneous

1. Oral Rationale The oral route is generally the preferred route of administration of analgesics. This is because oral administration is least expensive, best tolerated, and the easiest to administer. Topical, intramuscular, and subcutaneous routes are not commonly used to administer analgesics. These routes are preferable during an emergency and when the oral route is not feasible. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 54

The nurse is caring for four different patients who are experiencing pain. Which patient's assessment data is most consistent with acute pain? 1. Patient A - following surgical repair of a femur fracture, the patient reports that his pain medication is not helping. 2. Patient B - The patient with neck pain reports needing increasing assistance from family members when getting dressed. 3. Patient C - After sustaining a back injury, the patient reports that his energy level has significantly decreased. 4. Patient D - The patient with a lung tumor reports that his pain has spread to his abdomen and back.

1. Patient A Rationale Patient A's assessment data is most reflective of acute pain, which is associated with surgery. Patient B's report of needing increasing assistance from family members is consistent with chronic pain. Because it persists for an extended period, chronic pain can interfere with personal relationships and performance of ADLs, and may lead to increased dependence on family and friends. Patient C's assessment data is consistent with chronic pain, which is often accompanied by multiple quality-of-life and functional adverse effects, including depression and fatigue. Patient D's assessment data is reflective of chronic cancer pain. Patients with cancer pain generally have pain in two or more areas of the body. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the patient in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking. pp. 46-47

The nurse is caring for a patient who has severe pain due to a muscle cramp. Which type of pain does the nurse interpret in the patient? 1. Somatic pain 2. Visceral pain 3. Referred pain 4. Radiating pain

1. Somatic pain Rationale A muscle cramp indicates that the patient has initiation of pain from musculoskeletal tissues. Therefore, the patient has somatic pain. If the patient has pain from large internal organs then it indicates that patient has visceral pain. If the patient has pain at a particular site but an injury at a different site, it indicates referred pain. Radiating pain is felt along a specific nerve or nerves. 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. 48

Which conditions cause acute pain? Select all that apply. 1. Cancer 2. Nephrolithiasis 3. Sprained ankle 4. Failed back surgery 5. Rheumatoid arthritis

2, 3 Rationale Acute pain, such as that experienced from kidney stones or a sprained ankle, is short-lived. It is usually a result of injury or illness that has a definitive end. Conditions such as cancer, failed back surgery, and arthritic pain are chronic. They may have variations in the level of pain from day to day, but the pain does not completely subside for long stretches of time. pp. 46-47

What adverse effects will the nurse monitor for in a patient taking nonsteroidal anti-inflammatory drugs (NSAIDs)? Select all that apply. 1. Hypotension 2. Gastric toxicity 3. Thrombocytopenia 4. Gastrointestinal ulcer 5. Venous thromboembolism

2, 3, 4 Rationale Adverse effects of NSAIDs include gastric toxicity, gastrointestinal ulcer, and thrombocytopenia. Hypotension and venous thromboembolism are not adverse effects of taking NSAIDs. 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. 46

When is pain categorized as being chronic? Select all that apply. 1. It serves a biological purpose 2. It lasts for more than 3 months 3. It is accompanied by depression 4. It ranges from mild to severe intensity 5. It has a gradual onset and persists with time

2, 3, 4, 5 Rationale Chronic pain is characterized by its duration of lasting for more than 3 months, with mild to severe intensity. Such pain is known to start gradually and persists with time. Chronic pain may be accompanied by depression and serves no biologic purpose. Serving a biologic purpose is a feature of acute 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. pp. 46-47

The nurse is assessing a patient reporting pain in the back. What questions does the nurse ask to inquire about the precipitating factors of the pain? Select all that apply. 1. "Did the pain affect our diet and sleep?" 2. "Was the onset of the pain sudden or slow?" 3. "What do you think causes the present pain?" 4. "Have you done anything to relieve the pain?" 5. "What were the results of any steps you took?" 6. "Can you describe where the pain moves to from the back?"

2, 3, 4, 5 Rationale Precipitating factors are factors that trigger or cause the onset of pain. To know about the precipitating factors of the pain, the nurse asks the patient about the nature of the onset of pain, the likely cause, steps taken to relieve the pain, and the results of such steps. Effects of the pain on lifestyle factors, such as diet and sleep, provide information about the aggravating factors. A description of where the pain travels from its site of onset provides information about the localization of the pain. p. 52

Morphine is an opioid that blocks pain transmission. What are the common side effects of morphine? Select all that apply? 1. Diarrhea 2. Pruritus 3. Sedation 4. Allergic reaction 5. Excessive urination 6. Nausea and vomiting 7. Respiratory depression

2, 3, 6, 7 Rationale Morphine acts on the mu receptors. As with other mu receptors, the common side effects of morphine include nausea and vomiting, pruritus, sedation, and respiratory depression. Opioids inhibit peristalsis in the gastrointestinal tract. Patients who take regular doses of morphine almost always have constipation instead of diarrhea. Side effects like nausea, vomiting, and pruritus are sometimes mistaken as allergies, but an allergic reaction to morphine is rare. Morphine causes urinary retention. p. 62

Which cognitive behavioral distractions can be useful in reducing a patient's focus on pain? 1. Massage 2. Medication 3. Aqua therapy 4. Biofeedback 5. Guided imagery

2, 4, 5 Rationale Cognitive behavioral distractions that can be useful in reducing the patient's focus on pain include meditation, biofeedback, and guided imagery. Massage and aquatherapy are physical modalities of nonpharmacological management of pain. Test-Taking Tip: Read the question carefully before looking at the answers: (1) determine what the question is really asking, and look for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect. p. 66

The pain resource nurse (PRN) is teaching a team of staff nurses about the concept of pain. Which statements should the PRN included in the discussion about pain? Select all that apply. 1. "Potential tissue damage will not produce pain"" 2. "The experience of pain is subjective in nature" 3. "The concept of pain cannot be clinically defined" 4. "Pain may be associated with actual tissue damage 5. "An unpleasant sensory experience may cause pain"

2, 4, 5 Rationale Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. McCaffery's (1968) personalized definition, which reflects the subjective nature of pain, states that pain is whatever the experiencing person says it is and exists whenever he or she says it exists. McCaffery's definition has become the clinical definition of pain worldwide. As mentioned previously, pain is associated with potential tissue damage. 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. 46

A patient is brought to the hospital in a state of delirium. Which indicators on the Checklist of Nonverbal Pain Indicators (CNPI) does the nurse use to assess this patient's level of pain? Select all that apply. 1. Breathing 2. Facial expression 3. Lying in bed resting 4. Mental status changes 5. Changes in interpersonal interactions

2, 4, 5 Rationale The patient is in a state of delirium; therefore, the nurse uses the Checklist of Nonverbal Pain Indicators (CNPI). Facial expression, mental status changes, and changes in interpersonal interactions are all groups of behavioral indicators of pain as included under CNPI. Breathing is an indicator used on the Pain Assessment in Advanced Dementia (PAINAD) scale, not the CNPI. Lying in bed resting is not an indicator of pain in the CNPI. Test-Taking Tip: Look for answers that focus on the patient or are directed toward feelings. p. 54

The nurse is providing care for a patient experiencing chronic pain. Which are the characteristics of chronic pain the nurse can anticipate? Select all that apply. 1. The pain is usually reversible 2. The pain serves no useful purpose 3. The pain will decrease with healing 4. The pain usually has a well-defined cause 5. The pain ranges from mild to severe intensity

2, 5

Neuropathic pain is most likely to develop following which procedures? Select all that apply. 1. Femur fracture repair 2. Bilateral mastectomy 3. Total hip replacement 4. Chest tube insertion 5. Leg amputation

2, 5 Rationale Neuropathic pain is a descriptive term used to refer to pain that is believed to be sustained by a set of mechanisms driven by damage to or dysfunction of the peripheral nervous system (PNS) and/or central nervous system (CNS). Examples of neuropathic pain include phantom limb pain, which may develop following amputation of an extremity, and post-mastectomy pain. Orthopedic procedures, such as femur fracture repair and total hip replacement, are most likely to produce nociceptive pain. Chest tube insertion is associated with visceral pain. p. 48, Table 4-3

During assessment of the psychological impact of chronic pain, which question will the nurse ask the patient? 1. "Has your spouse been understanding about your pain?" 2. "How has your daily routine changed because of your pain?" 3. "Do you have friends who provide support when you struggle with pain?" 4. "Would counseling help you learn new strategies for coping with pain?"

2. "How has your daily routine changed because of your pain?" Rationale Open-ended questions are most effective for assessing the psychosocial effects of pain; for example, "How has your daily routine changed because of your pain?" Open-ended questions allow the patient to describe personal attitudes about pain and its influence on life. This opportunity can help someone whose life has been changed by pain. In contrast to open-ended questions, closed-ended questions can be answered with a simple "yes" or "no." Examples of closed-ended questions include "Do you have friends who provide support when you struggle with pain?", "Has your spouse been understanding about your pain?", and "Would counseling help you learn new strategies for coping with pain?" Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer. pp. 52-53

The nurse is performing a comprehensive pain assessment. Which statement by the nurse will be most useful in helping to differentiate between nociceptive and neuropathic pain? 1. "When did you first notice your pain?" 2. "Please describe what your pain feels like" 3. "Please rate your pain using a scale of 0 to 10" 4. ""Is your pain constant, or does it come and go?"

2. "Please describe what your pain feels like" Rationale Asking for a description of the pain addresses the pain's quality, which is the patient's sensory perception of the pain. Descriptions of the quality of pain (such as "sharp," "shooting," or "burning") may help with differentiating between neuropathic and nociceptive pain. Asking the patient to rate the pain using a scale of 0 to 10 addresses the pain's intensity (severity). Questioning the patient about when the pain was first noticed relates to the onset (when the pain started). Questioning the patient about whether the pain is constant or intermittent addresses the duration. p. 52

A patient being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." How does the nurse respond? 1. "I will cancel your medication order" 2. "That sounds like a great plan; can you tell me more about it?" 3. "That sounds like a wonderful idea, and I think it will definitely work!" 4. "Your plan will not work; people with your type of pain need narcotics."

2. "That sounds like a great plan; can you tell me more about it?" Rationale Complementary and alternative therapies should supplement, not replace, medication management. The nurse needs to obtain more data about the patient's plan. Telling the patient that his or her plan will not work is dismissive of the patient. The patient may not need to be prescribed narcotics for the pain. p. 66

A patient with chronic pain feels no relief with high-dose opioids and says, "I just can't manage living right now." What intervention does the nurse anticipate the health care provider will order for this patient? 1. Adding acetaminophen 2. Adding duloxetine as adjuvant therapy 3. Increasing the opioid dose to control the pain 4. Replacing the opioid with duloxetine for depression

2. Adding duloxetine as adjuvant therapy Rationale Both tricyclic and other antidepressants such as duloxetine help treat the depression that can accompany chronic pain. They also stimulate the activity of endogenous opiates (endorphins and enkephalins) by increasing levels of the neurotransmitter serotonin. Adding acetaminophen would not address the patient's depression. Increasing the opioid dose can cause respiratory depression. Discontinuing the opioid can cause relapse pain. pp. 47, 64

Pain duration may be described using which term? 1. Hot 2. Brief 3. Beating 4. Penetrating

2. Brief Rationale "Brief" is a descriptor that is used to describe pain duration. Descriptors such as "beating," "penetrating," and "hot" are used to describe pain quality. p. 52

An older patient reports increasing back pain. Imaging studies show no specific cause for this pain other than mild arthritic changes. what can the nurse conclude about this patient's pain? 1. The patient is experiencing psychosomatic pain 2. Chronic pain can be subjective in nature and is widespread 3. The patient is exaggerating the symptoms to obtain pain medications 4. The patient's pain can be managed with over-the-counter medications

2. Chronic pain can be subjective in nature and is widespread Rationale Inadequately controlled pain is one of the leading causes of disability, especially among older patients. It is not possible to apply standards to all measures of pain because of the subjective nature of pain. Just because there is little clinical evidence of pain does not mean the patient's pain is psychosomatic, that it is easily controlled by over-the-counter medications, or that the patient is exaggerating in an effort to obtain drugs. pp. 45-46

Which condition places the patient at highest risk for undertreatment of pain? 1. Cancer 2. Delirium 3. Traumatic injury 4. Autoimmune disease

2. Delirium Rationale Patients with problems of cognition, such as delirium, are among those at highest risk for undertreated pain because they are unable or have difficulty reporting their pain. Traumatic injuries, cancer-related illnesses, and autoimmune diseases do not necessarily impair cognition. p. 59, Chart 4-1

Which strategy represents correct use of behavioral signs as part of the pain assessment? 1. Asking the patient to rate perceived pain using a numeric scale 2. Identifying specific pain behaviors that are unique to the patient 3. Understanding that pain produces the same behaviors in all patients 4. Recognizing that a behavioral score is the same as a pain intensity score

2. Identifying specific pain behaviors that are unique to the patient Rationale When performing a behavioral pain assessment, the nurse should try to identify pain behaviors that are unique to the patient ("pain signature"). Pain does not produce identical behaviors in all patients; a pain behavior in one patient may not be exhibited by another. The patient's use of a numeric scale to rate pain is part of self-reporting, not behavioral pain assessment. A behavioral score is not the same as a pain intensity score. p. 53

A patient with chronic back pain has unrelieved pain. How does the pain have a significant financial impact? 1. Decreases immune response 2. Increases length of hospital stay 3. Interferes with activities of daily living 4. Impairs family and social relationships

2. Increases length of hospital stay Rationale Unrelieved pain will increase the length of the hospital stay, causing a significant financial impact due to an increased cost of health care and an absence from work. The decrease in immune response is a physiologic, not financial, impact. The interference with activities of daily living and impaired family and social relationships are the impacts on the quality of life of the patient, but not always the patient's finances. p. 46

The registered nurse is working with a student nurse who is trying to help gauge the level of pain in a patient who is unable to use other tools of communication. Which action by the student nurse needs correction? 1. Establishing a reliable yes-no signal 2. Misinterpreting lip-reading by eye contact 3. Using communication, picture, and alphabet boards 4. Ensuring that the patient's dentures are in before speaking

2. Misinterpreting lip-reading by eye contact Rationale Lip-reading by eye contact may serve as a potent tool for communicating pain levels. However, its misinterpretation will lead to improper assessment of the actual level of pain that the patient is having. At times, when the patient is unable to use other tools of communication to convey his or her levels of pain, the nurse can establish a reliable yes-no signal, or use communication, picture, or alphabet boards. The patient should have their dentures in when trying to speak. Test-Taking Tip: Be alert for details. Details provided in the stem of the item can provide a clue to the most appropriate response. p. 54

Which is a hydrophilic drug? 1. Fentanyl 2. Morphine 3. Methadone 4. Hydromorphine

2. Morphine Rationale A hydrophilic drug readily dissolves in water. Morphine is a classic example of a hydrophilic drug. Fentanyl and methadone are lipophilic or capable of dissolving in lipids. Hydromorphine is less hydrophilic than morphine and also less lipophilic than fentanyl. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. Recall what you know and proceed to give your answer. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. p. 59

Which drug is he gold standard opioid for both acute and chronic pain? 1. Codeine 2. Morphine 3. Methadone 4. Hydrocodone

2. Morphine Rationale In medicine, "gold standard" means the "best available" drug, test, or procedure with which others are compared. Morphine is the gold standard opioid for both acute and chronic pain. It is available in many dosage strengths (both short- and long-acting) and can be given through almost any route. Codeine is a slow-acting, weak drug mainly used for cough relief rather than pain relief. Hydrocodone is similar to codeine and is available in combination with acetaminophen and ibuprofen, but it is rarely used for controlling pain because of added toxicities from these non-opioids. Methadone is very effective as a pain reliever but its action is very complex and is potentially unsafe because of cardiac toxicity. pp. 56-57

The nurse is caring for patients in the emergency department. Which patient should limit opioid analgesic use? 1. Patient A - Migraine headache 2. Patient B - Acute kidney disease 3. Patient C - Joint replacement 4. Patient D - Peripheral artery disease

2. Patient B Rationale Opioid analgesics bind to opioid receptors found in the central and peripheral nervous systems and in the gastrointestinal tract. Opioids can cause respiratory depression and should not be used with such patients. Opioids are effective in the treatment of cancer pain, after joint replacement surgery, and for chronic pain. p. 56

Use of the term "scalding" applies to which component of pain assessment? 1. Onset 2. Quality 3. Intensity 4. Duration

2. Quality Rationale Descriptors such as "scalding" are used to describe pain quality, which refers to the patient's sensory perception of the pain. Intensity refers to severity of pain. Onset refers to when the pain started. Duration addresses whether the pain is constant or intermittent. p. 52

Which component of pain assessment is addressed by the patient describing his pain as "searing"? 1. Onset 2. Quality 3. Intensity 4. Duration

2. Quality Rationale Descriptors such as "searing" are used to describe pain quality, which refers to the patient's sensory perception of the pain. Intensity refers to severity of pain. Onset refers to when the pain started. Duration addresses whether the pain is constant or intermittent. p. 52

The nurse is attending to a patient with colon cancer at the hospital. What does the nurse teach the patient about administering prescribed oxycodone? 1. Break and crush the contents 2. Swallow the medication whole 3. Dissolve the contents in water 4. Chew the medication before swallowing

2. Swallow the medication whole Rationale The nurse teaches the patient how to swallow the drug completely as oxycodone is a time-release drug. The drug should not be broken, crushed, chewed, or dissolved in water or it will lose effectiveness. p. 59

On assessment of a patient who has osteoarthritis the nurse finds hat the patient has localize pain on palpation and rubs the lower back frequently. The patient complain of an irregular pattern of pain and is irritated when asked to rate the pain. What does the nurse document in the patient's assessment findings? 1. The patient has acute pain 2. The patient has chronic pain 3. The patient has visceral pain 4. The patient has referred pain

2. The patent has chronic pain Rationale The patient has an irregular pattern of pain, swelling in the knee, and frequently rubs the lower back. This indicates that the patient has chronic pain with increased intensity. The patient's pain is due to osteoarthritis, but not to short-term injury. Therefore, it indicates that the patient does not have acute pain. The patient does not have pain due to damage of large internal organs. Therefore, the patient is not experiencing visceral pain. The patient has localized pain in the area of palpation but not at a different site. Therefore, it is not referred pain. pp. 46-47

After assessing a patient, the nurse concludes that the patient has deep somatic pain. Which findings in the patient support the nurses conclusion? 1. The patient has pain due to burn injuries 2. The patient has pain due to deep venous thrombosis 3. The patient has intestinal pain with severe stomach pain 4. The patient has coronary syndrome with pain in the neck

2. The patient has pain due to deep venous thrombosis Rationale The patient who has pain due to damage in blood vessels, joints, and tendons experiences deep somatic pain. Deep venous thrombosis indicates damage to the blood vessels; therefore, the patient experiences deep somatic pain. Intestinal pain with severe stomach cramps indicates that the patient has visceral pain. The patient experiencing pain due to burn injuries indicates that the patient has cutaneous somatic pain. The patient who has coronary disease experiences pain in the neck; this indicates that the patient has referred pain. p. 48

Which term best describes the condition where continuous exposure to a drug leads to a decrease in the drug's effects over time? 1. Addiction 2. Tolerance 3. Pseudoaddiction 4. Physical dependence

2. Tolerance Rationale Tolerance is a normal response that occurs with regular administration of an opioid and consists of a decrease in one or more effects of the opioid. Addiction is a primary, chronic neurological disease that is characterized by behaviors that can include impaired control over drug use, compulsive use, continued use despite harm, and craving. Pseudoaddiction is an iatrogenic syndrome created by the undertreatment of pain. It is characterized by patient behaviors such as anger and escalating demands for more or different medications, and results in suspicion and avoidance by staff. Physical dependence is an adaptation manifested by a drug-class - it is a specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. p. 58

Which pain scale is most appropriate for the nurse to use when assessing pain in a 6-year-old child? 1. Faces pain scale 2. Wong-Baker FACES 3. Numeric rating scale 4. Verbal descriptor scale

2. Wong-Baker FACES Rationale The pain scale most appropriate for a 6-year-old child is the Wong-Baker FACES pain scale, which consists of six cartoon faces with word descriptors. This scale is developmentally appropriate for a child this age. The faces pain scale contains seven faces and uses a numeric rating associated with the faces. This scale is used for a cognitively impaired adult. The numeric rating scale uses numbers throughout the scale with words anchored at each end and in the middle of the scale. The verbal descriptor scale is used for a patient that can select a phrase to describe the pain. p. 50

Which are aspects of a multimodal analgesic approach? Select all that apply. 1. Produces increased side effects 2. Leads to minor changes in pain relief 3. Makes use of two or more classes of analgesics 4. Prevents analgesic gaps that may lead to worsening of pain 5. Involves lower doses of drug administration in the treatment plan

3, 4, 5 Rationale Multimodal analgesic treatment involves the use of two or more classes of analgesics. It prevents analgesic gaps that may lead to worsening of pain or unnecessary episodes of uncontrolled pain. Lower doses of a drug are generally administered as a part a multimodal approach. Multimodal analgesic treatment is effective for prolonged or persistent postsurgical pain. Multimodal analgesic treatment uses a combination therapy of different analgesics to maximize pain relief. Multimodal analgesia uses lower doses of medication so the risk of side effects is reduced. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. p. 54

Which patient's statement is consistent with the experience of visceral pain? 1. "My foot feels numb and painful" 2. "I have a dull ache in my knees" 3. "My entire abdomen is cramping" 4. "I feel pain shooting down my legs"

3. "My entire abdomen is cramping" Rationale Visceral pain, which involves the organs and the linings of body cavities, is diffuse, poorly localized, and may involve cramping. Painful numbness is associated with neuropathic pain. Shooting pain also is associated with neuropathic pain. Dull, aching bone pain is consistent with somatic pain. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Take some deep breaths for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension. p. 48

The nurse is planning a dressing change on a postoperative mastectomy patient. The patient is receiving acetaminophen and oxycodone orally for pain every 4 hours and is due to receive them at 4 PM. When will the nurse change the dressing? 1. 3:30 PM 2. 4:00 PM 3. 4:30 PM 4. 7:00 PM

3. 4:30 PM Rationale About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a patient. At 4:30 PM, the opioid has had time to take effect and provide relief for the patient. It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 PM), because the pain medication will be at its lowest concentrations in the patient's system. At 4:00 PM, the analgesic has not had time to enter the patient's system, so it is too soon to perform the dressing change. If the patient received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 PM to facilitate a dressing change with minimal discomfort. p. 58

A patient with cancer is receiving low-dose oral morphine but is reporting both "breakthrough" pain and constipation. What intervention does the nurse implement first? 1. Records the patient's bowel movements 2. Decreases the morphine dosage for the patient 3. Administers docusate sodium and Gabapentin as ordered 4. Five the patient a Fleet's (sodium biphosphate) enema

3. Administers docusae sodium and Gabapentin as ordered Rationale Docusate is a stool softener, and gabapentin is an adjuvant for breakthrough pain. Constipation is a side effect of morphine, but decreasing the morphine dose will cause this patient's pain to become even worse. Giving an enema is not the first intervention that should be tried by the nurse. Recording bowel movements is helpful for assessment, but does nothing to relieve the patient's constipation. p. 63

After administering a dose of opioids, the nurse evaluates the patient using the Pasero's Opioid Sedation Scale (POSS) and documents a 1. What patient behavior does this indicate? 1. Somnolence 2. Slight drowsy 3. Awake and alert 4. Asleep but easy to arouse

3. Awake and alert Rationale A Pasero Opioid Sedation Scale (POSS) score of 1 indicates the patient is awake and alert. If the patient is somnolent, the nurse will record a 4. If the patient is asleep but easy to arouse, the nurse will record an S. If the patient is slightly drowsy, the nurse will record a 2. p. 64

The nurse is performing a pain assessment on an alert, mechanically ventilated patient. Which patient behavior has the potential to provide the most useful assessment data for determining pain intensity? 1. Crying 2. Smiling 3. Blinking 4. Grimacing

3. Blinking Rationale Self-reports are the most accurate measures of pain. For patients who are unable to verbally or manually rate the intensity of their pain, alternative methods of communication may include blinking. During a pain assessment, behavioral signs are secondary in value to self-reporting. Behavioral signs include facial expressions, such as smiling and grimacing. Vocalizations such as crying or groaning are also behavioral signs, which are secondary in value compared to self-reports. p. 54

Which term is used to describe pain quality? 1. Steady 2. Periodic 3. Cramping 4. Intermittent

3. Cramping Rationale Cramping is a descriptor that is used to describe pain quality. Descriptors such as "steady," "intermittent," and "periodic" are used to describe pain duration. p. 52

A patient with chronic osteoarthritis is prescribed celecoxib as an analgesic. What makes this drug beneficial for long-term use? 1. Decreased risk for acute renal failure 2. Decreased risk for cardiovascular disease 3. Decreased risk for gastrointestinal bleeding 4. Decreased risk for fluid retention in the body

3. Decreased risk for gastrointestinal bleeding Rationale Celecoxib is a cyclooxygenase-2 (COX-2) inhibitor that causes effective pain relief without associated gastrointestinal bleeding generally seen with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). Renal side effects are similar to those with the non-selective NSAIDs. All COX-2 inhibitors, including celecoxib, are associated with an increase in cardiovascular disease. Fluid retention in the body occurs due to the renal effects of analgesic drugs; thus, celecoxib shows no difference in fluid retention when compared to other analgesics. p. 56

A patient with chronic osteoarthritis is prescribed celery in as an analgesic. What makes this drug beneficial for long-term use? 1. Decreased risk for acute renal failure 2. Decreased risk for cardiovascular disease 3. Decrease risk for gastrointestinal bleeding 4. Decreased risk for fluid retention in the body

3. Decreased risk for gastrointestinal bleeding Rationale Celecoxib is a cyclooxygenase-2 (COX-2) inhibitor that causes effective pain relief without associated gastrointestinal bleeding generally seen with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). Renal side effects are similar to those with the non-selective NSAIDs. All COX-2 inhibitors, including celecoxib, are associated with an increase in cardiovascular disease. Fluid retention in the body occurs due to the renal effects of analgesic drugs; thus, celecoxib shows no difference in fluid retention when compared to other analgesics. p. 56

A hospitalized patient expresses satisfaction after using a recommended complementary and alternative medicine (CAM) therapy, saying that pain was diminished and anxiety reduced. Which CAM did the patient most likely use? 1. Herbs 2. Tai chi 3. Imagery 4. Homeopathy

3. Imagery Rationale Imagery is often used for reducing pain, nausea and vomiting, and anxiety. The remaining CAM therapies are not typically used for pain control. Herbs are typically used as a means to promote health, prevent disease, or cure a variety of ailments. Homeopathic medicine uses small doses of specially prepared plant extracts and minerals to promote healing. Tai chi integrates body movements, mind concentration, muscle relaxation, and breathing to achieve a desired outcome. pp. 66-67

A postoperative patient is vomiting and states. "I am having a lot of pain - about a 7 on a scale of 0 to 10." Which route of administration does the nurse choose to administer an analgesic to the patient? 1. Oral 2. Rectal 3. Intravenous 4. Transdermal

3. Intravenous Rationale The intravenous route is the best choice for fast relief of nausea and pain. Oral pain medication may exacerbate the patient's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes. p. 54

Fentanyl is an opioid which can be administered through the transdermal route to relieve pain. Which factors are considered disadvantages of the transdermal route of opioid administration? 1. It is contraindicated in patients with neutropenia 2. It cannot be used in patients with cognitive impairment 3. It needs to be supplemented with other analgesics initially 4. Long-term use is associated with fibrosis and steroidal abscesses

3. It needs to be supplemented with other analgesics initially Rationale There is gradual increase in plasma concentration of the drug, so a supplemental analgesic is given for the first 12 to 18 hours after initial application. Transmucosal and intranasal routes cannot be used in patients with cognitive impairment; the transdermal route, however, can. Long-term use by the intramuscular route causes fibrosis and sterile abscesses; long-term use by the transdermal route is not known to cause these side effects. In patients with neutropenia, the rectal route is contraindicated; the transdermal route is acceptable. Text Reference: p. 59

Which group of medications includes fentanyl? 1. NSAIDS 2. Adjuvants 3. Opioid analgesics 4. Nonopioid analgesics

3. Opioid analgesics Rationale Fentanyl is an opioid analgesic. Nonopioid analgesics include acetaminophen and the NSAIDs. Adjuvant analgesics include a variety of agents with unique and widely differing mechanisms of action, such as local anesthetics and some anticonvulsants and antidepressants. p. 55

The nurse is conducting a pain assessment. Which assessment data in the most reliable indicator of the patient's pain? 1. Dilated pupils 2. Profuse sweating 3. Pain rating of 3 on 0-10 scale 4. Heart rate of 104 beats per minute

3. Pain rating of 3 on 0-10 scale Rationale Self-report such as describing the level of pain on a 0-10 scale is always the most reliable indication of pain. Brief acute pain serves a biologic purpose in that it acts as a warning signal by activating the sympathetic nervous system and causing various physiologic responses. Sweating and pupillary dilation, as well as an increase in heart rate and blood pressure may be associated with activation of the sympathetic nervous system due to pain; however, these responses are not consistent in all people. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 46

A patient with extensive burn injuries is to be weaned from long term opioid use. What type of opioid dependence does the nurse expect this patient to have? 1. Addiction 2. Equianalgesia 3. Physical dependence 4. Pseudoaddiction

3. Physical dependence Rationale Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the patient who is opioid-dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms. Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the patient's situation. Equianalgesia refers to the dose and route of administration of one drug that produces about the same degree of analgesia as the given dose and route of another drug; this term is used when switching opioids or routes of opioids. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the patient's situation. p. 58

Which term describes pain produces by inflammation of the trigeminal nerve (trigemina neuralgia) that is diffuse in nature, extending across the various nerves that innervate the face? 1. Localized 2. Radiating 3. Projected 4. Referred

3. Projected Rationale Pain that is caused by inflammation of the trigeminal nerve (trigeminal neuralgia) and that is diffuse in nature (as opposed to being well-localized), extending across the entire face is an example of projected pain. Radiating pain is a sensation that is felt along a specific nerve or nerves. Referred pain is felt in an area distant from the site of painful stimuli. Localized pain is confined to the site of origin. p. 50

Which data is most likely reliable for use in assessment of a patient's pain> 1. Emotional responses 2. Behavioral alterations 3. Subjective patient reports 4. Objective physiologic changes

3. Subjective patient reports Rationale Subjective descriptions of the experience and measurement of pain intensity are more reliable and accurate than observable qualities of pain. All accepted guidelines identify the patient's self-report as the gold standard for assessing the existence and intensity of pain (Pasero & McCaffery, 2011). Because the amount of pain and responses to it vary from person to person, interpreting pain solely on actions or behaviors, including emotional responses, can be misleading and is not recommended. Physiologic changes are not reliable indicators of pain, as patients may report pain in the absence of any observable or documented physiologic changes. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. p. 46

The health care provider has reduced the postsurgical patient's dose of morphine from 15 mg to 4 mg. Which nursing assessment would have prompted this change in orders? 1. The patient was somnolent 2. The patient was slightly drowsy 3. The patient drifted off to sleep during conversation 4. The patient had no response to verbal communication

3. The patient drifted off to sleep during conversation Rationale The dose of the opioid should be reduced 25-50% for a postoperative patient when the patient drifts off to sleep during conversation. When the patient is somnolent, the nurse should administer an opioid antagonist. When the patient is slightly drowsy, the dose of the drug can be increased. The nurse should stop the opioid drug administration when the patient does not respond to verbal communication. p. 64

A patient with acute pain from a muscle tear is prescribed an opioid analgesic drug. On the follow-up visit the primary health care provider prescribes senna to the patient along with the opioid analgesic. What is the likely reason for this intervention? 1. The patient has nausea 2. The patient has pruritic 3. The patient has constipation 4. The patient has double vision

3. The patient has constipation Rationale Senna is a peristalsis stimulant that helps reduce constipation caused by opioid analgesics. Nausea is a common side effect of opioid analgesia but it is not treated with senna. Pruritis is reduced with antihistamines, not senna. Double vision is not a side effect associated with opioid analgesics. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. p. 63

A nurse is caring for a patient who has been undergoing opioid medication therapy for the past three weeks. The patient has become demanding, persistently asking for an increase in the dose, even before it is time for the next dose, and a change in the medication. What is the nurse most likely to report to the primary health care provider regarding the patient's behavior? 1. The patient is addicted to opioids 2. The patient has developed a tolerance to opioids 3. The patient has developed a pseudoaddiction to opioids 4. The patient has developed a physical dependence on opioids

3. The patient has developed a pseudoaddiction to opioids Rationale Pseudoaddiction may manifest as signs and symptoms similar to addiction. It is common in patients on opioid therapy for whom the pain isn't under control. Once it is controlled, the signs will subside. A patient who is addicted will display impaired control over the drug and continue using the medication even if it is causing harm. Tolerance most commonly occurs within two weeks of starting the medication, a sign of which is reduced effectiveness of the medication. Physical dependence occurs due to sudden withdrawal of the symptoms. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. p. 58

Which strategy is most useful for pain assessment in the alert patient who is mechanically ventilated? 1. Observing for restlessness 2. monitoring facial expressions 3. Unsung a communication board 4. Identifying mental status changes

3. Using a communication board Rationale Self-reports are the most accurate measures of pain. For patients who are mechanically ventilated or may not be able to use other tools for communication, interventions to facilitate self-reporting include using a communication board. During a pain assessment, behavioral signs are secondary to self-reporting. Behavioral signs include facial expressions, body movements (such as restlessness), and mental status changes. p. 54

The nurse is teaching the patient about visceral pain following laparoscopic surgery. Which description of this type of postoperative pain is accurate? 1. "You are likely to experience pain at the incisional site" 2. "You may experience muscle spasms for a few days" 3. "You will feel an aching pressure near your shoulder or collarbone" 4. "You will experience poorly localized shooting, burning, and tingling sensations"

3. You will feel an aching pressure near your shoulder or collarbone Rationale Visceral pain comes from an organ and may be referred to another part of the body. Following laparoscopic surgery, abdominal distention from injected air can cause diaphragmatic pain that is referred to the shoulder. Incisional pain and muscle spasms are examples of somatic pain. Poorly localized shooting, burning, and tingling sensations indicate neuropathic pain that is unlikely to be caused by this type of surgery. p. 48

The nurse is assessing a patient who is reporting pain. Which questions would the nurse ask to determine if the pain is chronic in nature? Select all that apply. 1. Was your pain caused by something specific? 2. Is your pain sharp in quality? 3. Has your pain improved with healing? 4. Have your experienced sleeplessness or fatigue because of your pain? 5. Has your pain interfered with your ability to work or go about your daily life?

4, 5 Rationale Chronic pain lasts for 3 or more months and takes a toll on the person's life. To determine if pain is chronic, the nurse may ask if the patient has experienced sleeplessness or fatigue because of the presence of pain and if the pain interferes with the patient's quality of life. If the patient has a definite source of pain that is sharp in quality and is resolving as the source of pain is healing, this implies that the pain is acute, not chronic. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. p. 46

The nurse preceptor is educating the novice nurse about the use of McCaffery and Pasero's Hierarchy of Pain Measures. Which statement by the nurse preceptor accurately describes this tool? 1. "This tool assumes patients are unable to self-report their pain" 2. "The Hierarchy of Pain Measures replaces self-reporting of pain" 3. "This tool prioritizes behavioral pain assessment over self-reporting" 4. "The Hierarchy of Pain Measures includes behavioral pain assessment"

4. "The Hierarchy of Pain Measures includes behavioral pain assessment" Rationale McCaffery and Pasero's Hierarchy of Pain Measures provides several strategies for promoting self-reporting of pain by patients. Included in this tool are measures for use in behavioral pain assessment. Rather than replacing self-reporting of pain, this tool prioritizes self-reporting. The Hierarchy does not assume that patients are unable to self-report pain. Instead, this tool incorporates behavioral pain assessment tools for use in patients who are unable to self-report. p. 53

The nurse is caring for a patient who has a history of osteoarthritis and peptic ulcer disease. Which analgesic medication will the nurse anticipate administering to the patient? 1. Aspirin 2. Ibuprofen 3. Naproxen 4. Acetaminophen

4. Acetaminophen Rationale Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice in patients with comorbidities such as peptic ulcer disease. NSAIDs, which include ibuprofen, naproxen, and aspirin, are contraindicated in individuals with peptic ulcer disease. NSAIDs have more adverse effects than acetaminophen, with gastric toxicity and ulceration being the most common of the adverse effects. pp. 55-56

A patient reports sharp, shock-like, burning, shooting pain in the feet and legs that is associated with numbness. The nurse suspects that the patient is experiencing what condition? 1. Pancreatitis 2. Bone metastasis 3. Rheumatoid arthritis 4. Diabetic neuropathy

4. Diabetic neuropathy Rationale Neuropathic pain is usually sharp, shock-like, burning, and stabbing pain. Diabetic neuropathy is a neuropathic disorder associated with diabetes mellitus and involves injury to the small blood vessels, nerve fibers, spinal cord, and central nervous system. A patient with pancreatitis experiences diffuse and deep cramping. A patient with bony metastases and rheumatoid arthritis will most likely experience dull, aching pain with cramps. 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. 52

Which nursing action reflects correct use of the Wong-Baker FACES Pain Rating Scale? 1. Matching a face shown on the scale to the patient's facial expression 2 Instructing the patient to choose a phrase that best describes the pain 3. Asking the patient to rate the pain using a horizontal 0-to-10 scale 4. Encouraging the patient to choose a cartoon face that best represents the pain

4. Encouraging the patient to choose a cartoon face that best represents the pain Rationale The Wong-Baker FACES® Pain Rating Scale consists of 6 cartoon faces with word descriptors, ranging from a smiling face on the left for "no pain (or hurt)" to a frowning, tearful face on the right for "worst pain (or hurt)." The faces are most commonly numbered 0 to 10. Patients are asked to choose the face that best describes their pain. It is important to appreciate that faces scales are self-report tools; clinicians should not attempt to match a face shown on a scale to the patient's facial expression to determine pain intensity. The Numeric Rating Scale (NRS) is usually presented as a horizontal 0- to 10-point scale, with word anchors of "no pain" at one end of the scale, "moderate pain" in the middle of the scale, and "worst possible pain" at the end of the scale. The Verbal Descriptor Scale (VDS) uses different words or phrases to describe the intensity of pain, such as "no pain, mild pain, moderate pain, severe pain very severe pain, and worst possible pain." The patient is asked to select the phrase that best describes the pain intensity. p. 52

The nurse is establishing a plan of care for a hospitalized patient with chronic pain caused by fibromyalgia. Which nursing action does the nurse delegate to a nursing assistant? 1. Application of a transcutaneous electrical nerve stimulation (TENS) device 2. Education about nonpaharmacologic interventions for pain control 3. Referral to available community resources for pain management 4. Engagement in conversation about the patient's family to distract the patient

4. Engagement in conversation about the patient's family to distract the patient Rationale Distraction techniques such as conversation, music, and television may be implemented by unlicensed nursing staff members. Application of a TENS unit, education about nonpharmacologic pain interventions, and community resource referrals require specialized nursing education and scope of practice and should be performed by licensed nursing staff. p. 66

The nurse is attending to a patient who is terminally ill with leukemia and in severe pain. What is the realistic outcome for this patient? 1. Reducing levels of medications 2. Living remaining days free of pain 3. Participation in activities of daily living 4. Experiencing improved quality of life

4. Experiencing improved quality of life Rationale The nurse strives to achieve a realistic outcome by assisting the patient to experience improved quality of life by controlling pain at a desired level. Terminal pain may never be completely resolved without medication. As a patient's condition declines in the terminal phases, the patient may be unable to participate enthusiastically in the care procedure because of a decline in level of consciousness and progression of disease. p. 50

Which type of chronic non cancer pain do veterans of recent wars most often experience? 1. Nociceptive 2. Neuropathic 3. Neurological 4. Musculoskeletal

4. Musculoskeletal Rationale Veterans of recent wars most often experience musculoskeletal pain. They experience neuropathic and nociceptive pain less often, and while the neurological system is affected by pain, pain is not classified as neurological. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 47

The nurse is caring for a patient with type 1 diabetes with an A1C frequently at 9%. The patient is complaining of a "burning" feeling in both feet. Which type of pain is the patient experiencing? 1. Perceptual 2. Neurogenic 3. Nociceptive 4. Neuropathic

4. Neuropathic Rationale The patient is experiencing neuropathic pain. The underlying mechanism of neuropathic pain is damage to or dysfunction of the peripheral nervous system and/or the central nervous system. High blood sugar in diabetics causes nerve damage resulting in neuropathies. Neurogenic pain arises from or is caused by the nervous system and is a phrase that encompasses more than just neuropathic pain. Perceptual pain is not a category of pain. Nociceptive pain is the result from actual or potential tissue damage or inflammation and is often categorized as somatic or visceral. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten. p. 48

Which is a risk factor for opioid-induces respiratory depression? 1. Smoking 2. Immobility 3. Age below 40 years 4. Obstructive sleep apnea

4. Obstructive sleep apnea Rationale Obstructive sleep apnea is a risk factor for opioid-induced respiratory depression. Smoking is a risk factor for respiratory problems such as chronic obstructive pulmonary disease and cough, but not for opioid-induced respiratory depression. Immobility is a risk factor for opioid-induced constipation, not respiratory depression. Age over 55 years, not below 40, is a risk factor for opioid-induced respiratory depression. p. 64

Which information will the nurse prioritize when analyzing data obtained during a pain assessment to determine the amount of pain the patient is experiencing? 1. Blood pressure 184/92 2. Grimacing during movement 3. Withdrawing from socialization 4. Pain rating of 6 on a scale of 0 to 10

4. Pain rating of 6 on a scale of 0 to 10 Rationale All accepted guidelines identify the patient's self-report as the gold standard for assessing the existence and intensity of pain (Pasero & McCaffery, 2011). The patient's subjective measurement of pain using a valid pain rating scale for measurement of pain intensity provides the priority data. Subjective descriptions of the experience and measurement of pain intensity are more reliable and accurate than observable qualities of pain. Responses to pain vary from person to person, so interpreting pain solely on actions (such as withdrawing from socialization) or behaviors (such as grimacing during movement) can be misleading and is not recommended. Physiologic changes, including blood pressure, are not reliable indicators of pain. p. 46

The nurse is caring for a group of patients in a health care center. Which patient does the nurse conclude had referred pan? 1. Patient 2 who has skin burns 2. Patient 3 who has menstrual pain 3. Patient 4 who has shoulder fracture 4. Patient 1 who has acute appendiicitis

4. Patient 1 who has acute appendicitis Rationale Referred pain is the pain which is sensed at the site different from origin of injury. Patient 1 who has appendicitis has an inflamed appendix in the upper right quadrant of abdomen but has sensation of pain in umbilical area. This indicates that the patient has referred pain. Patient 2 has deep throbbing pain due to skin burns, which indicates that the patient has cutaneous pain. Patient 3 has menstrual pain and severe vomiting, which indicates that the patient has somatic pain. Patient 4 has pain due to shoulder fracture, which indicates that the patient has somatic pain. Test-Taking Tip: Be alert and observant regarding the answer choices. Some options may seem closely related to the correct answer and may divert your attention. p. 50

The nurse is caring for four different patients who are experiencing pain. Which patient's assessment data is most consistent with projected pain? 1. Patient A - The patient who is diagnosed with sciatica reports pain that starts in her lower back and runs down both of her legs 2. Patient B - The patient who sustain a right humerus fracture reports experiencing pain in his right upper arm 3. Patient C - The patient who is having a myocardial infarction (heart attack) denies chest pain, but reports feeling right jaw pain 4. Patient D - The patient who is diagnosed with herpes zoster (shingles) reports feeling the sensation of pain all over his body

4. Patient D Rationale Projected pain is diffuse around the site of origin and is not well localized; for example, the generalized pain associated with herpes zoster (shingles). Sciatica pain that originates in the lower back and extends into both legs is an example of radiating pain, which is a sensation that is felt along a specific nerve or nerves. Referred pain is felt in an area distant from the site of painful stimuli; for example, jaw pain that occurs in relationship to a myocardial infarction (heart attack). Localized pain is confined to the site of origin; for example, pain at the site of a humerus fracture. p. 50

A postoperative patient is receiving epidural analgesia and reports itching. What does the nurse do next? 1. Call the surgeon 2. Gives an antiemetic 3. Give a diphenhydramine 4. Reduces the analgesic dose

4. Reduces the analgesic dose Rationale Pruritus (itching) is a common side effect of epidural opioids and is first treated by reducing the analgesic dose. Because epidural-induced pruritus does not appear to be caused by histamine release, diphenhydramine may not be effective in relieving itching and may work only via its sedating effects. Antiemetics are given to relieve nausea and vomiting. If a health care provider needs to be called, it would be the anesthesiologist, not the surgeon. p. 62

When caring for a patient who is receiving morphine, the nurse prioritizes assessing for which medication side effect? 1. Tolerance 2. Constipation 3. Nausea and vomiting 4. Respiratory depression

4. Respiratory depression Rationale Respiratory depression is a potentially life-threatening side effect of opioid analgesics, such as morphine. Additional side effects associated with opioid medications such as morphine include tolerance, nausea and vomiting, and constipation; however, these effects are not life threatening. p. 56

The nurse is preparing a care plan for a patient with lower back pain and hypothyroidism who has been prescribed acetaminophen. Which instruction would the nurse give regarding this medication? 1. "The drug is not contraindicated if there is a bleeding episode" 2. "It is acceptable to take the drug along with propoxyphene" 3. Do not take more than 6000 mg per day" 4. "Schedule regular renal and liver function tests"

4. Schedule regular renal and liver function texts Rationale Acetaminophen is antipyretic and analgesic and has several side effects. Renal and hepatic toxicities may occur with prolonged use of this drug. The nurse should remind the patient to have renal and hepatic function tests performed regularly to avoid complications. Acetaminophen has poor antiplatelet action. The nurse should not recommend the drug to a patient who is bleeding. The maximum daily dose of this medication is 4000 mg of acetaminophen per day. Patients with hypothyroidism should be taught to avoid taking acetaminophen and propoxyphene concurrently. The half-life of propoxyphene increases in patients with a low metabolism, as in hypothyroidism, so the effects of the medication can be toxic. p. 55

A patient suffering from pain for the past couple of months visits a primary health care provider. Following the initial interview, the primary health care provider concludes that the patient is suffering from neuropathic pain. Which finding in the patient's history supports this conclusion? 1. Dull, aching with cramps 2. Sharp, burning sensation 3. Poorly localized but diffused pain 4. Shooting, burning, shock-like sensation with painful numbness

4. Shooting, burning, shock-like sensation with painful numbness Rationale Neuropathic pain is the result of abnormal processing of pain message from the site of injury to the nerve fiber. It is characterized by shooting, burning, shock-like sensation with painful numbness. Dull, aching with cramps represents nociceptive pain in the connective tissue. Nociceptive pain develops on stimulation of functioning nerve fibers. Sharp, burning sensation denotes nociceptive pain in the skin or superficial level. Poorly localized but diffused pain is characteristic of nociceptive pain in the visceral organs. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question. p. 48

A patient asks the nurse for information about transcutaneous electrical nerve stimulation (TENS). What does the nurse tell the patient? 1. Very fine needles are inserted in the painful area. 2. Patients are assisted through a sequence of thoughts. 3. Electrodes are implanted into the skin in the nerve area. 4. Small electrical currents are applied to the painful area.

4. Small electrical currents are applied to the painful area. Rationale Small electrical currents are applied to the painful area with TENS therapy; voltage is regulated based on the amount of pain relief and level of comfort needed. In acupuncture, very fine needles are inserted in the painful area. In case of temporary or permanent nerve blocks, spinal cord stimulation is performed by implanting electrodes into the skin in the nerve area. In the guided imagery procedure, the patient is assisted through a sequence of thoughts. p. 66

A patient who has mild abdominal pain is prescribed ibuprofen. What instruction does the nurse five to the patient? 1. Take the mediation with grape juice 2. Stop taking the mediation if you have itching 3. Take the mediation on an empty stomach 4. Stop taking the mediation if you have bleeding

4. Stop taking the medication if you have bleeding Rationale Ibuprofen is a nonsteroidal anti-inflammatory drug that may increase gastrointestinal bleeding. Therefore, the nurse instructs the patient to stop medication if bleeding occurs. Grape juice increases absorption of the drug. Therefore, ibuprofen should not be taken with grape juice. Ibuprofen may cause gastric irritation if taken on empty stomach. Ibuprofen does not cause or aggravate itching. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 56

Which factor contributes to the development of acute pain for the patient with cancer? 1. Tumor growth 2. Bone metastasis 3. Invasion of tissue 4. Surgical procedures

4. Surgical procedures Rationale For the patient with cancer, related treatments such as surgery can cause acute pain. Chronic cancer pain results from tumor growth, including nerve compression, invasion of tissue, and/or bone metastasis. p. 46

The nurse is teaching a patient about the administration of a prescribed liquid form of acetaminophen. What information does the nurse include when advising this patient? 1. Take medication after meals 2. Observe for gastric discomfort 3. Observe for bleeding or bruising 4. Take (a maximum up to) 4000 mg/day

4. Take (a maximum up to) 4000 mg/day Rationale The nurse teaches the patient not to exceed the specified quantity of medication which is 4000 mg per day. Frequent high doses can lead to hepatotoxicity and nephrotoxicity. Liquid acetaminophen is taken on empty stomach and has no adverse GI effects. It has no effect on platelet aggregation and hence, it is a safe option for patients who are prone to bleeding. p. 55

A patient with fibromyalgia is scheduled to receive noninvasive, non pharmacological pain management treatment. The nurse identifies that which substances will be released in the body during treatment? 1. Opioids 2. Endorphins 3. Substance P 4. Cyclooxygenase-1 (COX-1)

Endorphins Rationale Morphine-like substances called endorphins are released when large-diameter nerve fibers are stimulated. These fibers close the gate and decrease pain transmission. This helps explain why many noninvasive pain management techniques work to relieve pain. Opioids are drugs that bind to opioid receptors to reduce pain. Substance P is a pain neurotransmitter that promotes the pain threshold. The enzyme COX-1 converts arachidonic acid into many chemicals that are further processed into substances that continue the inflammatory response in the tissues. p. 48

A patient with colon cancer experiences constant, excruciating abdominal pain. What is most likely triggering the patient's pain? 1. Invasion of tissue 2. Impulse blockage 3. Muscle-splitting 4. Sympathetic nervous response

Invasion of tissue Rationale A patient with colon cancer experiences severe pain because of invasion of tissue metastasis. Impulse blockage is common in chronic non-cancer pain. Thoracic and upper intra-abdominal surgeries involve muscle-splitting that causes pain during movement. Sympathetic nervous response causes a fight-or-flight reaction in instances of acute pain. p. 46

Which term is used to describe pain duration? 1. Splitting 2. Crushing 3. Gnawing 4. Momentary

Momentary Rationale "Momentary" is a descriptor that is used to describe pain duration. Descriptors such as "splitting," "crushing," and "gnawing" are used to describe pain quality. p. 52

The nurse is caring for a postoperative patient who had an abdominal hysterectomy. What approach to pain management is the most appropriate to integrate but the plan o care to address this patient's pain? 1. Patient-controlled analgesia 2. Intrathecal medication pump 3. Multimodal analgesic approach 4. Around-the-clock medication dosing

Multimodal analgesic approach Rationale A multimodal analgesic approach is the most appropriate measure to integrate into the plan of care to address pain following an abdominal hysterectomy. This treatment involves the use of two or more classes of analgesics or interventions to target different pain mechanisms in the peripheral and central nervous systems. The intrathecal medication pump is used for chronic pain. Patient-controlled analgesia is an interactive method of management that allows patients to treat their own pain by self-administering doses of analgesics, but it may require supplemental dosing. Around-the-clock dosing is effective for the first 24 to 48 hours after surgery, but supplemental dosing for breakthrough pain may be needed. p. 54

The nurse is caring for four patients who are experiencing pain. Which patient's assessment findings are consistent with neuropathic pain? 1 Patient A - Following abdominal surgery, the patient describes a dull, aching pain at the site of her surgical incision 2. Patient B - The patient who sustained a forehead abrasion reports burning pain at the site of the injury 3. Patient C - The patient reports sharp, shooting left leg pain. No visible signs of trauma are present and the patient denies any known injury 4. Patient D - While hospitalized for dehydration, the patient reports aching and cramping in his legs, as well as calf muscle spasms

Patient C Rationale Neuropathic pain, which is sustained by the abnormal processing of stimuli, may occur in the absence of either tissue damage or inflammation. Sharp, shooting pain sensations are characteristic of neuropathic pain. In contrast, nociceptive pain is the result of actual or potential tissue damage or inflammation and is often categorized as being somatic or visceral. Sources of somatic pain include damage to the skin and subcutaneous tissues, such as burn-related injuries and skin incisions. Common descriptors of somatic pain related to skin injury include burning, dull, and aching. Skeletal muscle spasms, including calf muscle spasms, are an example of deep somatic pain, which is often described as dull, aching, or cramping. p. 48

Which component of pain assessment is addressed by the patient describing his pain as "searing"? 1. Onset 2. Quality 3. Intensity 4. Duration

Quality Rationale Descriptors such as "searing" are used to describe pain quality, which refers to the patient's sensory perception of the pain. Intensity refers to severity of pain. Onset refers to when the pain started. Duration addresses whether the pain is constant or intermittent. p. 52

Which component of a comprehensive pain assessment is most helpful for differentiating between nociceptive and neuropathic pain? 1. Intensity 2. Quality 3. Onset 4. Duration

Quality Rationale Quality refers to the patient's sensory perception of the pain. Descriptions of the quality of pain (such as "sharp," "shooting," or "burning") may help identify the presence of neuropathic pain. Intensity (severity of pain), onset (when the pain started) and duration (whether the pain is constant or intermittent) may be similar for nociceptive and neuropathic pain. p. 52

Which term describes pain that originates at the site of a herniated cervical disk and extends into the arm, hand, and fingers? 1. Radiating 2. Projected 3. Localized 4. Referred

Radiating Rationale Pain that originates at the site of a herniated cervical disk and extends into arm, hand, and fingers is an example of radiating pain, which is a sensation that is felt along a specific nerve or nerves. Referred pain is felt in an area distant from the site of painful stimuli. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. p. 50

Which condition is associated with neuropathic pain? 1. Appendicitis 2. Radiculopathy 3. Liver metastasis 4. Rheumatoid arthritis

Radiculopathy Rationale Radiculopathies produce neuropathic pain. Rheumatoid arthritis is associated with somatic pain. Appendicitis and liver metastases produce visceral pain. p. 48, Table 4-3

The nurse is preparing a plan of care for a patient who has received a prescription for fentanyl through a patient-controlled analgesia pump. The nurse should question the prescription if the patient has a history of what? 1. Bell's palsy 2. Cataracts 3. COPD 4. West Nile Virus

Rationale Rationale: Fentanyl is a potent opioid agonist and may cause respiratory depression. It should be used with caution in patients with decreased respiratory reserve or potentially compromised respiration. No extra precautions are needed for patients with a history of Bell's palsy, cataracts, or West Nile Virus; they are not at an increased risk of an adverse effect. p. 55

Which term describes back pain caused by pancreatitis? 1. Radiating 2. Localized 3. Referred 4. Projected

Referred Rationale Back pain that is caused by pancreatitis is an example of referred pain, which is felt in an area distant from the site of painful stimuli. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Radiating pain is felt along a specific nerve or nerves. p. 50

Which term describes right should pain caused by gallstones? 1. Projected 2. Referred 3. Localized 4. Radiating

Referred Rationale Right shoulder pain related to gallstones is an example of referred pain, which is felt in an area distant from the site of painful stimuli. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Radiating pain is felt along a specific nerve or nerves. p. 50

Which pain rating scale requires the patient to select the phrase that best corresponds with the pain intensity? 1. The Verbal Descriptor Scale (VDS) 2. The Wong-Baker FACES Pain Rating Scale 3. The Numeric Rating Scale (NRS) 4. The Faces Pain Scale-Revised (FPS-R)

The Verbal Descriptor Scale (VDS) Rationale The Verbal Descriptor Scale (VDS) uses different words or phrases to describe the intensity of pain, such as "no pain, mild pain, moderate pain, severe pain very severe pain, and worst possible pain." The patient is asked to select the phrase that best describes the pain intensity. The Wong-Baker FACES® Pain Rating Scale consists of 6 cartoon faces with word descriptors, ranging from a smiling face on the left for "no pain (or hurt)" to a frowning, tearful face on the right for "worst pain (or hurt)." The faces are most commonly numbered 0 to 10. Patients are asked to choose the face that best describes their pain. It is important to appreciate that faces scales are self-report tools; clinicians should not attempt to match a face shown on a scale to the patient's facial expression to determine pain intensity. The Faces Pain Scale-Revised (FPS-R) has 7 faces to make it consistent with other scales using the 0 to 10 metric. The faces range from a neutral facial expression to one of intense pain. As with the Wong-Baker FACES® scale, patients are asked to choose the face that best reflects their pain. The Numeric Rating Scale (NRS) is usually presented as a horizontal 0- to 10-point scale, with word anchors of "no pain" at one end of the scale, "moderate pain" in the middle of the scale, and "worst possible pain" at the end of the scale. pp. 51-52

Which term is used to describe pain duration? 1. Pulling 2. Tugging 3. Transient 4. Pressing

Transient Rationale "Transient" is a descriptor that is used to describe pain duration. Descriptors such as "pulling," "tugging," and "pressing" are used to describe pain quality. p. 52

Which pain radiating scale makes use of six cartoon faces with word descriptors to depict pain levels in a patient? 1. Verbal descriptor scale 2. Numeric rating scale (NRS) 3. Faces pain scale-revised (FPS-R) 4. Won-Baker FACES pain rating scale

Wong-Baker FACES pain rating scale Rationale The Wong-Baker FACES pain scale makes use of six cartoon faces with words describing the intensity of pain. A verbal descriptor scale uses a set of words or phrases to describe the intensity of pain. A numeric rating scale (NRS) is a horizontal 0-to-10 point scale with word anchors such as "no pain'' at one end and "worst possible pain'' at the end of the scale. The faces pain scale-revised (FPS-R) is similar to the Wong-Baker FACES pain rating scale, with seven kinds of facial expressions to adjudge the assessment of pain. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 50

Which condition is most likely to lead to the development of somatic pain? 1. Bladder spasms 2. Limb amputation 3. Intestinal distention 4. Wound complications

Wound complications Rationale Wound complications produce somatic pain. Bladder spasms and intestinal distention are associated with visceral pain. Limb amputation is associated with phantom limb pain, which is neuropathic in nature. p. 48

Which drug should be administered to reverse opioid-induced respiratory depressions? 1. Nalaxone 2. Ketamine 3. Oxycodone 4. Gabapentin

1. Nalaxone Rationale Nalaxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Nalaxone is administered slowly until the patient awakens and breathes properly thereby reducing respiratory depression. Ketamine is a N-methyl-D-aspartate (NMDA) antagonist used as an anesthetic to reduce pain perception. However, it is not effective to reduce respiratory depression. Oxycodone is a mu opioid agonist given to relieve pain caused by cancer. Gabapentin is an anticonvulsant used for treating surgical pain as a part of postoperative treatment. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 57

Which statement about opioid addiction is correct? 1. Opioid addiction is a chronic disease that is a treatable disease. 2. Use of clonidine may increase the distressing symptoms of withdrawal. 3. Physical dependence occurs only in older and immunologically compromised patients. 4. The opioid-dependent patient's skin may become hot and dry during the withdrawal phase.

1. Opioid addiction is a chronic disease that is a treatable disease. Rationale Opioid addiction is a chronic neurologic and biologic disease. The disease of addiction is a treatable disease and the patient should be referred to an expert for diagnosis and treatment. Physical dependence is observed in all patients who take opioids over a period of time, not only in older and immunologically compromised patients. During the withdrawal phase, the patient's skin feels wet due to excessive perspiration, not hot and dry. Clonidine acts by central inhibition of the hyper-noradrenergic state that occurs during opioid withdrawal. It thus alleviates the distressing symptoms of withdrawal and does not increase them. p. 58

A patient had a hip replacement 2 days ago and reports having a moderate amount of pain, stating that it is "a 7 on a 0-to-10 scale" of intensity. What intervention has the highest priority in the patient's nursing care plan? 1. Using preemptive analgesia 2. Encouraging diversion all activities 3. Teaching key points of the relaxation response 4. Incorporating activities of daily living as soon as possible

1. Using preemptive analgesia Rationale Use of preemptive analgesia is a technique designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay. Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the patient to perform activities of daily living (ADLs) is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. p. 54

What are the common side effects of non-steroidal anti-inflammatory drugs (NSAIDS) when they are used in older adults? Select all that apply. 1. Confusion 2. Neal toxicity 3. Bleeding episodes 4. Excessive sedation 5. Hyperkalemia 6. Gastrointestinal problems

2, 3, 6 Rationale Common side effects of NSAIDs in older adults include gastrointestinal problems, bleeding episodes, sodium and water retention, and renal toxicity. Excessive sedation may occur with the use of opioid analgesics, but is not seen with non-opioid analgesics like NSAIDs. Confusion and seizures may occur due to the accumulation of a toxic metabolite (normeperidine) when meperidine is used in the older adult patient; most agencies have discontinued its use because of its toxic effects. Hyperkalemia is not associated with use of NSAIDs. p. 56

What physiologic response will the patient experience related to unrelieved pain? 1. Reduced oxygen demand 2.. Decreased gastric motility 3. Suppressed stress response 4. Prolonged immune response

2. Decreased gastric motility Rationale Unrelieved pain causes a decrease in gastric motility. In response to unrelieved pain, oxygen demand increases rather than decreases. Rather than suppressing the stress response, unrelieved pain prolongs the stress response. The immune response is decreased rather than prolonged due to unrelieved pain. p. 46, Table 4-1

Which term is the patient most likely to use when describing neuropathic pain? 1. Dull 2. Shooting 3. Aching 4. Cramping

2. Shooting Rationale Common descriptions of neuropathic pain include shooting, burning, and fiery. Deep somatic pain is typically described as dull, aching, or cramping. P. 48

Which term is the patient most likely to use when describing neuropathic pain? 1. Dull 2. Shooting 3. Aching 4. Cramping

2. Shooting Rationale Common descriptions of neuropathic pain include shooting, burning, and fiery. Deep somatic pain is typically described as dull, aching, or cramping. p. 48

A patient rates their pain at a 2 or 3 on a pain rating scale on a calibrated 0-to-10. How does the nurse interpret this finding? 1. The patient has no pain 2. The patient has mild pain 3. The patient has severe pain 4. The patient has moderate pain

2. The patient has mild pain Rationale On a pain rating scale, 2 or 3 would indicate mild pain. A pain rating of 0 means no pain. At 7 or higher, severe pain is implied; and moderate pain is at the middle of the scale, denoted by 5. p. 50

A postoperative patient is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the patient before administering the medication? 1. "Are you bleeding?" 2. "Are you really hurting every 4 hours?" 3. "Is your pain controlled between doses?" 4. "What do you do for pain when you're at home?"

3 "Is your pain controlled between doses?" Rationale Asking the patient about the frequency of pain and how the pain is being controlled helps in formulating an effective pain management plan. Asking the patient about the occurrence of bleeding does not address the pain issue; it is a separate problem. Indicating that the patient isn't really hurting sounds judgmental and places the patient on defense. Asking what the patient does for pain at home is helpful in assessing chronic pain, but not for assessing postoperative pain; it is not relevant in this scenario. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude. p. 52

Which objectives are accomplished by conducting an analgesic trial for a cognitively impaired patient? Select all that apply. 1. Determining the cause of pain 2. Assessing the severity of pain 3. Confirming the presence of pain 4. Estimating the patient's pain tolerance 5. Establishing a basis for a pain treatment plan

3, 5 Rationale An analgesic trial may be conducted to confirm the presence of pain and to establish a basis for developing a treatment plan if pain is thought to be present. An analgesic trial is not used to determine the cause of the patient's pain, nor is it used to estimate pain tolerance. Assessment of severity of pain, which requires self-reporting, cannot be accomplished by way of an analgesic trial. p. 59

The nurse if preparing to assess pain in a patient with peripheral vascular disease. Which open-ended question is appropriate for this assessment? 1. "Are you feeling well today?" 2. "Does it hurt when you walk?" 3. "How does your pain affect your job?" 4. "Do you take medication as directed by your primary care provider?"

3. "How does your pain affect your job?" Rationale In a patient with peripheral vascular disease, arteries that supply blood to the heart and peripheral tissue are narrow, which can cause severe leg pain. The nurse should ask open-ended questions such as, "How does your pain affect your job?" to assess the severity of pain. Closed questions that can be answered with "Yes" or "No" are less effective for pain assessment. Examples of closed questions include "Are you feeling well today?", "Does it hurt when you walk?", and "Do you take medication as directed by your primary health care practitioner?" p. 53

Which term describes back pain caused by pancreatitis? 1. Radiating 2. Localized 3. Referred 4. Projected

3. Referred Rationale Back pain that is caused by pancreatitis is an example of referred pain, which is felt in an area distant from the site of painful stimuli. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Radiating pain is felt along a specific nerve or nerves. p. 50

The nurse is attending to an Asian-American patient who cannot communicate in English. What tool does the nurse use when assessing the pain of the patient? 1. Percent Relief Scale 2. 0-10 Numeric Pain Distress Scale 3. Wong-Baker FACES Pain Rating Scale 4. Simple Descriptive Pain Distress Scale

3. Wong-Baker FACES Pain Rating Scale Rationale When assessing the pain of a patient who does not understand English, the nurse should use the Wong-Baker Faces Pain Rating Scale. This scale is also useful for children, older adults, and developmentally disabled patients. The Percent Relief Scale, Simple Descriptive Pain Distress Scale, and 0-10 Numeric Pain Distress Scale are used most commonly in clinical practices for adults who are able to communicate well in English. p. 51

Which intervention facilitates nursing assessment of the severity of the patient's pain? 1. Obtaining a self-report 2. Measuring vital signs 3. Observing behavioral signs 4. Conducting an analgesic trial

1. Obtaining a self-report Rationale Of these interventions, only self-report allows for assessment of pain severity. Behavioral signs, analgesic trials, and vital signs are not reliable sources of data related to pain severity. p. 46