Ch 44 Pain Management NCLEX Q'S
Reasons for untreated pain by health care providers include:
(1) inadequate knowledge and skills to assess pain; (2) unwillingness to believe patients' reports of pain; (3) lack of time, expertise, and perceived importance of regular pain assessments; (4) inaccurate and inadequate information about addiction, tolerance, respiratory depression, and other side effects of opioids; and (5) the fear that aggressive pain management may hasten nor cause death.
(Table 10-2, p. 128) The biopsychosocial model of pain acknowledges the multidimensional nature of pain. The five dimensions are:
(1) physiologic, (2) affective, (3) cognitive, (4) behavioral), and (5) sociocultural.
Nociception includes four processes:
(1) transduction, (2) transmission, (3) perception, and (4) modulation.
Three segments are involved in nociceptive signal transmission:
(1) transmission along the peripheral nerve fibers to the spinal cord, (2) dorsal horn processing, and (3) transmission to the thalamus and the cerebral cortex.
____ 9. When should the nurse assess pain? 1) Whenever a full set of vital signs is taken 2) During the admission interview 3) Every 4 hours for the first 2 days after surgery 4) Only when the patient complains of pain
1
____ 24. A patient had a bowel resection 5 days ago. Which request by the patient might alert the nurse that the patient has a history of substance abuse? 1) Oral pain medication once every 6 to 8 hours 2) Patient-controlled analgesic 3) Oral pain medications instead of the IM form 4) Only nonpharmacological pain measures
2
Increasingly higher doses of opioid are needed to control pain. Correct
28. The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? • Increasingly higher doses of opioid are needed to control pain. • The patient needed a substantial dose of naloxone (Narcan). • The patient asks for pain medication close to the time it is due around the clock. • The patient no longer experiences sedation from the usual dose of opioid.
For what age should the nurse use the OUCHER tool?
3 - 13 years
Ask the patient to rate and describe the pain.
30. The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? • Call the rapid response team. • Ask the patient to rate and describe the pain. • Raise the head of the bed. • Administer pain relief medications.
Accurate Dosage
4g max in 24 hrs for Acetamionphen and Acetylsalicylic Acid 3200 mg for ibuprofen Large doses of opioids are acceptable in opioid tolerant patients but not in opioid naive patients.
Addiction
A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
Cancer Pain
Can be acute or chronic Cancer pain is normal (nociceptive), resulting from stimulus of an undamaged nerve and/or neuropathic, arising from abnormal or damaged pain nerves. A patient senses pain at the actual site of the tumor or distant to the site, called referred pain. Always completely assess reports of new pain by a patient with existing pain.
Concomitant Symptoms
Caused by pain: nausea, dizziness, depression, constipation, urge to urinate, restlessness
Idiopathic pain
Chronic pain without identifiable physical or psychological cause
gender and culture
Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive
postoperative cognitive dysfunction
Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder
32. Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? • Administer pain medication before any activity. • Provide intravascular bolus as needed for breakthrough pain. • Give medications around-the-clock. • Administer pain medication only when nonpharmacological measures have failed.
Give medications around-the-clock. Correct
C. the client must be believed about perceptions of own pain The client must be believed and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to other options in developing the treatment plan.
In applying the principles of pain treatment, what is the first consideration? A.treatment is based on client goals B. a multidisciplinary approach is needed C. the client must be believed about perceptions of own pain D. drug side effects must be prevented and managed
lorazepam (Ativan)
Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion
5. The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? • Neurological factors • Competency of the surgeon • Meaning of pain • Postoperative support personnel
Meaning of pain Correct
Commonly Used topical agents:
NSAID products (ketoprofen patch) and capsaicin. ** ex: The Lidoderm patch is a topical analgesic effective for cutaneous neuropathic pain, such as postherpetic neuralgia, in adults. Place three patches, cut to size, on and around the pain site using a 12-hour on, 12-hour off schedule.
Breakthrough Pain
Pain that occurs between doses of pain medication **A patient can be given a total of 2 units of transmucosal fentanyl per episode of breakthrough pain.
Acute/transient pain
Protective, identifiable, short duration; limited emotional response
8. A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? • Relaxation and guided imagery • Transcutaneous electrical nerve stimulation (TENS) • Herbal supplements with analgesic effects • Pudendal block
Relaxation and guided imagery Correct
What is an example of a thermal stimulus?
Sunburn
what is tidal volume
Tidal volume is a measure of the amount of air a person inhales during a normal breath
An appropriate nonopioid analgesic for mild pain is (select all that apply) a. oxycodone. b. ibuprofen (Advil). c. lorazepam (Ativan). d. acetaminophen (Tylenol). e. codeine with acetaminophen (Tylenol #3).
b. ibuprofen (Advil, and d. acetaminophen (Tylenol). Nonopioid analgesics include acetaminophen, aspirin and other salicylates, and nonsteroidal antiinflammatory drugs (NSAIDs).
A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? a. Transient pain b. Superficial pain c. Phantom pain d. Referred pain
d. Referred pain
A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of: a. Pruritus b. Urinary retention c. Vomiting d. Respiratory depression
d. Respiratory depression
ISAP "Declaration of Montreal"
declared that access to pain management is a fundamental human right (IASP, 2015). Nurses are legally and ethically responsible for managing pain and relieving suffering.
2. A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? • "Your vitals do not show that you are having pain; can you describe your pain?" • "You do not look like you are in pain." • "OK, I will go get you some narcotic pain relievers immediately." • "What would you like to try to alleviate your pain?"
"What would you like to try to alleviate your pain?"
Examples of Opioids
- Morphine (IV/PO) - Hydromorphone (Dilaudid) (IV/PO) - Oxymorphone - Butorphanol - Hydrocodone (PO) -Oxycodone (PO) - Fentanyl - Etorphine - Buprenorphine - Pentazocine - Methadone - Codeine - Tramadol - Diphenoxlate, Loperamide, Apomorphone Most are available in a short-acting form, which provides relief for about 4 hours; some are also available in longer-acting preparations (oral morphine, oxycodone, hydromorphone, and a transdermal fentanyl patch). (Potter 1035)
____ 2. A patient diagnosed with lung cancer who is receiving morphine (MS Contin) complains of constipation. Which instruction(s) by the nurse might help relieve the patients constipation? Choose all that apply. 1) Be sure the amount of fruit, vegetables, and fiber in your diet is adequate. 2) Drink at least eight 8-ounce glasses of water each day. 3) Avoid using stool softeners because they may become habit forming. 4) Increase your exercise routine to include 1 hour of exercise a day.
1,2
Persons with __________ loci of control perceive themselves as having control over events in their life and the outcomes such as pain; persons with ____________ loci of control perceive that other factors in their life, such as nurses, are responsible for the outcome of events.
1. Internal 2. External
Anxiety and fear
17. The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? • Age and gender • Anxiety and fear • Culture • Previous pain experience
For what age should the nurse use the FLACC tool?
2 months - 7 years
"What would you like to try to alleviate your pain?"
2. A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? • "Your vitals do not show that you are having pain; can you describe your pain?" • "You do not look like you are in pain." • "OK, I will go get you some narcotic pain relievers immediately." • "What would you like to try to alleviate your pain?"
Use the FACES scale.
22. The nurse knows that which technique is best for assessing pain in a child who is 4 years of age? • Ask the parents if they think their child is in pain. • Use the FACES scale. • Ask the child to rate the level of pain on a 0 to 10 pain scale. • Check to see what previous nurses have charted.
"I need to reassess the patient's pain 1 hour after administering oral pain medication." Correct
24. A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? • "This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." • "The patient is sleeping, so I pushed her PCA button for her." • "I need to reassess the patient's pain 1 hour after administering oral pain medication." • "It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."
The nurse asks a patient to rate his pain from no pain to unbearable pain. Which pain rating scale is the nurse using for pain assessment? 1 Oucher scale t2 Numeric rating scale (NRS) 3 Visual analogue scale (VAS) 4 Verbal descriptor scale
3 The VAS assesses the pain level in the patient by rating the pain along a 10-centimeter line in 1-centimeter increments from no pain to unbearable pain. The Oucher scale requires the patient to look at six faces with different expressions and point at the face that best matches the pain he or she is experiencing. With the NRS, the nurse asks the patient to choose a number to rate the level of pain. With the verbal descriptor scale, the nurse asks the patient to describe his or her feelings about the intensity of pain.
Which drug is unsafe for the central nervous system as a supplement to epidural anesthesia? 1 Aspirin 2 Naproxen 3 Ibuprofen 4 Oxycodone
4 Because opioid analgesics like oxycodone depress the central nervous system, they are not safe in combination with epidural anesthesia because of possible additive central nervous system adverse effects. Aspirin, naproxen, and ibuprofen are nonsteroidal antiinflammatory drugs (NSAIDs) which do not affect the central nervous system.
6. The nurse anticipates administering an opioid fentanyl patch to which patient? • A 15-year-old adolescent with a broken femur • A 30-year-old adult with cellulitis • A 50-year-old patient with prostate cancer • An 80-year-old patient with a broken hip
A 50-year-old patient with prostate cancer Correct
lumbar puncture positioning before and after
Before lumbar puncture, clients are placed in the side-lying fetal position or hunched seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of a post-puncture headache from the loss of cerebrospinal fluid
Family members are encouraging your client to "tough it out" rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family's wishes. Priority nursing interventions for this client should target which dimension of pain? A.Sensory B.Affective C.Sociocultural D.Behavioral E.Cognitive
C. Sociocultural The family is part of the sociocultural dimension of pain. They are influencing the client and should be included in the teaching sessions about the appropriate use of narcotics and about the adverse effects of pain on the healing process. The other dimensions should be included to help the client/family understand overall treatment plan and pain mechanism
What are dermatomes?
Dermatomes are areas on the skin that are innervated primarily by a single spinal cord segment. The distinctive pattern of the rash cause by _____ across the back and trunk is determined by dermatomes.
C.PT 14 seconds When a client takes aspirin, monitor for increases in PT (normal range 11.0-12.5 seconds in 85%-100%). Also monitor for possible decreases in potassium (normal range 3.5-5.0 mEq/L). If bleeding signs are noted, hematocrit should be monitored (normal range male 42%-52%, female 37%-47%). An elevated BUN could be seen if the client is having chronic gastrointestinal bleeding (normal range 10-20 mg/dL).
For a client who is taking aspirin, which laboratory value should be reported to the physician? A. Potassium 3.6 mEq/L B. Hematocrit 41% C.PT 14 seconds D. BUN 20 mg/dL
high-flow oxygen delivery devices
High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, exacerbation COPD, type II respiratory failure [hypercarbic]).
postoperative positioning of a client post right sided mastectomy
Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling. Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over the next few postoperative days. Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks of the mastectomy. laying in semi-fowler's promotes lung expansion Placing the client in a high-Fowler's position immediately after anesthesia might cause a decrease in blood pressure and subsequent dizziness. Resting the affected side's arm on the bed would place the arm in a dependent position, which would lead to swelling due to decrease in lymphatic and venous drainage.
care for coronary artery bypass graft
Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows: 1. Wash incisions daily with soap and water in the shower. Gently pat dry 2. Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves 3. Tub baths should be avoided due to risk of introducing infection 4. Do not apply powders or lotions on incisions as these trap the bacteria at the incision 5. Report any redness, swelling, and increase in drainage or if the incision has opened 6. Wear a supportive elastic hose on the legs. 7. Elevate legs when sitting to decrease swelling
side effect of opioids
Itching (pruritus) and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), and an antiemetic, such as ondansetron (Zofran), can provide relief.
Key points: _________________ commonly underreport pain and believe that it is unacceptable to show/express pain
Older Adults
Restorative and Continuing Care for Pain:
Pain clinics, palliative care, and hospices Pain centers treat patients on an inpatient or outpatient basis. The goal of palliative care is to learn how to live life fully with an incurable condition. Hospices are programs for end-of-life care. The American Nurses Association (ANA) supports aggressive treatment of pain and suffering, even if it hastens a patient's death.
Nursing Process and Pain
Pain management needs to be systematic. Pain management needs to consider the patient's quality of life. > Clinical guidelines are available to manage pain: American Pain Society Sigma Theta Tau National Guidelines Clearinghouse
postmortem care
Postmortem care is conducted with respect and dignity. The nurse should provide opportunities for family participation and accommodate religious and cultural rituals when possible. To perform postmortem care: Maintain standard or isolation precautions in place at the time of death. Gently close the client's eyes. Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending. Straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased. Leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor mortis sets in. A towel folded under the chin may be needed to keep the jaw closed. Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters Place a pillow under the head to prevent blood from pooling and discoloring the face. Remove equipment and soiled linens from the room. Give client's belongings to a family member or send with the body.
under what circumstances is post mortem care delayed?
Postmortem care typically is performed immediately following the pronouncement of death to allow visitation of the deceased by the family. There are several circumstances in which postmortem care may be delayed or not performed. Certain cultural or religious beliefs require that care be performed by the family or clergy. The family also may want religious ceremonies performed or last rites given before the body is cleaned or disturbed in any way. Postmortem care can also be delayed, altered, or not performed in accordance with state law and agency policies. These situations include deaths that are considered non-natural, traumatic, or associated with criminal activity
What is an example of a mechanical stimulus?
Surgical incision
The action potential potential travels from the nociceptors to the spinal cord primarily by what?
The A-delta fibers within primary afferent fibers (action potential can also be transferred along the C fibers of the primary afferent fibers).
Describe transduction.
Transduction involves the conversion of a noxious (tissue-damaging) mechanical, thermal, or chemical stimulus into an electrical signal called an action potential.
22. The nurse knows that which technique is best for assessing pain in a child who is 4 years of age? • Ask the parents if they think their child is in pain. • Use the FACES scale. • Ask the child to rate the level of pain on a 0 to 10 pain scale. • Check to see what previous nurses have charted.
Use the FACES scale.
15. A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? • Superficial pain • Idiopathic pain • Chronic pain • Visceral pain
Visceral pain Correct
You would question an order written for Percocet for a patient exhibiting which of the following clinical manifestations? a. Severe jaundice b. Oral candidiasis c. Increased urine output d. Elevated blood glucose
a. Severe jaundice Acetaminophen and oxycodone are the ingredients in Percocet. Because acetaminophen is metabolized in the liver, the patient could develop acetaminophen toxicity in the presence of severe liver disease (evidenced by jaundice). The prudent nurse would question the order before administration.
The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emptional experience associated with _____ or _____ tissue damage, or described in terms of such damage."
actual, potential
Opioids
are prescribed for moderate to severe pain. They are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes. Sedation is an adverse effect of opioids that always happens before respiratory depression. One way to maximize pain relief while potentially decreasing opioid use is to administer analgesics around the clock (ATC) rather than on a prn basis.
When assessing pain in a child, the nurse needs to be aware of what considerations? a. Immature neurologic development results in reduced sensation of pain. b. Inadequate or inconsistent relief of pain is widespread. c. Reliable assessment tools are currently unavailable. d. Narcotic analgesic use should be avoided.
b. Inadequate or inconsistent relief of pain is widespread.
You are caring for a patient who is receiving morphine sulfate via PCA. Which of the following patient assessment data demonstrate the most therapeutic effect of this medication? a. Pain rating 1/10, drowsy but arousable, respirations 16 b. Pain rating 2/10, awake and alert, respirations 18 c. Pain rating 3/10, awake and alert, respirations 20 d. Pain rating 2/10, drowsy but arousable, respirations 18
b. Pain rating 2/10, awake and alert, respirations 18 Effective pain management is achieved when there is adequate pain control (rating of 3 or less on a scale of 1 to 10) with normal respirations and an absence of sedation. These data exhibit the best effectiveness of the pain medication in all of these areas.
Pain is best described as a. a creation of a person's imagination. b. an unpleasant, subjective experience. c. a maladaptive response to a stimuls. d. a neurologic event resulting from activation of nociceptors.
b. an unpleasant, subjective experience. The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."
An example of distraction to provide pain relief is a. TENS. b. music. c. exercise. d. biofeedback.
b. music. Distraction involves redirection of attention away from the pain and to something else. Distraction can be achieved by engaging the patient in any activity that can hold his or her attention (e.g., watching TV or a movie, conversing, listening to music, playing a game).
key points: _______________ pain is still not adequately treated, despite clinical guidelines for the effective use of opioids and other pharmacological alternatives
cancer
Key Points: A persons _______________ influences the meaning of pain and how it is expressed
cultural background
regional anesthesia
the injection or infusion of local anesthetics to block a group of sensory nerve fibers.
Pain assessment of the adolescent
>Verbal expressions of pain with less protest >Muscle tension with body control
Pain tolerance
The level of pain a person is willing to accept
what diseases are more common to African American people?
cervical cancer, hypertension, ischemic stroke
The distinctive pattern of the rash cause by _____ across the back and trunk is determined by dermatomes.
herpes zoster (shingles)
Addiction ________ occurs in patients who take opioids to relieve pain
rarely
ABCDE of Pain
• Ask about pain/assess • Believe pts • Choose pain control option • Deliver pain medication/interventions • Empower pt/family
____ 1. A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patients pain? 1) Acute 2) Chronic 3) Intractable 4) Neuropathic
1
____ 15. The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using? 1) Distraction 2) Guided imagery 3) Sequential muscle relaxation 4) Hypnosis
1
The electrocardiogram of an elderly male patient who had chest pain shows signs of myocardial infarction. What are the likely sites for referred pain for a male patient with myocardial infection? Select all that apply. 1 Jaw 2 Groin 3 Left ear 4 Left arm 5 Left shoulder
1, 4, 5 When pathological changes in one part cause pain at a distant site on the body, then the pain is called referred pain. Pathological changes in the heart often cause referred pain in the jaw, left arm, and left shoulder, but they do not usually cause pain in the groin or left ear.
4. A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route
2 Long-acting or sustained-release opioids are dosed on a scheduled basis, not prn, to provide a base of continuous opioid analgesia.
Pain assessment of the older infant
>Loud cry >Deliberate withdrawal from pain >Facial expression of pain
what does STAT mean
A STAT order indicates that the medication should be given immediately and only one time
Drug tolerance
A state of adaptation in which exposure to a drug induces changes that result in a reduction of one or more effects of the drug over time
Implementation: Acute Care Pharmacological Pain Therapies
Analgesics: • Nonopiods • Opioids • Adjuvants/co-analgesics
which route of administration is preferable for administration of daily analgesics? A. IV B. IM or subcutaneous C. Oral D. Transdermal E. PCA
C oral If the gastrointestinal system is function, the oral route is preferred for routine analgesics because of lower cost and ease of administration. Oral route is also less painful and less invasive than the IV, IM, subcutaneous, or PCA routes. Transdermal route is slower and medication availability is limited compared to oral forms.
Referred Pain
Common in visceral pain because many organs themselves have no pain receptors (the sensory neurons from the affected organ travel into the spinal cord segment, as neurons from areas where the person feels pain causes the perception of pain in unaffected areas) Pain is in part of the body, separate from source of pain and assumes any characteristic Examples of Cause: MI, which causes referred pain to the jaw, left arm, and left shoulder, kidney stones, which refer pain to the groin.
Donepezil (Aricept)
Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly at increased risk of adverse effects.
What is the FACES tool?
Pain rated on a scale of 0 - 5 using to convert to the 0 - 10 scale >Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale >Explain each face to the child - 0 = no hurt - 1 = hurts a bit - 2 = hurts a little more - 3 = hurts even more - 4 = hurts a whole lot - 5 = hurts worst >Ask child to choose a face that best describes how they are feeling
Faces Pain Scale - Revised (FPS-R)
Self-report pain analog measure that uses pictures of facial expressions across a rating scale, primarily designed for children ages 4 - 16 years
Numeric Rating Pain Scale (NRS)
Self-report pain measure where a client verbalizes a number to correspond with a perceived level of pain from no pain to most severe pain 0= relaxed and comfortable without any pain. 1-3= mild pain. 4-6= moderate pain. 7-10= severe pain.
sudden onset of restlessness/agitation
When there is new, sudden onset of restlessness/agitation, the nurse should first think about oxygenation (or blood glucose). The desired level of sedation is level 3 on the Ramsay Sedation Scale, during which the client is drowsy but responds to a voice command.
perineural local anesthetic infusion
a surgeon places the tip of an unsutured catheter near a nerve or groups of nerves and the catheter exits from the surgical wound.
Which of the following nursing interventions is most appropriate when preparing to administer an opioid analgesic agent? a. Give the medication on an empty stomach. b. Count the number of doses on hand before administration. c. Give the medication with a glass of juice or other cold beverage. d. Assess the patient for allergies to aspirin before administration.
b. Count the number of doses on hand before administration. Because opioid analgesics are controlled substances, the nurse needs to count the number of doses and check that it matches the number recorded before removing and administering the medication.
Margo McCaffery, a nurse and pioneer in pain management, defined pain as
"whatever the person experiencing the pain says it is, existing whenever the person says it does."
____ 11. Which drug might the primary care provider prescribe to help facilitate pain management in a client with chronic pain? 1) Selective serotonin reuptake inhibitor 2) Selective norepinephrine reuptake inhibitor 3) Narcotic analgesic 4) Anti-emetic
1
____ 1. A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scale(s) would be appropriate to use with this patient? Choose all that apply. 1) Visual analog 2) Numerical rating 3) Wong-Baker face rating 4) Simple descriptor
1, 3
8. Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? (Select all that apply.) 1. Only the patient should push the button. 2. Do not use the PCA until the pain is severe. 3. The PCA system can set limits to prevent overdoses from occurring. 4. Notify the nurse when the button is pushed. 5. Do not push the button to go to sleep.
1,3,5 The safety of PCA is based on the fact that it requires an awake patient to activate the button. The safety is compromised when someone else pushes the button for the patient. A limit on the number of doses per hour or 4-hour intervals may be set. Opioids (morphine PCA) are intended to provide analgesia; drowsiness is an undesirable potential side effect of opioids, and the PCA should only be used for analgesia.
____ 10. Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer? 1) Acute pain secondary to surgery 2) Acute pain (abdominal) secondary to surgery for colon cancer 3) Chronic pain secondary to cancer diagnosis 4) Chronic pain (abdominal) secondary to abdominal surgery
2
____ 12. The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient complaining of a severe headache. When should the nurse reassess the patients pain? 1) 15 minutes after administration 2) 60 minutes after administration 3) 90 minutes after administration 4) Immediately before the next dose is due
2
A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1 Stool softener 2 Stimulant laxative 3 H2 receptor blocker 4 Proton pump inhibitor
2 Patients usually become tolerant to the side effects of opioids, with the exception of constipation. Routinely administering stimulant laxatives, not simple stool softeners, will prevent and treat constipation in these patients.
While taking a patient's medical history, a nurse records that the patient has asthma. Which medications for pain management might the physician avoid prescribing? Select all that apply. 1 Tramadol 2 Naproxen 3 Ibuprofen 4 Oxycodone 5 Hydromorphone
2, 3 Some patients who have asthma or an allergy to aspirin are also allergic to other nonsteroidal antiinflammatory drugs (NSAIDs). Naproxen and ibuprofen are NSAIDs, so the physician may avoid prescribing these medicines to the patient for pain management. Tramadol, oxycodone, and hydromorphone are opioid analgesics, which may be less risky for allergic reaction in this patient.
how long should hydromorphone be administered over?
2-3 minutes. Rapid IV administration of opioid analgesics can cause severe hypotension and respiratory or cardiac arrest.
The nurse notices that a patient has received oxycodone/acetaminophen (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1 The patient's level of pain 2 The potential for addiction 3 The amount of daily acetaminophen 4 The risk for gastrointestinal bleeding
3 The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-hour dose is 4 g. It is often combined with opioids (e.g., oxycodone) because it reduces the dose of opioid needed to achieve successful pain control.
Which pain management drug is considered the best tolerated and safest analgesic? 1 Fentanyl 2 Tramadol 3 Acetylcysteine 4 Acetaminophen
4 Acetaminophen is considered the best tolerated and safest analgesic used in pain management. Fentanyl and tramadol are opioids, which have the potential for significant side effects and often result in patients building a tolerance to them. Acetylcysteine is not an analgesic; rather, it is used to treat acetaminophen overdose.
A patient took more than the prescribed amount of acetaminophen and is experiencing hepatotoxicity. Which drug might the nurse anticipate the health care provider to use to treat this patient? 1 Naloxone 2 Tramadol 3 Oxycodone 4 Acetylcysteine
4 Overdose of acetaminophen may lead to hepatotoxicity, which is treated with acetylcysteine. Naloxone is used to reverse the adverse effects of opioids, not acetaminophen. Tramadol and oxycodone are used to manage pain, not to treat acetaminophen overdose.
For what age should the nurse use the Numeric Scale?
5 years +
Pain assessment of the young infant
>Loud cry >Rigid body or thrashing >Local reflex withdrawal from pain stimulus >Expressions of pain (eyes tightly closed, mouth open in a squarish shape, eyebrows lowered & drawn together) >Lack of association between stimulus & pain
C. diaphoresis Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours.
A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? A. fever B. nausea C. diaphoresis D. abdominal cramps
C. "Please tell him that I will be right there to check of him." directly ask the client about the pain and do a complete pain assessment. This information will determine which action to take next.
A family member asks you, "Why can't you give more medicine? He is still having a lot of pain." What is your best response? A. "The doctor ordered the medicine to be given every 4 hours." B. "If the medication is given too frequently he could suffer ill effects." C. "Please tell him that I will be right there to check of him." D. "Let's wait about 30-40 minutes. If there is no relief I'll call the doctor."
physical dependence
A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
How Pain Affects Quality of Life
ADL interference Anxiety Depression Hopelessness Fear Anger Sleeplessness Impairs relationships-family, Work, social life
post liver biopsy client positioning
After a liver biopsy, clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for ≥3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding.
________________ pain is challenging aspect of cancer because it can impact the quality of life of patients and family caregivers; thus it requires a holistic approach to treatment.
Breakthrough pain
Which client is most likely to receive opioids for extended periods of time? A. a client with fibromyalgia B. a client with phantom limb pain C. a client with progressive pancreatic cancer D. a client with trigeminal neuralgia
C. a client with progressive pancreatic cancer Cancer pain generally worsens with disease progression and the use of opioids is more generous. Fibromyalgia is more likely to be treated with non-opioid and adjuvant medications. Trigeminal neuralgia is treated with anti-seizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins.
In applying the principles of pain treatment, what is the first consideration? A.treatment is based on client goals B. a multidisciplinary approach is needed C. the client must be believed about perceptions of own pain D. drug side effects must be prevented and managed
C. the client must be believed about perceptions of own pain The client must be believed and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to other options in developing the treatment plan.
Visual Descriptive Scale (VDS) for pain
Consists of a line with 3-6 word descriptors equally spaced along the line. Show a patient eh scale and ask him or her to choose the descriptor that best represents the severity of pain.
Which client is at greater risk for respiratory depression while receiving opioids for analgesia? A. an elderly chronic pain client with a hip fracture B. a client with a heroin addiction and back pain C. a young female client with advanced multiple myeloma D. a child with an arm fracture and cystic fibrosis
D. a child with an arm fracture and cystic fibrosis at greatest risk are elderly clients, opiate naïve clients, and those with underlying pulmonary disease. The child has two of the three risk factors.
what to monitor for digoxin administration
Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) . Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity
Explain the difference between fibers that an action potential can travel across.
Each fiber is responsible for a different pain sensation. A-delta fibers are myelinated and rapidly conducting and are responsible for the initial, sharp pain associated with an injury. C fibers are unmyelinated and slow conducting and are responsible for transmitting sensation that is aching and throbbing in quality.
non pharm garlic application
Garlic application involves placing crushed garlic directly on the skin. It is thought to heal infections but can cause contact dermatitis and burns on the wrists. This is appropriate to include in a culturally competent care in-service.
Long- Acting pain meds
Long-acting or controlled-release medications may provide relief for all types of chronic pain, including cancer pain. These controlled-release medications (e.g., morphine [MS Contin, Roxanol SR], and oxycodone [OxyContin]) relieve pain for 8 to 12 hours. Long-acting or sustained-release opioids are dosed on a scheduled basis, not prn or "as needed."
low-flow oxygen delivery devices
Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable COPD, type I respiratory failure [hypoxemic]).
Implementation: Health Promotion
Maintaining wellness: • Help patient understand • Health literacy (affects a patient's pain experience and understanding of pain management strategies.) • Patients actively participate in their own well-being whenever possible
Administering Nalaxone
Nalaxone (narcan) 0.4mg diluted with 9mL saline IV push at a rate of 0.5mL every 2 min until respiratory rate is greater than 8 breaths/min with good depth. -Administering any faster can cause sever pain and serious complications, like hypotension, hypertension, cardiac arrhythmia, dyspnea and pulmonary edema. - Evaluate patients every 15 min for 2 hrs following a drug administration because its duration may be less than that of the opioid and respiratory depression can return.
tramadol
Narcotic It can treat moderate to severe pain. Tramadol (Ultram) 50-100 mg orally every 4-6 hours is prescribed for moderate-to-severe postoperative pain. The client was medicated 1.5 hours ago. The drug onset is 1 hour, the peak is 2-3 hours, and the duration is 4-6 hours. Therefore, this client is most likely stable at this time. The nurse does not need to care for this client first.
chronic episodic pain
Occurs sporadically over an extended duration
Where do primary afferent fibers terminate?
Primary afferent fibers terminate within the dorsal horn of the spinal cord, which contains the cell bodies for afferent nerve fibers.
Characteristics of Pain
Quality Aggravating and precipitating factors Relief measures
receptive aphasia
Receptive aphasia (ie, Wernicke aphasia) is impairment of verbal and written language comprehension. Visual aids and hand gestures may be more effective means of communication.
Radiating Pain
Sensation of pain extending from initial site of injury to another body part. Pain feels like it travels along or down a body part. It is intermittent or constant. Examples of Causes: Low back pain from ruptured intervertebral disk, accompanied by pain radiating down leg from sciatic nerve irritation.
Once generated, an action potential travels all the way to the spinal cord unless it is blocked by a _____ inhibitor or disrupted by a lesion at the _____.
Sodium channel inhibitor (e.g., local anesthetic), terminal of the fiber (e.g., by a dorsal root entry zone [DREZ] lesion)
33. A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has? • Visceral pain • Somatic pain • Peripherally generated pain • Centrally generated pain
Somatic pain
Sympathetic Nervous System Response to Pain
Stimulation of the sympathetic branch of the ANS results in physiological responses. Response: • Dilation of bronchial tubes and increased RR= provides increased O2 intake • Increased HR: provides increased o2 transport • Peripheral Vasoconstriction (pallor, elevation in BP)=provides additional energy • Increased Cortisol Level (short term)=Heightened memory functions, a burst of increased immunity, and lower sensitivity to pain • Diaphoresis= Controls body temp during stress • Increased Muscle tension= prepares muscles for action • Dilation of pupils= affords better vision • Decreased GI motility= frees energy for more immediate activity
who has the highest risk of respiratory depression
The following are at greatest risk for respiratory depression related to opioid use for analgesia: the elderly; those with underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naïve, especially if treated for acute pain; and post surgery (first 24 hours). The 70-year old client has 3 significant risk factors: advanced age, COPD, and surgery within 24 hours. COPD clients who have hypercarbia and hypoxemia are at even greater risk for respiratory depression when receiving opioids. the client with a hx of heroin abuse has a high tolerance of opioids
when is the peak of hydromorphone effects?
The nurse should reassess pain and sedation level during the opioid's peak effect, which is 15-30 minutes after administration of IV hydromorphone.
Assessment for Pain
Through the patient's eyes: >>Ask the patient's pain level >>Use ABCs of pain management >>Pain is not a number • In selecting a tool to be used with a patient, be aware of the clinical usefulness, reliability, and validity of the tool in that specific patient population. • Be aware of possible errors in pain assessment.
25. The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? • "Have you considered working with a physical therapist?" • "What activities, if any, has your pain prevented you from doing?" • "Would you please rate your pain on a scale from 1 to 10 for me?" • "What effect does your pain medication typically have on your pain?"
What activities, if any, has your pain prevented you from doing?"
D. a child with an arm fracture and cystic fibrosis at greatest risk are elderly clients, opiate naïve clients, and those with underlying pulmonary disease. The child has two of the three risk factors.
Which client is at greater risk for respiratory depression while receiving opioids for analgesia? A. an elderly chronic pain client with a hip fracture B. a client with a heroin addiction and back pain C. a young female client with advanced multiple myeloma D. a child with an arm fracture and cystic fibrosis
Patient-controlled analgesia (PCA)
a drug delivery system that uses a computerized pump with a button the patient can press to deliver a dose of an analgesic through an intravenous catheter Maintains a constant plasma level of analgesic
Wong-Baker FACES scale
a pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain
A postoperative patient has an order to receive morphine sulfate 4 mg IM every 3 to 4 hours prn for pain. On hand are prefilled syringes labeled morphine sulfate 10 mg/ml. How many milliliters should you administer? a. 0.4 ml b. 0.55 ml c. 0.6 ml d. 0.75 ml
a. 0.4 ml Dose (mg) ÷ availability (mg/ml) = ml to administer. Therefore, 4 mg ÷ 10 mg/ml = 0.4 ml.
Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? a. Encouraging regular use of analgesics b. Applying a moist heating pad to the area at prescribed intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication
b. Applying a moist heating pad to the area at prescribed intervals
You are preparing to administer celecoxib (Celebrex) 200 mg PO for pain relief. Available are capsules containing 100 mg. How many capsules should the nurse administer? a. 0.5 Capsules b. 1 Capsule c. 2 Capsules d. 4 Capsules
c. 2 capsules Dose ÷ availability = number of capsules to administer. Therefore, 200 mg ÷ 100 mg = 2 capsules.
What should you monitor in a patient taking high doses of acetaminophen over a prolonged period? a. Prothrombin time b. GI irritation c. Liver function d. Kidney function
c. Liver function Prolonged use of high doses of acetaminophen increases the risk of liver damage.
Key Points: Misconceptions about pain often result in _______ and degree of the patients suffering and unwillingness to provide relief
doubt
Nursing implications for administering ___________________ analgesia include preventing infection, assessing sensation, and motor function, and monitoring closely for respiratory depression.
epidural
A person who is suffering may experience _____ distress
spirtual
Physiology of Pain
transduction, transmission, perception, modulation
isosorbide mononitrate
treatment of angina similar to nitrate by causing vasodilation
9. Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? • "This is the only pain medication I will need to be on." • "I can administer the pain medication as frequently as I need to" • "I feel less anxiety about the possibility of overdosing." • "I will need the nurse to notify me when it is time for another dose."
"I feel less anxiety about the possibility of overdosing."
24. A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? • "This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." • "The patient is sleeping, so I pushed her PCA button for her." • "I need to reassess the patient's pain 1 hour after administering oral pain medication." • "It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."
"I need to reassess the patient's pain 1 hour after administering oral pain medication." Correct
19. A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal anti-inflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works? • "Ibuprofen helps to remove factors that cause or stimulate pain." • "Ibuprofen reduces anxiety, which will help you better cope with your pain." • "Ibuprofen helps to decrease the production of prostaglandins." • "Ibuprofen binds with opiate receptors to reduce your pain."
"Ibuprofen helps to decrease the production of prostaglandins."
31. The nurse is caring for a patient who recently had surgery to repair a hernia. The patient's pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurse's best response? • "This medication can be given only every 4 hours. It is not time for you to have any other pain medication right now." • "I will notify the health care provider to come perform an assessment if your pain doesn't improve in 30 minutes." • "If the pain becomes severe, we may need to transfer you to an intensive care unit." • "It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."
"It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."
3. Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? • "Meditation controls pain by blocking pain impulses from coming through the gate." • "Meditation will help me sleep through the pain because it opens the gate." • "Meditation stops the occurrence of pain stimuli." • "Meditation alters the chemical composition of pain neuroregulators, which closes the gate."
"Meditation controls pain by blocking pain impulses from coming through the gate."
23. Which statement made by a nursing educator best explains why it is important for nurses to determine a patient's medical history and recent drug use? • "Health care providers have a responsibility to prevent drug seekers from gaining access to drugs." • "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." • "Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain." • "Getting this information gives the nurse an opportunity to provide patient teaching about drug abstinence."
"This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." Correct
10. A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? • "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." • "You should take your medication after you walk to make sure you do not fall while you are walking." • "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." • "You need to take oral pain medications when you experience severe pain."
"We should work together to create a regular schedule of medications that does not allow for breakthrough pain." Correct
20. A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? • "This medication will still be providing you relief at the time of your dressing change." • "OK, swallow this pain pill, and I will return in a minute to fill your wound." • "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?" • "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."
"Would you like medication to be given for dressing changes on top of your regularly scheduled medication?"
14. A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? • "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." • "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." • "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." • "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."
"You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."
12. A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? • "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." • "Narcotics can be addictive, so do not take them unless you are in severe pain." • "You need to drink plenty of fluids and eat a diet high in fiber." • "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."
"You need to drink plenty of fluids and eat a diet high in fiber."
Opioid Effects
- Numerous side effects - Except for constipation and CNS changes - Patients usually become tolerant to many of them -Effects Associated with Long Term Use: - Depression - Impaired Sleep patterns - Endocrine effects (decreased testosterone levels, decreased libido) - Immune system supression To reduce side effects: - Patients should take lowest dose of an opioid needed to manage pain - If reducing a dose does not relieve a side effect, ask prescriber about a change in the type of opioid - If side effects persist, it may be necessary to prevent or treat them by administering other medications (antihistamines, antiemetics, stimulants)
Assessment Questions for Pain
- Onset - Duration - Quality - Severity *Palliative or Provocative factors:* What makes your pain worse? What makes it better? *Quality:* How do you describe your pain? *Relief measures:* What do you take at home to gain pain relief? *Region (location)*: Show me where you hurt. *Severity*: On a scale of 0 to 10, how bad is your pain now? • What is the worst pain you have had in the past 24 hours? • What is the average pain you have had in the past 24 hours? *Timing:* Is your pain constant, intermittent, or both? *U:* Effect of pain: What are you not able to do because of your pain? • With whom do you live, and how do they help you when you have pain? (Potter 1023)
____ 18. A patient is prescribed morphine sulfate 4 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication? 1) Monitor the patients respiratory status. 2) Auscultate the patients heart sounds. 3) Check blood pressure in supine and sitting positions. 4) Monitor the patient for psychological drug dependence.
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____ 19. A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use? 1) Caution the patient against combining acetaminophen with alcohol. 2) Explain that acetaminophen increases the risk for bleeding. 3) Advise taking acetaminophen with meals to prevent gastric irritation. 4) Explain that physical dependence may occur with long-term oral use.
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____ 26. Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale? 1) Stimulate the patient. 2) Prepare to administer naloxone (Narcan). 3) Administer a dose of pain medication. 4) Notify the physician immediately.
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____ 27. A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient? 1) Anticoagulant therapy 2) Diabetes mellitus 3) Hypertension 4) Embolectomy
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____ 30. What is typically the most reliable indicator of pain? 1) Patients self-report 2) Past medical history 3) Description by caregiver(s) 4) Behavioral cues
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____ 7. The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? 1) Blood pressure 160/82 mm Hg 2) Temperature 100.6F 3) Heart rate 80 beats/min 4) Oxygen saturation 95%
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15. A postoperative patient currently is asleep. Therefore the nurse knows that: 1. The sedative administered may have helped him sleep, but it is still necessary to assess pain. 2. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. 3. Pain assessment is not necessary. 4. The patient can be switched to the same amount of medication by the oral route.
1 A pain assessment is still needed because sleep in a postoperative patient cannot be used as an assessment of a patient's pain level. Sleep may result from sedating effects of medication, but analgesia may not be present. It is important to wake and assess the patient to ensure that the pain is controlled and the patient is not overly sedated from the medication (a sign of impending respiratory depression).
A primary health care provider prescribes 10 mg of codeine every 4 hours to a patient who has chronic pain from cancer. However, after taking a second dose of the prescribed drug, the nurse notices that the patient is very drowsy and nauseous. Which dose alteration may provide effective pain relief while improving the drowsiness and nausea? 1 5 mg codeine every 4 hours 2 10 mg codeine every 8 hours 3 20 mg codeine every 8 hours 4 5 mg codeine every 12 hours
1 Because codeine is short-acting, relief is likely only attainable with administration every 4 hours. If 5 mg is not enough, or the side effects remain, the patient may require a different opioid. Even at every 8 hours, 10-mg and 20-mg doses are too much for the patient to tolerate without adverse side effects. A 5-mg dose every 12 hours is probably too long of an interval for this patient to obtain relief from the pain.
A patient with bronchial carcinoma reports constipation for the past 2 months. The patient has been on meperidine and ibuprofen for pain relief for the past 6 months. The patient has also been taking metformin and captopril for the past 10 years. What could be the most probable reason for constipation in the patient? 1 Side effects of the opioid 2 Side effects of the captopril 3 Interaction of metformin and captopril 4 Metastasis of cancer to other organs
1 Constipation is a common side effect of opioids that are used for pain relief. Captopril is an ACE-inhibitor drug that is used to treat hypertension. Cough is the common side effect of captopril. Metformin is an oral hypoglycemic drug. Interaction between metformin and captopril does not cause constipation. It is unlikely that metastasis of cancer caused the constipation.
A health care provider writes the order for an opioid-naïve patient who returned from the operating room following a total hip replacement. The order states, "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse plans to implement which actions? 1 The nurse calls the health care provider and questions the order. 2 The nurse applies the patch on the third postoperative day. 3 The nurse applies the patch as soon as the patient reports pain. 4 The nurse places the patch as close to the hip dressing as possible.
1 Fentanyl is 100 times more potent than morphine and not recommended for acute postoperative pain.
The primary health care provider prescribes intravenous (IV) opioid medication for flank pain associated with a kidney stone in the ureter. On the follow-up visit, the patient reports thigh pain to the nurse. What does the nurse infer from patient's report? 1 The patient is experiencing referred pain. 2 The patient is experiencing neuropathic pain. 3 The patient has acute pain progressing to chronic pain. 4 The patient has pain perception due to previous opioid medication.
1 Flank pain is associated with kidney stones in the ureter. The spread of pain to uninjured tissue is referred pain. Here, the pain spreads to the uninjured thigh tissue. Neuropathic pain refers to pain caused by nerve damage rather than by tissue injury or damage. When pain is short term and associated with an acute event such as a kidney stone, it is acute pain, not chronic pain. IV opioid administration would decrease the perception of pain intensity of the kidney stone but would be unrelated to the new complaint of thigh pain.
The nurse has given one unit of transmucosal fentanyl to an opioid-tolerant patient with breakthrough pain. The patient is still not feeling pain relief. How many more units of the drug can the nurse administer before notifying the primary health care provider? Record your answer using a whole number. ___ unit(s)
1 One transmucosal fentanyl unit is given to patients with breakthrough pain. It is swabbed over the buccal mucosa and gums to be dissolved in the mouth. It should not be chewed. The nurse has given one unit of fentanyl already; if the pain persists, the nurse can administer one more unit of fentanyl. A patient can be given a total of 2 units of transmucosal fentanyl per episode of breakthrough pain. If the patient's pain is not relieved, then the nurse should notify the primary health care provider.
A patient complains of nausea after receiving the first dose of morphine for pain. What should the nurse do? 1 Treat nausea with an anti-nausea medication and continue to use morphine 2 Request an order for a nonsteroidal anti-inflammatory drug (NSAID) instead of morphine. 3 Encourage the patient to wait as long as possible for the next dose. 4 Withhold the next dose of morphine until reevaluated by the health care provider.
1 Opioids can cause nausea and vomiting because of the action on the brainstem centers. This side effect decreases with repeated use, but until then, treatment for nausea should be instituted. Decreasing the dose may be ineffective for pain relief. Asking the patient to wait for pain relief is unethical. Withholding the dose may increase the pain.
A registered nurse is teaching a nursing student about using nonsteroidal antiinflammatory drugs (NSAIDs) for pain management. Which of the nursing student's statements indicates a need for further teaching? 1 "NSAIDs work by depressing the central nervous system." 2 "NSAIDs act by inhibiting the synthesis of prostaglandins." 3 "Patients allergic to aspirin are more likely to be allergic to other NSAIDs." 4 "Use of NSAIDS in older adults may result in increased risk of adverse events."
1 Opioids, not nonsteroidal antiinflammatory drugs (NSAIDs), depress the central nervous system. The other statements indicate effective teaching: NSAIDs inhibit prostaglandin synthesis, which inhibits cellular responses to inflammation; this helps relieve pain. An allergy to aspirin may be indicative of an allergy to other NSAIDs, and NSAIDs may put older adults at an increased risk for gastrointestinal bleeding.
A patient has had arthritic pain for 8 years and has surgery to remove a buildup of septic fluid. Postoperative, the patient received morphine through a patient-controlled analgesia (PCA) device for the management of pain. What is the advantage of PCA that the nurse should teach the patient? 1 PCA allows self-administration of analgesics. 2 PCA is associated with a risk of overdose. 3 PCA does not allow administration of opioids. 4 PCA allows intramuscular administration of medications.
1 PCA allows the patient to self-administer analgesic medication whenever needed. There is no risk of overdosage due to the programming. Opioids can be safely administered using PCA. It allows intravenous or subcutaneous administration of medications.
Which instructions are crucial for the nurse to give to both family members and the patient who is about to be started on patient-controlled analgesia (PCA) of morphine? 1 Only the patient should push the button. 2 Do not use the PCA until the pain is severe. 3 The PCA prevents constipation. 4 Notify the nurse when the button is pushed.
1 Patient preparation and teaching are critical to the safe and effective use of PCA devices. Patients need to understand PCA and be physically able to locate and press the button to deliver the dose. Be sure to instruct family members not to push the button for the patient.
11. A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1. Patient's self-report 2. Behaviors 3. Surrogate (wife) report 4. Vital sign changes
1 Patient's self-report of pain. Sleep is not an indicator of pain intensity. Unless a patient is stimulated, it is difficult to distinguish sleep from sedation, which may occur as a side effect of the opioid. Patients in pain sometimes sleep from exhaustion.
A postoperative patient is currently asleep. Which statement is correct? 1 The sedative administered may have helped him sleep, but assessment of pain is still needed. 2 The intravenous (IV) pain medication is effectively relieving his pain. 3 Pain assessment is not necessary. 4 The patient can be switched to the same amount of medication by the oral route.
1 Sedatives, antianxiety agents, and muscle relaxants have no analgesic effect; however, they can cause drowsiness impaired coordination, judgment, and mental alertness and contribute to respiratory depression. It is important to avoid attributing these adverse effects solely to the opioid. You need to conduct a thorough reassessment.
The nursing instructor asks the student nurse to differentiate between A and C peripheral nerve fibers. Which statement made by the student nurse indicates effective learning? 1 "The A fibers are myelinated and the C fibers are unmyelinated." 2 "The A fibers are smaller in diameter and the C fibers are larger in diameter." 3 "The A fibers transmit signals slowly and the C fibers transmit signals rapidly." 4 "The A fibers cause diffuse sensation and the C fibers cause localized sensations."
1 The A fibers are myelinated, whereas the B fibers are unmyelinated. The A fibers are larger in diameter, whereas the B fibers are smaller in diameter. Because A fibers are larger in diameter, they transmit signals to the central nervous system (CNS) more rapidly than the smaller C fibers. The sensations caused by the stimulation of the A fibers are localized, whereas the sensations caused by the stimulation of the B fibers are diffuse.
When performing pain assessment, the nurse shows a series of photographs to a child and asks the child to point to the face that shows how he or she feels. Which pain-rating scale is the nurse using for pain assessment? 1 Oucher scale 2 Numeric rating scale (NRS) 3 Visual analogue scale (VAS) 4 Verbal descriptor scale
1 The Oucher scale consists of six cartoon faces of a child ranging from a smiling face to less happy faces, to a final sad, tearful face. The child is asked to point to the face that best matches his or her pain. With the NRS, the nurse asks the child to choose a number to rate the level of pain. The VAS has the patient assess the pain on a 10-centimeter line, ranging from no pain to severe pain. With the verbal descriptor scale, the nurse asks the child to describe his or her feelings about the intensity of pain.
What is recommended on the World Health Organization (WHO) analgesic ladder while caring for a patient with cancer pain? 1 Transitioning use of adjuvants with nonsteroidal anti-inflammatory drugs (NSAIDs) to opioids 2 Using acetaminophen for refractory pain 3 Limiting the use of opioids because of the likelihood of side effects 4 Avoiding total sedation regardless of how severe the pain is
1 The WHO analgesic ladder transitions from the use of nonopioids (NSAIDs) with or without adjuvants to opioids with or without adjuvants. Acetaminophen is recommended for lesser levels of pain. Side effects related to the use of opioids may be unavoidable but are treatable. Treatment for severe pain may result in some level of sedation.
A patient is on a lidocaine patch for neuropathic pain. How should the lidocaine be given to the patient to achieve adequate pain control and avoid lidocaine toxicity? 1 12-hours-on, 12 hours-off schedule 2 12-hours on, 6 hours-off schedule 3 48-hours -on, 12 hours-off schedule 4 24-hours-on, 12 hours-off schedule
1 The lidocaine patch is a topical analgesic and is used for cutaneous neuropathic pain control in adults. Three patches of the appropriate size are placed over and around the pain site. To avoid lidocaine toxicity, the 12-hours-on, 12-hours-off schedule is used. All the other schedules such as the 12-hours-on, 6-hours-off schedule; 48-hours-on, 12-hours-off schedule; and the 24-hours-on, 12-hours-off schedule may cause toxicity.
During the subjective data collection for pain assessment, the nurse asks the patient, "Can you tell me what your discomfort feels like?" What is the reason for this question? 1 The nurse wants the patient to identify the quality of pain. 2 The nurse wants the patient to identify the severity of pain. 3 The nurse wants the patient to identify the duration of pain. 4 The nurse wants the patient to indentify the intensity of pain.
1 The nurse asks questions such as, "Can you tell me what your discomfort feels like?" to assess the quality of pain. To identify the severity of pain, the nurse can ask, "On a scale of 0 to 10, how bad is your pain now?" To identify the onset and duration of pain the nurse can ask, "When did your pain start?" To identify the intensity of pain the nurse can ask, "How much pain do you have now?"
2. A health care provider writes the following order for a patient who is opioid-naïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible
1 The nurse needs to call the health care provider about the order because Fentanyl patches are not indicated for acute pain. They are indicated for patients with chronic pain who are opioid tolerant.
The nurse explains patient-controlled analgesia to a patient. If the patient has understood this information, what would be the patient's most appropriate statement? 1 The device reduces the risk of an overdose of medication. 2 The caregivers can operate the device if the patient is unable to do so. 3 The patient will be lying in a prone position during the procedure. 4 The patient will decide about the loading dose of the analgesic drug.
1 The nurse should teach about the use of patient-controlled analgesia (PCA) to a patient before any procedure. It is important to tell the patient that PCA reduces any risk of overdose. It should be emphasized to the patient that the patient-controlled analgesia device (PCA device) should not be operated by the caregivers. The caregivers are not able to perceive the patient's pain and thus cannot decide the amount of drug required. The patient should be placed in a comfortable position in which the IV line is accessible. The prone position is not likely to be a comfortable position for the patient. The patient does not decide the loading dose of the drug; the loading dose is prescribed before use.
The registered nurse and a nursing student are discussing opioid pain management therapy and naloxone (Narcan). Which of the nursing student's statements indicate a need for further teaching? Select all that apply. 1 "The infusion rate of an intravenous push of naloxone should be 0.5 mL for 1 minute." 2 "0.4 mg of naloxone should be diluted with 15 mL saline." 3 "Opioid-naïve patients should be closely monitored for sedation." 4 "Administering naloxone faster than the recommended rate may cause severe pain." 5 "If an adult patient experiences respiratory depression, naloxone should be administered."
1, 2 Naloxone (Narcan) is used to reverse the effects of opioids, especially in cases of overdose. While administering naloxone, the intravenous (IV) push should be at a rate of 0.5 mL every 2 minutes, not for 1 minute, until the respiratory rate is greater than eight breaths/min. Generally, 0.4 mg of naloxone is diluted with 9 mL, not 15 mL, saline. The remaining statements are correct. Opioid-naïve patients should be closely monitored for sedation, which occurs before respiratory depression. If naloxone is administered too quickly, the patient may experience severe pain and other serious complications. If an adult patient who is on pain management therapy with opioid analgesics experiences respiratory depression, naloxone should be administered.
When using ice massage for pain relief, which procedures are correct? Select all that apply. 1 Apply ice using firm pressure over the skin. 2 Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. 3 Apply ice until numbness occurs and discontinue application. 4 Apply ice for no longer than 10 minutes. 5 The ice is applied directly to the surface of the skin.
1, 2 Cold therapies are particularly effective for pain relief. Ice massage involves applying a frozen cup of ice firmly over the skin, which is covered with a lightweight cloth. When numbness occurs, remove the ice for usually 5 to 10 minutes.
The nurse has to administer opioids to a female patient after a surgical procedure. Which conditions may require special consideration before administration of opioids? Select all that apply. 1 Breastfeeding 2 Dialysis 3 Respiratory disease 4 History of orthopedic surgery 5 Chronic headache
1, 2, 3 Special considerations such as a breastfeeding mother, a patient on dialysis, and any respiratory conditions should be assessed carefully before administering opioids. Opioids may pass into the breast milk. It is excreted through the kidneys, and a patient on dialysis may require adjustment of the dose. Opioids tend to depress the respiratory system. Therefore, a preexisting respiratory disease may become aggravated. A history of orthopedic surgery and chronic headaches do not affect opioid administration.
The nurse is teaching a patient the use of patient-controlled analgesia (PCA). Which interventions should the nurse perform? Select all that apply.
1, 2, 3 The nurse should teach the patient about PCA and evaluate the patient's understanding by asking the patient to repeat what the nurse has taught. The patient should control the administration of the medication based on the pain. The device is programmed to prevent overdose. The family members should not operate the PCA device for the patient because the dose depends on the patient's perception of pain. The patient should be taught the use of the device before the procedures in order to be ready to administer the analgesia after awakening from sedation.
A patient has had arthritic pain for 8 years. Which questions should the nurse ask to assess the patient's pain? Select all that apply. 1 "Which factors relieve your pain?" 2 "How would you describe the pain?" 3 "Are you having any trouble passing stools?" 4 "Are you allergic to any food item or medication?" 5 "On a scale of 0 to10, how high would you rate the pain?"
1, 2, 5 To assess the pain completely and accurately, the nurse needs to assess its onset, palliative factors, quality, radiation, severity, and time factors related to the pain. Asking about palliative factors helps to determine the factors that influence the pain. A description of the pain helps to understand the nature and location of the pain. Asking a patient to rate the pain on a pain scale helps to assess the intensity of the pain. Asking questions regarding elimination and allergies does not help in pain assessment.
The nurse is planning effective pain management for a patient. What patient barriers prevent pain management? Select all that apply. 1 Lack of money 2 Fear of legal repercussions 3 Difficulty in filling prescriptions 4 Extensive documentation requirements 5 Belief that patients need to learn to live with pain
1, 3, 4 Lack of money prevents access to appropriate resources for pain medications. Difficulty in filling prescriptions can prevent the patient from using pain medications. A requirement of extensive documentation makes the process tedious, interfering with the prescriber's directions for effective pain management. The fear of legal repercussions and a belief that patients need to learn to live with pain are barriers erected by health care providers.
A patient is in the first postoperative day following a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. The nurse decides to use the ABCDE approach while assessing and managing pain for this patient. What are the correct components of the ABCDE approach? Select all that apply.
1, 3, 4 The ABCDE approach helps in accurately assessing pain and its management. A stands for "Ask regularly about the pain." B stands for "Believe the patient and family in the report of pain." C stands for "Choose pain control options appropriate for the patient." D stands for "Deliver interventions in an orderly and coordinated fashion." E stands for "Empower patients and their families."
The nurse is caring for a patient on pain management therapy. Which types of therapy cause a release of endorphins that can block the transmission of painful stimuli? Select all that apply. 1 Massage 2 Opioid analgesics 3 Cold application 4 Nonsteroidal antiinflammatory drugs (NSAIDs) 5 Transcutaneous electrical nerve stimulation (TENS)
1, 3, 5 Cutaneous stimulation releases endorphins, which block the transmission of painful stimuli. Massage, cold application, or transcutaneous electrical nerve stimulation (TENS) all stimulate the skin, which may be helpful in reducing pain perception via endorphin release. Opioid analgesics reduce pain by binding with opiate receptors to modify pain perception, not by releasing endorphins. Nonsteroidal antiinflammatory drugs (NSAIDs) reduce pain by inhibiting prostaglandin synthesis, which inhibits the body's cellular response to inflammation.
The nurse is teaching a group of caregivers about the concept of pain in older adults. What should the nurse include in the teachings? Select all that apply. 1 Older patients underreport pain. 2 Sleeping indicates pain relief. 3 Opioids are safe to use in older patients. 4 Older adults tend to perceive more pain. 5 Older adults with cognitive impairment do not experience less pain.
1, 3, 5 Older patients underreport pain with the fear of losing their independence, and do not want to alarm loved ones. Opioids are safe to use with proper monitoring of the patient to note any side effects. There is no evidence that cognitively impaired older adults experience less pain compared to individuals with intact cognitive function. Sleeping does not indicate pain relief. It indicates exhaustion, and in fact, pain may prevent the patient from having a good sleep. Age does not dull the sensitivity to pain. Older adults perceive pain as much as young adults.
The nurse is caring for a patient who is on opioid therapy. For which findings is the nurse carefully observing the patient? Select all that apply. 1 Decreased pulse rate 2 Increased respiratory rate 3 Decreased blood pressure 4 Pupil dilatation 5 Peripheral edema
1, 3, 5 Potential adverse effects of opioids include bradycardia (decreased pulse rate), hypotension (decreased blood pressure), and peripheral edema due to the accumulation of fluids. Decreased, not increased, respiratory rate may occur with opioid administration. Pupil constriction may occur with the use of opioids, but pupil dilatation is an effect of opioid withdrawal.
The nurse is learning about the effects of pain on the sympathetic system. What are the manifestations of sympathetic stimulation in response to the pain? Select all that apply. 1 Increased heart rate 2 Rapid, irregular breathing 3 Increased glucose level 4 Decreased blood pressure 5 Decreased gastrointestinal motility
1, 3, 5 The stimulation of the sympathetic branch of the autonomous nervous system causes an increased heart rate, an increased glucose level, and decreased gastrointestinal motility. Stimulation of the parasympathetic branch results in rapid, irregular breathing and decreased blood pressure.
A patient is in the first postoperative day following a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. The patient is apprehensive about being given opioid drugs and is afraid of becoming addicted to the drug. The patient is also afraid of chronic side effects. What explanation should the nurse give the patient? Select all that apply. 1 Opioids can be used safely in cases of moderate to severe pain. 2 Opioids can be given only after surgery or for postsurgical pain. 3 Slow titration prevents potentially dangerous opioid-induced side effects. 4 The drug is administered carefully, because its action cannot be reversed. 5 In case of any adverse effects, opioid antagonist drugs can be given to reverse the effects.
1, 3, 5 There are many misconceptions about the use of opioid drugs. Opioids can be safely given to people for management of moderate to severe pain. Opioids are given in slow titration to prevent the appearance or development of any side effects. In rare cases, there may be respiratory depression as an adverse effect of opioid drugs. In such cases, an opioid antagonist drug can be administered to the patient to reverse the effects of opioids. It is not mandatory to give opioids only after surgery. They can be administered to relieve pain of any origin. The action of opioids can be reversed with the proper antagonist drug.
Which statements about opioid analgesics for pain management are correct? Select all that apply. 1 Opioid analgesics act on higher centers of the brain. 2 Use of opioid analgesics will increase libido in male patients. 3 Opioid analgesics are prescribed for relieving mild forms of pain. 4 The short-acting forms of opioids provide pain relief for approximately 4 hours. 5 Prolonged use of opioid analgesics will increase patient tolerance to depression of the central nervous system
1, 4 Opioid analgesics act on higher centers of the brain and spinal cord by binding with opiate receptors. The short-acting forms of opioid analgesics provide pain relief for approximately 4 hours. Opioid analgesics will decrease the testosterone levels in male patients, decreasing, not increasing, libido. Opioid analgesics are prescribed to relieve moderate to severe levels of pain; other drugs are more appropriate for mild pain. Prolonged use of opioid analgesics will increase patient tolerance to most opioid side effects except central nervous system depression.
Which drugs may provide relief from bone pain? Select all that apply. 1 Calcitonin 2 Gabapentin 3 Nortriptyline 4 Bisphosphonates 5 Infusional lidocaine
1, 4 Calcitonin and biphosphates are effective in relieving bone pain. Gabapentin, nortriptyline, and infusional lidocaine are typically used to treat neuropathic pain, not bone pain.
The human body has a mechanism to reduce pain perception by inhibitory neurotransmitters. What are the inhibitory neurotransmitters of pain in the brain? Select all that apply. 1 Serotonin 2 Histamine 3 Substance P 4 Norepinephrine 5 Gamma aminobutyric acid
1, 4, 5 During the process of pain modulation, endogenous opioids, serotonin, norepinephrine, and gamma aminobutyric acid (GABA) are some of the inhibitory neurotransmitters released to inhibit the pain impulse. This happens in the fourth and final phase of the nociceptive process. Histamine and substance P have no role in pain modulation. Histamine is released by mast cells and plays a major role in the inflammatory process. Substance P transmits pain impulses from the periphery to higher brain centers.
The nurse works in a postsurgical ward. Which statements by the nurse indicate common misconceptions about pain? Select all that apply. 1 Psychogenic pain is not real. 2 Chronic pain is not psychological. 3 Patients who cannot speak can feel pain. 4 Administering analgesics regularly leads to drug addiction. 5 Patients who abuse substances overreact to discomfort.
1, 4, 5 Psychogenic pain is real and requires intervention. Regular administration of analgesics does not lead to drug addiction. However, some analgesics such as morphine should not be overused. The patients who abuse substances do not overreact to discomfort; their discomfort may be real. Chronic pain is not psychological; it may be real and can have an impact on daily activities. Patients who do not speak can still feel pain and need intervention.
12. When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.
1,2,5 Apply the ice with firm pressure over the skin; then use a slow, steady circular massage. Apply ice for 5 minutes or until the patient feels numbness. It is acceptable to apply ice 2 to 5 times a day.
7. A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) 1. Transcutaneous electrical nerve stimulation (TENS) 2. Administer naloxone (Narcan) 2 mg intravenously 3. Provide back massage 4. Reposition the patient 5. Withhold any pain medication and tell the patient that she is at risk for addiction
1,3,4 Non-pharmacological therapies may provide comfort for the patient. It is much too early to consider possible addiction. Naloxone is not appropriate at this time because the patient does not show signs of over sedation or respiratory depression.
14. While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: (Select all that apply.) 1. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. 2. Stopping acetaminophen when the pain becomes very severe. 3. Avoiding polypharmacy by limiting the use of medication to one agent at a time. 4. Avoiding total sedation, regardless of the severity of the pain. 5. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.
1,5 Multimodal analgesia involves the use of a combination of drugs with at least two different mechanisms of action so pain control can be optimized. The use of acetaminophen, NSAIDs, gabapentin, and opioids represents a multimodal analgesic plan because each agent relies on a different mechanism of action to reduce pain, with the benefit of reducing the amount of opioid that is needed to control pain. This differs from polypharmacy because the combination of drugs is intentional and based on understanding of the action of each product on the pain pathway.
using an interpreter
1. Address the client directly in the first person 2. Speak in short sentences, pausing to allow the interpreter to speak 3. Ask only one question at a time 4. Avoid complex issues, idioms, jokes, and medical jargon 5. Hold a pre-conference with the medical interpreter to review the goals of the interview 6. Use a qualified professional interpreter whenever possible
A patient's___________ to pain, ______________________, and _________________________ will affect pain experiences. Repeated pain experiences may help the patient deal with the present pain experience. When in pain, a patient may rely heavily on others for assistance.
1. Attention 2. Previous Experience 3. Support Systems
Two types of peripheral nerve fibers conduct painful stimuli:
1. The fast, myelinated A fibers send sharp, localized and distinct sensations that specify the source of the pain, and detect its intensity. 2. The C fibers relay impulses that are poorly localized, visceral and persistent. For example, after stepping on a nail, a person initially feels a sharp, localized pain, which is a result of A-fiber transmission, or first pain. Within a few seconds the whole foot aches from C-fiber transmission, or second pain.
Ask the patient to rate the level of pain. Correct
1. What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? • Assess the patient's body language. • Observe cardiac monitor for increased heart rate. • Ask the patient to rate the level of pain. • Ask the patient to describe the effect of pain on the ability to cope.
"We should work together to create a regular schedule of medications that does not allow for breakthrough pain." Correct
10. A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? • "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." • "You should take your medication after you walk to make sure you do not fall while you are walking." • "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." • "You need to take oral pain medications when you experience severe pain."
transdermal fentanyl
100 times more potent than morphine, available for opioid tolerant patients with cancer or chronic pain. Delivers predetermined doses that provide analgesia for up to 72 hrs. -Good for patients who cannot take PO meds - Not for adult patients who weigh less than 100 lbs (to little subcutaneous tissue for absorption) or who are hyperthermic (increases drug absorption) - Do NOT place heating pads over a patch, and never cut it. - To dispose of a patch, fold it in half, adhesive side onto itself, and flush down the toilet.
The patient's culture is possibly influencing the patient's experience of pain. Correct
11. A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior and response to surgery? • The surgery successfully cured the patient's pain. • The patient's culture is possibly influencing the patient's experience of pain. • The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain. • The nurse is allowing personal beliefs about pain to influence pain management at this time.
"You need to drink plenty of fluids and eat a diet high in fiber."
12. A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? • "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." • "Narcotics can be addictive, so do not take them unless you are in severe pain." • "You need to drink plenty of fluids and eat a diet high in fiber." • "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."
Softly plays music that the patient finds relaxing
13. A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? • Frequently reassesses the patient's pain scores • Reassures the patient that the provider will come to the emergency department soon • Softly plays music that the patient finds relaxing • Teaches the patient how to do yoga
"You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."
14. A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? • "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." • "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." • "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." • "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."
Visceral pain Correct
15. A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? • Superficial pain • Idiopathic pain • Chronic pain • Visceral pain
normal pre albumin levels
16-35 mg/dL. Prealbumin, also called transthyretin, is one of the major proteins in the blood and is produced primarily by the liver. Its functions are to carry thyroxine (the main thyroid hormone) and vitamin A throughout the body. This test measures the level of prealbumin in the blood
The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. Correct
16. A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? • The patient is sleeping and is difficult to arouse. • The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. • Sufficient medication is left in the PCA syringe. • The patient presses the control button to deliver pain medication.
The patient's need for analgesic medication decreases during the dressing changes. Correct
18. The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient's pain during dressing changes? • The patient's need for analgesic medication decreases during the dressing changes. • The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. • The patient's facial expressions are stoic during the procedure. • The patient can tolerate more pain, so dressing changes can be performed more frequently.
"Ibuprofen helps to decrease the production of prostaglandins."
19. A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal anti-inflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works? • "Ibuprofen helps to remove factors that cause or stimulate pain." • "Ibuprofen reduces anxiety, which will help you better cope with your pain." • "Ibuprofen helps to decrease the production of prostaglandins." • "Ibuprofen binds with opiate receptors to reduce your pain."
The nurse is assessing a patient who had been administered morphine for pain relief. The nurse finds that the patient's respiratory rate is 5 breaths/minute. Which drug would be the most helpful in reversing this adverse effect? 1 Meperidine 2 Naloxone 3 Flumazenil 4 Metoclopramide
2
____ 17. A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen (Aleve, Naprosyn), for treatment of arthritis complains of stomach upset. What should the nurse instruct the patient to do? 1) Notify the prescriber immediately. 2) Take the medication with food. 3) Take the medication with 8 ounces of water. 4) Take the medication before bedtime.
2
____ 20. Which side effects associated with opioid use may improve after taking a few doses of the drug? 1) Constipation 2) Drowsiness 3) Dry mouth 4) Difficulty with urination
2
____ 28. After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviate the patients pain? 1) Encourage the client to ambulate to promote flow of spinal fluid. 2) Offer caffeinated beverages to constrict blood vessels in his head. 3) Encourage coughing and deep breathing to increase CSF pressure. 4) Restrict oral fluid intake to prevent excess spinal pressure.
2
____ 29. An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client: 1) Experiences less pain than in earlier stages of cancer. 2) Cannot communicate the character of his pain effectively. 3) Recalls pain at a later time than when it occurs. 4) Relies on caregiver to provide pain relief without asking.
2
____ 3. A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain? 1) Psychogenic 2) Phantom 3) Referred 4) Radiating
2
____ 5. In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord? 1) Transduction 2) Transmission 3) Perception 4) Modulation
2
The primary health care provider (PHP) administers epidural anesthesia to a patient with chronic cancer pain. The PHP instructs the nurse to monitor the patient every 15 minutes. Which intervention does the nurse implement to prevent complications? 1 Inspect the catheter for breaks. 2 Administer antiemetics as ordered. 3 Change the infusion tubing every 24 hours. 4 Assess for bladder and bowel distention.
2 A patient with chronic cancer pain is usually administered epidural anesthesia for pain management. This patient has to be monitored for side effects every 15 minutes. Nausea and vomiting are common side effects associated with epidural anesthesia. To prevent such undesirable complications, the nurse administers antiemetics as ordered. To maintain catheter function, the nurse inspects the catheter for breaks. The nurse changes the infusion tubing every 24 hours to prevent infection. To maintain urinary and bowel function, the nurse assesses for bladder and bowel distension.
The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain, because he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1 The patient's wife is the best resource for determining the level of pain, because she has been with him continually for the entire day. 2 The patient's report of pain is the best method for assessing the pain. 3 The patient's health care provider has the best knowledge of the level of pain that the patient that should be experiencing. 4 The nurse is the most experienced at assessing pain.
2 A patient's self-report of pain is the single most reliable indicator of the existence and intensity of pain.
A postoperative patient reports pain at the site of surgery. On examination, the nurse finds that the incision is healing well and there are no signs of infection. The nurse instructs a student nurse to give a placebo drug to the patient. Which action would be the most appropriate action for the student nurse to take? 1 Follow the instructions given by the nurse. 2 Question the action of the placebo prescription. 3 Administer another analgesic drug. 4 Administer the placebo and inform the primary health care provider immediately.
2 A placebo for pain does not have any analgesic properties. If a placebo is ordered, it must be questioned. The student should not blindly follow the instructions without knowing the purpose of administering the placebo. The student cannot directly administer another analgesic drug without an appropriate order to do so.
During a preoperative assessment, a patient reports history of a heart attack and use of anticoagulant medications. If epidural anesthesia is administered to the patient for the surgery, for which possible complication should the nurse look? 1 Synergistic effects 2 Hematoma 3 Allergic reaction 4 Respiratory depression
2 Because anticoagulants reduce the action of the blood's platelets, hematoma is a possible complication when epidural anesthesia is administered to a patient on anticoagulants. Anticoagulants and anesthesia have different actions, so a synergistic effect is not a concern. Anticoagulants do not predispose a patient to an allergic reaction to epidural anesthesia. Respiratory depression is an adverse effect of opioids, but anticoagulants do not make it more likely.
The nurse is caring for a patient who has severe pain due to muscle cramps. How does the nurse interpret this pain? 1 Visceral pain 2 Somatic pain 3 Referred pain 4 Cutaneous pain
2 Muscle cramps indicate that the patient has initiation of pain from musculoskeletal tissues. Therefore, the patient has somatic pain. If the pain arises from internal organs such as the gastrointestinal (GI) tract or pancreas, it indicates visceral pain. If the patient has pain at a particular site and injury at a different site, it indicates referred pain. If the patient has pain due to damage to the skin's surface, it indicates cutaneous pain.
During emotional pain assessment, the patient reports numbness and tingling sensations interspersed with shooting or electric-like pain. What does the nurse infer from the patient's report? 1 The patient is experiencing idiopathic pain. 2 The patient is experiencing neuropathic pain. 3 The patient is experiencing nociceptive visceral pain. 4 The patient is experiencing nociceptive somatic pain.
2 Neuropathic pain is characterized by burning, shooting, or electric-like pain accompanied by a tingling sensation. Idiopathic pain is chronic pain in the absence of an identifiable physical or psychological cause. When idiopathic pain is present, it is generally more than what would be expected for the organic pathological condition. Nociceptive pain originating from visceral sites is described as aching or cramping, or as aching or throbbing when it originates from somatic sites.
Which statement is true regarding nonpharmacological pain interventions? 1 Nonpharmacological interventions should only be used alone. 2 Nonpharmacological interventions are useful for patients who cannot tolerate pain medications. 3 Nonpharmacological interventions have a clear set of guidelines regarding intensity and duration. 4 Nonpharmacological interventions should be used in place of pharmacological therapies for acute pain.
2 Nonpharmacological pain relief can be useful for patients who cannot tolerate pain medications. The remaining statements, however, are false. Nonpharmacological interventions may be used alone, but they can also be used in combination with pharmacological therapies. Depending on the nonpharmacological therapy, research is still in progress to determine clear guidelines for intensity and duration. For acute pain, nonpharmacological therapy should never replace pharmacological therapy.
Which class of pain management drugs may interfere with bowel or bladder function? 1 Anticonvulsants 2 Opioid analgesics 3 Nonopioid analgesics 4 Nonsteroidal antiinflammatory drugs
2 Opioid analgesics are effective when used for pain management, but a common side effect is disruption of bowel or bladder function. Anticonvulsants are more commonly associated with side effects like dizziness, fatigue, and confusion than with disrupted bowel and bladder function. Nonopioid analgesics and nonsteroidal antiinflammatory drugs more commonly result in gastric bleeding, hypertension, and nausea than in disruption of bowel and bladder function.
Which signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1 Oxygen saturation of 95% 2 Difficulty arousing the patient 3 Respiratory rate of 10 breaths/minute 4 Pain intensity rating of 5 on a scale of 0 to 10
2 Opioid-naïve patients may develop a rare adverse effect of respiratory depression. Sedation always occurs before respiratory depression. The change in the level of consciousness supersedes oxygen saturation of 95% and moderate pain.
The nurse concludes that a patient has radiating pain. Which assessment findings support the nurse's conclusion? 1 The patient has pain from a small cut or laceration. 2 The patient has pain in the back accompanied by pain in the leg. 3 The patient has a crushing sensation with pain in the chest. 4 The patient has a burning sensation with severe stomach pain.
2 Pain extending from the initial site of injury to another body part is radiating pain. Therefore, because the patient has pain in the back accompanied by pain in the leg, it indicates radiating pain. Pain resulting from stimulation of the skin is cutaneous pain. A patient with pain from a small cut or laceration has cutaneous pain. If the patient has pain at one site but injury at a different site, it indicates referred pain. A patient experiencing a crushing sensation with pain in chest and a burning sensation with severe stomach pain indicates referred pain.
While treating a patient, the primary health care provider encourages the patient to watch funny videos. This is an example of which pain management technique? 1 Relaxation 2 Distraction 3 Acupressure 4 Music therapy
2 Patients who are bored or in isolation may think more frequently about their pain, thus perceiving it more acutely. Watching videos may direct the patient's attention to something other than pain, reducing awareness of it. This is an example of using distraction to manage pain. Relaxation techniques include meditation, yoga, guided imagery, and progressive relaxation exercises. Acupressure is applying pressure to specific points on the body in order to influence nerve pathways to decrease pain perception. Like distraction, music therapy works by taking the patient's attention away from the pain, but this is done with music, not videos.
1. Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 10 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10
2 Sedation is a concern because it may indicate that the patient is experiencing opioid-related side effects. Advancing sedation may indicate that the patient may progress to respiratory depression.
A patient with a history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The health care provider's order reads, "Hydrocodone/acetaminophen 1 tab, per tube, q4 hours, prn." Which action by the nurse is most appropriate? 1 No action is required by the nurse because the order is appropriate. 2 Request to have the ordered changed to ATC (around the clock) for the first 48 hours. 3 Ask for a change of medication to meperidine 50 mg IVP, q3 hours, prn. 4 Begin the hydrocodone/acetaminophen when the patient shows nonverbal symptoms of pain.
2 The American Pain Society (2003) states that if you anticipate pain for most of the day, you should consider ATC administration. Insertion of a gastrostomy tube is painful. This patient will most likely experience pain for at least the next 48 hours.
An opioid-naïve patient is on naloxone for respiratory depression caused by methadone overdose. The nurse is instructed to reassess the patient every 15 minutes for 2 hours following drug administration. What is the reason behind the schedule of reassessment of the patient? 1 The half-life of naloxone is greater than that of methadone. 2 Duration of the action of naloxone is less than that of methadone. 3 Naloxone acts as an agonist to methadone after 2 hours of administration. 4 Naloxone can cause methadone withdrawal symptoms in an opioid-naïve patient.
2 The duration of action or half-life of naloxone is less than that of methadone. Therefore, recurrence of respiratory depression by the relatively long action of methadone can be prevented by reassessing the patient every 15 minutes for 2 hours after naloxone administration. Methadone has a greater half-life than naloxone. Therefore, the effect of methadone is more prolonged than that of naloxone. Naloxone is an opioid-antagonist drug. Naloxone does not act as an agonist to morphine after 2 hours. Opioid-naïve patients are patients who have not taken opioid medications for at least a week. Naloxone causes morphine withdrawal symptoms only in patients who are physically dependent on morphine, not the patients who are opioid naïve.
A patient with rheumatoid arthritis reports acute joint pain in the hand. Which intervention is inappropriate for providing pain relief? 1 Encouraging the patient to listen to music or watch television 2 Collaborating with an occupational therapist to provide assistive devices for grooming 3 Administering ordered analgesics around the clock for 24 to 48 hours 4 Applying cool compresses to the patient's joints with the prescriber's approval
2 The nurse may collaborate with an occupational therapist to provide assistive devices to the patient for grooming, but this is not done to relieve pain; rather, this is an intervention to help the patient dress and prepare for the day if the joint pain is making this difficult. The remaining interventions are appropriate for pain relief. Music and television can help relieve pain by taking the patient's attention away from it. Analgesic administration is a pharmacological therapy method to provide pain relief. Cool compresses may also help soothe the pain caused by rheumatoid arthritis.
A patient who is on aspirin therapy for pain relief reports that there has been no change in the pain even after taking the drug. On assessment, the nurse finds that the patient had a history of a bleeding gastric ulcer and obstructive sleep apnea. What immediate action should the nurse take? 1 Add an opioid analgesic. 2 Stop the aspirin administration. 3 Increase the dose of aspirin. 4 Stop the aspirin and give ibuprofen.
2 The nurse should be aware of some of the common contraindications of analgesics. Nonsteroidal anti-inflammatory drugs (NSAIDs) should not be given to a patient with a history of gastrointestinal bleeding or renal insufficiency. Therefore, administration of aspirin should be stopped for this patient. Opioids should not be given to a patient with a history of obstructive sleep apnea, because they cause respiratory depression. Increasing the dose of aspirin would further worsen the gastrointestinal bleeding. Ibuprofen is also an NSAID and, therefore, should be avoided in this patient.
9. A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock (ATC) for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. 4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.
2 The patient can be expected to have acute pain related to the G-tube insertion; in addition, she has a history of chronic pain. Her pain should be treated with ATC medication to match the timing of her pain.
Which statement about transcutaneous electrical nerve stimulation (TENS) is incorrect? 1 TENS is helpful in reducing pain perception. 2 TENS is effective for chronic and postsurgical pain control. 3 A TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. 4 TENS requires a health care provider's order that identifies the site(s) for electrode placement.
2 Transcutaneous electrical nerve stimulation (TENS) is effective for acute, emergent, and postsurgical and procedural pain control but not for chronic pain. The remaining statements are correct. TENS is helpful in reducing pain perception. A TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. TENS requires a health care provider's order that identifies the site(s) for electrode placement.
The nurse advises a patient with neuropathic pain to undergo guided imagery therapy to alleviate pain. Which pharmacological treatment interventions would be beneficial to the patient for pain management? Select all that apply. 1 Corticosteroids 2 Anticonvulsants 3 Antidepressants 4 Muscle relaxants 5 Bisphosphonates
2, 3 The nonpharmacological interventions that are usually recommended for pain relief in a patient with neuropathic pain include relaxation and guided imagery. This allows patients to alter affective-motivational and cognitive pain perception. The pharmacological pain management therapies that would be beneficial to a patient with neuropathic pain include anticonvulsants such as gabapentin and antidepressants such as nortriptyline. Gabapentin acts on the supraspinal region to stimulate noradrenaline-mediated descending inhibition to reduce neuropathic pain. Nortriptyline alleviates neuropathic pain by altering neurotransmitter levels. Corticosteroids relieve pain associated with inflammation and bone metastasis. Muscle relaxants have no analgesic effect. Bisphosphonates are prescribed for bone pain.
The nurse is attending to a postsurgical patient who underwent a nephrectomy. What observations would tell the nurse the patient is in severe pain? Select all that apply. 1 The patient is motionless. 2 The patient has a reduced attention span. 3 The patient is constantly asking for pain relief medication. 4 The patient has clenched teeth and is biting his or her lips. 5 The patient is talking incessantly for a long time.
2, 3, 4 A patient in acute pain may not be able to concentrate on anything. The patient may have a reduced attention span and may focus only on pain relief. The nurse may observe the patient clenching teeth or biting his or her lips to tolerate or suppress the pain. These patients are usually physically restless due to pain and they do not interact or talk incessantly.
The nurse is assessing a patient with acute pain. Which statements are true about acute pain? Select all that apply. 1 Acute pain is not protective. 2 Acute pain has an identifiable cause. 3 Acute pain has limited tissue damage. 4 Acute pain results in prolonged hospitalization. 5 Patients with acute pain seek numerous health care providers.
2, 3, 4 Acute pain has an identifiable cause, limited tissue damage, and an emotional response. Acute pain results in prolonged hospitalization as it seriously threatens a patient's recovery, so the health team members treat it aggressively. Acute pain is protective, unlike chronic pain, which is not protective. A patient with chronic pain may seek numerous health care providers because of its unknown cause.
A group of nursing students is learning about nociceptive and neuropathic pain. What are examples of neuropathic pain? Select all that apply. 1 Aching muscles 2 Diabetic neuropathy 3 Trigeminal neuralgia 4 Nerve root compression 5 Throbbing pain at knee joint
2, 3, 4 Neuropathic pain arises when there is abnormal processing of sensory input by the peripheral or central nervous system. Pain felt along the distribution of many peripheral nerves as in diabetic neuropathy is a neuropathic pain. Pain felt partly along the distribution of a damaged nerve such as in nerve root compression is also an example of neuropathic pain. Pain associated with trigeminal neuralgia is also a neuropathic pain. Aching muscles and a throbbing pain at the knee joint are examples of nociceptive pain.
The nurse is assessing a hospitalized patient with acute pain. Which questions should the nurse ask the patient for an appropriate assessment? Select all that apply. 1 "How bad is your pain now?" 2 "What makes your pain worse?" 3 "Describe your pain." 4 "What is the worst pain you have had in past 24 hours?" 5 "Show me where you are hurt. Does it stay there or does it spread?"
2, 3, 5 When assessing a patient with acute pain, the questions should be specific. The questions should aim to determine the intensity, location, and quality of pain. Ask provocative questions such as, "What makes the pain worse?" Ask about the region of the pain and the radiation of pain. Asking how bad the pain is may not yield specific details. Instead, the patient should be asked to rate the pain on a scale of 0 to 10. Other details can be asked once the patient is comfortable.
The nurse is teaching a group of nursing students about concepts of pain in infants. Which information should the nurse include in the teaching? Select all that apply. 1 Infants cannot express pain. 2 Absorption of drugs is faster than expected. 3 Infants are less sensitive to pain than adults are. 4 Preterm neonates have greater sensitivity to pain than older children do. 5 Assessment of pain involves behavioral cues and physiological indicators.
2, 4, 5 Absorption of drugs in infants is faster than expected. The drugs that are excreted by the kidneys should be administered in a lower dosage. Preterm neonates have greater sensitivity than term neonates or older children. Using behavioral cues such as facial expression and physiological indicators such as changes in vital signs provide proper assessment of pain. Infants cannot verbalize pain but respond with behavioral changes. Term neonates have the same sensitivity to pain as older children.
The registered nurse is teaching a nursing student about applying transcutaneous electrical nerve stimulation (TENS) to a patient. Which of the nursing student's statements indicate a need for further teaching? Select all that apply. 1 "I should set the frequency to no more than 50 Hz." 2 "I should use TENS on patients who have chronic cancer pain." 3 "I should place TENS electrodes directly over or near the site of pain." 4 "I should apply hair or skin preparations before placing TENS electrodes." 5 "I should remove TENS electrodes if the patient feels a buzzing or tingling sensation."
2, 4, 5 Transcutaneous electrical nerve stimulation (TENS) is effective in treating acute, emergent, and postsurgical and procedural pain control, but not chronic conditions, like cancer pain. The nurse should not apply any hair or skin preparations before attaching the TENS electrodes. Buzzing or tingling sensations are normal, and do not require the nurse to remove electrodes. The other statements indicate understanding. The range of frequency of TENS is 10 Hz to 50 Hz. The TENS electrodes should be placed directly over or near the site of pain.
Which adjuvant drugs are preferred for treating neuropathic pain? Select all that apply. 1 Corticosteroids 2 Anticonvulsants 3 Opioid analgesics 4 Nonopioid analgesics 5 Tricyclic antidepressants
2, 5 Anticonvulsants and tricyclic antidepressants can be effective for treating chronic pain, especially neuropathic pain. Corticosteroids are typically used to relieve pain from inflammation and bone metastasis. Opioid and nonopioid analgesics are not adjuvant drugs.
A primary health care provider recommends ibuprofen to a patient in pain. Which statements about this medication are correct? Select all that apply. 1 It depresses the central nervous system in order to relieve pain. 2 It acts by inhibiting the synthesis of prostaglandins. 3 It is highly recommended for older adults experiencing pain. 4 It is the most effective prescription drug available for pain relief. 5 One of its serious side effects is gastrointestinal bleeding.
2, 5 Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, act by inhibiting prostaglandin synthesis, thereby inhibiting cellular response to inflammation and thus reducing pain. Gastrointestinal bleeding is a major adverse effect of NSAIDs. The remaining statements are incorrect. Opiates, not NSAIDs, depress the central nervous system to relieve pain. Because of the risk for gastrointestinal bleeding, ibuprofen and other NSAIDs are not frequently the first choice for treating pain in older adults. Ibuprofen is not a prescription drug; it is widely available over the counter.
10. A patient is prescribed morphine patient-controlled analgesia (PCA). Arrange the following steps for administering PCA in the correct order. 1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval. 2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly. 3. Administer loading dose of analgesia as prescribed. 4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. 5. Identify patient using two identifiers. 6. Insert and secure needleless adapter into injection port nearest patient.
2,5,1,4,6,3= Check Label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly. Identify patient using 2 identifiers. Program computerized PCA pump to deliver prescribed medication dose and lockout interval. Attach drug reservoir to infusion device, prime tubing and attach needleless adapter to end of tubing. Insert and secure nedleless adapter into injection port nearest to patient. Administer loading dose of analgesia as prescribed.
"Would you like medication to be given for dressing changes on top of your regularly scheduled medication?"
20. A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? • "This medication will still be providing you relief at the time of your dressing change." • "OK, swallow this pain pill, and I will return in a minute to fill your wound." • "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?" • "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."
Ask the health care provider to verify the dosage and frequency of the medication.
21. A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action? • Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. • Ask the health care provider to verify the dosage and frequency of the medication. • Ask the health care provider for an order for a nonsteroidal anti-inflammatory drug (NSAID). • Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.
"This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." Correct
23. Which statement made by a nursing educator best explains why it is important for nurses to determine a patient's medical history and recent drug use? • "Health care providers have a responsibility to prevent drug seekers from gaining access to drugs." • "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." • "Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain." • "Getting this information gives the nurse an opportunity to provide patient teaching about drug abstinence."
What activities, if any, has your pain prevented you from doing?"
25. The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? • "Have you considered working with a physical therapist?" • "What activities, if any, has your pain prevented you from doing?" • "Would you please rate your pain on a scale from 1 to 10 for me?" • "What effect does your pain medication typically have on your pain?"
The patient who is experiencing 8/10 pain and has a STAT order for pain medication Correct
26. The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding? • "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." • "When patients say they don't need pain medication, they aren't in pain." • "The patient who is experiencing 8/10 pain and has a STAT order for pain medication • "A patient's behavior is more reliable than the patient's report of pain."
The patient who is experiencing 8/10 pain and has a STAT order for pain medication Correct
27. The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? • The patient who needs to take a scheduled dose of maintenance pain medication • The patient who needs to be premedicated before walking • The patient with a PCA running who needs to have the syringe replaced • The patient who is experiencing 8/10 pain and has a STAT order for pain medication
Patient drinks 1 to 2 glasses of wine every night. Correct
29. A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? • Patient drinks 1 to 2 glasses of wine every night. • Patient smokes 2 packs of cigarettes a day. • Patient occasionally smokes marijuana. • Patient takes antianxiety medications.
____ 14. The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan? 1) Place the cold pack directly on the skin over the ankle. 2) Apply the cold pack to the ankle for 30 minutes at a time. 3) Check the skin frequently for extreme redness. 4) Keep the cold pack in place for at least 24 hours.
3
____ 16. The nurse uses his hands to direct energy fields surrounding the patients body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention? 1) Tactile distraction was performed and appeared effective in reducing pain. 2) Guided imagery was effective to relax the patient and reduce the pain. 3) Therapeutic touch was performed; patient verbalized lessening of pain after treatment. 4) Sequential muscle relaxation was performed; patient states pain is less.
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____ 2. How should the nurse classify pain that a patient with lung cancer is experiencing? 1) Radiating 2) Deep somatic 3) Visceral 4) Referred
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____ 21. A patient develops a respiratory rate 6 breaths/minute after receiving IV hydromorphone (Dilaudid) 2 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? 1) Physostigmine (Antilirium) 2) Flumazenil (Romazicon) 3) Naloxone (Narcan) 4) Protamine sulfate
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____ 22. Which pain management task can be safely delegated to nursing assistive personnel? 1) Assessing the quality and intensity of the patients pain 2) Evaluating the effectiveness of pain medication 3) Providing a therapeutic back massage 4) Administering oral dose of acetaminophen
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____ 23. Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia? 1) The patient will verbalize a reduction in pain after receiving pain medication and repositioning. 2) The patient will rest quietly when undisturbed. 3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation. 4) The patient will receive pain medication every 2 hours as prescribed.
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____ 4. A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response? 1) Histamine 2) Prostaglandin 3) Bradykinin 4) Serotonin
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____ 8. A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication? 1) Metabolic alkalosis 2) Pneumothorax 3) Pneumonia 4) Hemothorax
3
The nursing instructor is teaching a student nurse about using a patient-controlled analgesia (PCA) pump. Which intervention does the student nurse follow to establish the route of medication and rapid administration of the medication? 1 Administer the loading dose of analgesia as prescribed. 2 Attach the drug reservoir to the infusion device and prime the tubing. 3 Insert and secure a needleless adapter into the injection port nearest the patient. 4 Attach a needleless adapter to the tubing adapter of the patient-controlled module.
3 A needleless adapter is inserted into the injection port nearest the patient to establish the route of medication and facilitate continuous delivery of the medication. The nurse administers the loading dose of analgesia as prescribed by giving one-time doses manually or programming it into the PCA pump. Attaching the drug reservoir to the infusion device and prime tubing locks the system and prevents air from infusing into the intravenous (IV) tubing. Attaching a needleless adapter to the tubing adapter of a patient-controlled module is done to connect with the IV line. It does not facilitate continuous delivery of the medication.
A patient is in the first postoperative day following a nephrectomy. The patient is receiving morphine through a patient-controlled analgesia (PCA) device for management of pain. The patient complains of pain in the shoulders. The nurse understands that it is a referred pain. What explanation should the nurse give to the patient regarding the referred pain? 1 It is a pain that occurs sporadically over time. 2 It is a moderate pain that occurs for more than 6 months constantly. 3 It is a pain that is sensed at a site away from its actual origin or pathology. 4 It is neuropathic pain that is caused generally after cancer or a tumor.
3 A pain that is sensed at a site away from its actual origin or pathology is known as referred pain. A pain that occurs sporadically over time is known as chronic episodic pain. A moderate pain that occurs constantly for more than 6 months is known as chronic or persistent noncancerous pain. A cancer pain is neuropathic pain that is caused generally after cancer or a tumor.
A registered nurse is teaching a nursing student about various nonpharmacological pain management interventions. Which of the nursing student's statements indicates a need for further teaching? 1 "Biofeedback can help change a patient's perception of pain." 2 "Music therapy can be used in combination with pharmacological measures." 3 "Guided imagery provides effective pain relief for a patient who has acute appendicitis." 4 "Therapeutic touch is a complementary and alternative medicine pain relief method."
3 Acute pain cannot be effectively managed by nonpharmacological pain management interventions alone, so the nursing student requires further teaching to understand that guided imagery alone will be inadequate for a patient experiencing acute appendicitis. The remaining statements indicate understanding. Cognitive-behavioral interventions like biofeedback can change a patient's perception of pain. Any nonpharmacological intervention like music therapy can be used in combination with pharmacological interventions to provide pain relief. Therapeutic touch is a complementary and alternative pain relief method.
Which type of pain management is cold application? 1 Relaxation 2 Distraction 3 Cutaneous stimulation 4 Acupressure
3 Cold application stimulates the skin, which helps reduce pain perception, perhaps by releasing endorphins or activating large, fast-transmitting A-beta sensory nerve fibers. Relaxation techniques include meditation, yoga, guided imagery, and progressive relaxation exercises. Distraction works by diverting the patient's attention to something other than pain, thus reducing awareness of it. Acupressure involves the application of pressure, not cold.
3. A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants
3 Constipation is a common opioid-related side effect, and patients do not become tolerant to it.
A patient who is in the terminal stages of liver cancer reports continuous vomiting after taking oral opioid analgesics. The patient's weight is 85 pounds. The nurse applies a transdermal fentanyl patch to the patient. The next day, the patient informs the nurse that the pain is not alleviated. What could be the possible reason for this? 1 The dose of pain medication is not enough. 2 The number of patches used is not enough. 3 The route of administration of the analgesic is not correct. 4 The patient needs to wait longer for the medication to act.
3 Fentanyl is an opioid analgesic and is available for intravenous or transdermal administration. It is 100 times more potent than morphine. However, transdermal patches are not effective in patients weighing less than 100 pounds, because these patients have very little subcutaneous tissue for absorption. Therefore, the nurse should discuss a more appropriate analgesic drug with the primary health care provider. The dose and the number of patches for the therapeutic action are predetermined. The duration of drug action is about 48 to 72 hours.
The patient complains of intermittent back pain that travels down the left leg. What is this type of pain called? 1 Visceral 2 Referred 3 Radiating 4 Superficial
3 Intermittent or constant pain that travels down or along a body part is called radiating pain. Deep or visceral pain results from the stimulation of internal organs. It is diffuse and radiates in several directions. Referred pain is in a part of the body separate from the source of pain. Superficial pain is of short duration and is localized.
A student nurse is reading about the mode of action of nonsteroidal anti-inflammatory drugs (NSAIDS). The NSAID drug decreases the level of a chemical that is known to increase pain sensitivity. With which chemical does the NSAID react? 1 Renin 2 Serotonin 3 Prostaglandin 4 Diclofenac sodium
3 Prostaglandins are generated from the breakdown of phospholipids of the cell membrane and are known to increase pain sensitivity. NSAIDs act by decreasing the levels of such compounds in the blood. Renin is involved in balancing water and electrolytes in the body. Neurotransmitters such as serotonin inhibit the transmission of pain. Diclofenac sodium is a painkiller that reduces pain sensitivity.
5. The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding
3 The Food and Drug Administration (FDA) recommends a maximum daily dose of 4 g of acetaminophen, and many authorities believe that the maximum daily dose should be lower (3000 to 3200 mg/day) in the outpatient setting to reduce the risk of hepatotoxicity.
Which topical analgesic is effective for relieving postherpetic neuralgia in adults? 1 Capsaicin 2 ELA-Max/LMX 3 Lidoderm patch 4 Eutectic mixture of local anesthetics (EMLA)
3 The Lidoderm patch is effective for treating postherpetic neuralgia, a cutaneous neuropathic pain. Capsaicin is more appropriate for relieving minor aches and pains of the muscles and joints. ELA-Max/LMX and a eutectic mixture of local anesthetics (EMLA) are more often used to treat children.
The primary health care provider (PHP) prescribes a patient-controlled analgesia (PCA) pump to a postoperative patient for pain relief. The nurse reviews the PHP's order for the patient's name, the name of the medication, dose, frequency of medication, and lockout period. Why does the nurse perform this review? 1 To prevent medication errors 2 To ensure that the patient receives the correct medications 3 To ensure that the medication is administered safely 4 To avoid placing the patient at risk for allergic reactions
3 The nurse checks the computer printout with the PHP's order for the patient's name, the name of medication, dose, frequency of medication, and lockout period to ensure that the medication is administered safely. A second registered nurse confirms the PHP's order and correct setup of the PCA pump to prevent medication errors. To ensure that the patient receives the correct medications, the nurse checks the patient's prescription. The nurse checks the patient's history for drug allergies to avoid placing the patient at risk for allergic reactions.
A physician put a postoperative patient on a patient-controlled opioid analgesic pump to be used around the clock for a week. Which assessment should the nurse make at regular intervals? 1 Liver enzymes 2 Blood pressure 3 Respiratory rate 4 Body temperature
3 While there is little risk for overdose with patient-controlled analgesic pumps, respiratory depression is a side effect associated with opioids, so while the patient is on opioid pain management, the nurse should regularly check respiratory rate. A nurse may check liver enzymes in a patient who is taking acetaminophen, not opioids, because acetaminophen can adversely affect the liver. Whereas blood pressure and body temperature may be checked regularly, it is unlikely that the nurse is doing this to monitor for side effects of opioid pain management.
For what age should the nurse use the Non-communicating children's pain checklist?
3 - 18 yrs
For what age should the nurse use the FACES tool?
3 years +
Which nonpharmacological techniques pose a risk of injury to the patient if the patient has a history of diabetic neuropathy? Select all that apply. 1 Yoga 2 Massage 3 Hot bath 4 Cold application 5 Relaxation exercises
3, 4 A patient who has diabetic neuropathy may not be able to adequately monitor temperature in areas affected by nerve damage, so application of any heat or cold may place this patient at a higher risk for injury. If done safely and properly, yoga, massage, and relaxation exercises should not place a patient with diabetic neuropathy at a higher risk for injury than any other patient.
The nurse is assessing the touch, pain, and temperature sensation of a patient who is diagnosed with diabetic neuropathy. Arrange in ascending order the parts of the central nervous system through which pain sensation is carried. 1. Cerebrum 2. Thalamus 3. Spinal cord 4. Medulla, pons, midbrain
3, 4, 2, 1 Spinal cord, Medulla, pons, midbrain, Thalamus, Cerebrum Pain sensation is transmitted from afferent fibers to the spinal cord. From the spinal cord, the pain sensation is carried to medulla, pons, and midbrain. From here it continues through the spinothalamic tract to the thalamus and then to the cerebrum.
The nurse attending to a postoperative patient finds that the patient's pain medications have been changed from morphine to ibuprofen. What are the possible reasons for the change in medication by the health care provider? Select all that apply. 1 The patient's pain has increased. 2 Morphine is known to cause seizures. 3 The patient experienced clinical respiratory depression. 4 Ibuprofen does not affect the central nervous system the way morphine does. 5 Ibuprofen does not interfere with bowel and bladder function.
3, 4, 5 Opioids (morphine) can cause respiratory depression in some patients who are not used to them. Secondly, unlike nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, opioids interfere with the activity of the central nervous system and affect the bowel and the bladder function. Opioids are generally prescribed when pain is severe. NSAIDs are useful for mild to moderate pain. Morphine is not known to cause seizures.
"Meditation controls pain by blocking pain impulses from coming through the gate."
3. Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? • "Meditation controls pain by blocking pain impulses from coming through the gate." • "Meditation will help me sleep through the pain because it opens the gate." • "Meditation stops the occurrence of pain stimuli." • "Meditation alters the chemical composition of pain neuroregulators, which closes the gate."
"It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."
31. The nurse is caring for a patient who recently had surgery to repair a hernia. The patient's pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurse's best response? • "This medication can be given only every 4 hours. It is not time for you to have any other pain medication right now." • "I will notify the health care provider to come perform an assessment if your pain doesn't improve in 30 minutes." • "If the pain becomes severe, we may need to transfer you to an intensive care unit." • "It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."
Give medications around-the-clock. Correct
32. Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? • Administer pain medication before any activity. • Provide intravascular bolus as needed for breakthrough pain. • Give medications around-the-clock. • Administer pain medication only when nonpharmacological measures have failed.
Somatic pain
33. A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has? • Visceral pain • Somatic pain • Peripherally generated pain • Centrally generated pain
Infants respond behaviorally and physiologically to painful stimuli. Correct
34. The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient? • Infants cannot tolerate analgesics owing to an underdeveloped metabolism. • Infants have an increased sensitivity to pain when compared with older children. • Pain cannot be accurately assessed in infants. • Infants respond behaviorally and physiologically to painful stimuli.
Stated allergy to aspirin Correct
35. The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.) • Past medical history of gastric ulcer Correct • Patient states last bowel movement was 4 days ago • Stated allergy to aspirin • Patient states has 2/10 intermittent joint pain • Patient experienced respiratory depression after administration of an opioid medication
____ 13. After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take? 1) Use nonpharmacological therapy while waiting 3 more hours before the next dose. 2) Administer an additional 800 mg oral dose of ibuprofen right away. 3) Do nothing because the patients facial expression indicates he is comfortable. 4) Notify the prescriber that the current pain management plan is ineffective.
4
____ 25. A patient with Raynauds disease receives no symptomatic relief with diltiazem (Cardizem). Which surgical intervention might be a treatment option for this patient to help provide symptomatic relief? 1) Cordotomy 2) Rhizotomy 3) Neurectomy 4) Sympathectomy
4
____ 6. A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process? 1) Perception 2) Transduction 3) Transmission 4) Modulation
4
A 65-year-old patient is experiencing mild musculoskeletal pain. Which drug is the primary health care provider most likely to prescribe? 1 Aspirin 2 Naproxen 3 Ibuprofen 4 Acetaminophen
4 A physician may first recommend acetaminophen to this patient because the pain is mild, and acetaminophen is relatively safe and widely available over the counter for musculoskeletal pain. The physician may prescribe aspirin, naproxen, or ibuprofen, but these may be second-choice drugs because they are nonsteroidal antiinflammatory drugs which carry a risk for bleeding, especially in older adults, and may not be necessary if the pain is mild.
The physician tells the nurse to administer a second drug to a patient already on oxycodone. Which drug would be safe for this patient? 1 Fentanyl 2 Morphine 3 Codeine 4 Acetaminophen
4 Acetaminophen is safe to use in combination with opioids like oxycodone for pain relief. A health care provider may do so to lower the opioid dose. Fentanyl, morphine, and codeine are also opioids, so combining them with another opioid would have potentially dangerous synergistic effects.
The nurse is assessing a patient who complains of back pain. After taking the patient's history, the nurse does not expect the physician to recommend acetaminophen. Which of the patient's statements led the nurse to this conclusion? 1 "I drink alcohol occasionally." 2 "I have been constipated for 3 days." 3 "I am allergic to penicillin." 4 "Two months ago, I was diagnosed with hepatitis B."
4 Because acetaminophen can cause hepatotoxicity, and a patient who has hepatitis B has a compromised liver, the nurse may expect the physician to avoid recommending acetaminophen to this patient. Acetaminophen is safe for a patient who consumes alcohol occasionally, but it should be used with caution for a patient who frequently drinks alcohol. Occasional alcohol intake might not affect the administration of acetaminophen. Nonsteroidal antiinflammatory drugs, not acetaminophen, may aggravate constipation. An allergy to penicillin will not necessarily predispose a patient to an allergy to acetaminophen.
The registered nurse is teaching a patient about the use of cold therapy in acute pain management. Which of the patient's statements indicates a need for further teaching? 1 "I will apply ice two to five times a day." 2 "I will apply ice with a lightweight cover, with firm pressure to my skin." 3 "I will apply ice within a 6-inch circular area near where I have pain." 4 "I will place ice between my thumb and index finger if I have shoulder pain."
4 Cold is effective for tooth or mouth pain, not shoulder pain, when the ice is placed on the web of the hand between the thumb and index finger. This is an acupressure point that influences nerve pathways to the face and head. The remaining statements indicate understanding: Ice can be applied two to five times a day with firm pressure to the skin, covered with a lightweight cloth. Ice should also be applied within a 6-inch circular area near the site of pain.
A new medical resident writes an order for oxycodone SR 10 mg PO q12 hours prn. Which part of the order does the nurse question? 1 The drug 2 The time interval 3 The dose 4 Prn
4 Controlled- or extended-release opioid formulations such as oxycodone are available for administration every 8 to 12 hours around the clock (ATC). Health care providers should not order these long-acting formulations prn.
Why would a primary health care provider prescribe acetylcysteine to a patient who is on pharmacological pain management therapy? 1 Overdose of aspirin 2 Overdose of fentanyl 3 Overdose of morphine 4 Overdose of acetaminophen
4 Dangerous hepatotoxic overdoses of acetaminophen are treated with acetylcysteine. Antiulcer drugs may be prescribed to treat gastric bleeding caused by overdose of aspirin. Overdoses of fentanyl and morphine may be treated with naloxone.
After having received 0.2 mg of naloxone intravenous push (IVP), a patient's respiratory rate and depth are within normal limits. The nurse now plans to implement which actions? 1 Discontinue all ordered opioids. 2 Close the room door to allow the patient to recover. 3 Administer the remaining naloxone over 4 minutes. 4 Assess patient's vital signs every 15 minutes for 2 hours.
4 Every 15 minutes for 2 hours following drug administration reassess patients who receive naloxone because the duration of the opioid may be longer than the duration of the naloxone, and respiratory depression may return.
A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. What is the nurse's first action? 1 Call the patient's health care provider. 2 Administer pain medication as ordered. 3 Check the patient's vital signs. 4 Assess the characteristics of the pain.
4 It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number.
Which pain characteristics might the nurse suspect in a patient with kidney stones? 1 The pain is of short duration and localized. 2 The pain is diffuse and radiates in several directions. 3 The pain radiates from the site of the injury to another body part. 4 The pain is in a part of the body separate from the source of pain.
4 Kidney stones cause groin pain, an example of referred pain, which occurs in a part of the body separate from the source of pain. Superficial or cutaneous pain, for example from a needle stick or small cuts, is of short duration and is localized. Deep or visceral pain, for example from angina pectoris, is diffuse and radiates in several directions. Radiating pain travels down from the site of injury to another body part, for example in sciatica.
A patient has had arthritic pain for 8 years and has surgery to remove a buildup of septic fluid. Postoperative, the patient received morphine through a patient-controlled analgesia (PCA) device for the management of pain. After a while, the patient starts getting drowsy and symptoms of respiratory depression begin to appear. The nurse is ordered to administer naloxone. What is the rate of administering naloxone? 1 Intravenous push at the rate of 1 mL every 1 minute 2 Intravenous push at the rate of 1 mL every 2 minutes 3 Intravenous push at the rate of 0.5 mL every 1 minute 4 Intravenous push at the rate of 0.5 mL every 2 minutes
4 Naloxone is an antidote for respiratory depression caused by opioids. The dosage of naloxone is 0.4 mg diluted by 9 mL saline. This is administered by intravenous push at the rate of 0.5 mL every 2 minutes. This dosage is optimal for reversal of respiratory depression. Doses larger than this can cause severe pain and other serious complications.
A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking, chills, abdominal cramps, and joint pain. What does the nurse recognize as these symptoms? 1 Addiction 2 Tolerance 3 Pseudoaddiction 4 Physical dependence
4 Physical dependence is a state of adaptation that is manifested by a drug-class specific withdrawal syndrome produced by abrupt cessation of the drug, rapid dose reduction, decreasing blood levels of the drug, and/or the administration of an antagonist.
What is the immediate intervention if a patient on oxycodone 10 mg/mL infusion therapy experiences respiratory depression? 1 Administering acetylcysteine 2 Reducing the dose of oxycodone to 5 mg/mL 3 Decreasing the rate of infusion 4 Administering 0.4 mg of naloxone
4 Respiratory depression is a serious side effect of opioid administration. Naloxone counters the effects of opioids, so this drug would be used to treat respiratory depression resulting from oxycodone administration. Acetylcysteine is used to counter acetaminophen, not opioid, overdose. Decreasing the dose or rate of infusion may be done to decrease less serious side effects like drowsiness or nausea.
The nurse is teaching a group of nursing students about pain sensations in infants. Which information should be included in the teaching about pain sensation in infants? 1 Infants do not perceive pain sensation immediately after birth. 2 Nurses cannot accurately assess pain in infants. 3 Infants cannot express pain sensation in the first month of life. 4 Infants learn to perceive pain by experiencing the first unpleasant stimulus.
4 Some common misconceptions about pain sensation in infants exist, of which the nurse should be aware. Infants immediately respond to pain on experiencing the first noxious stimulus. Infants feel pain from birth; a functional processing of pain is developed by mid to late gestation. Nurses can use behavioral changes and alterations in vital signs to assess pain in infants. Although infants cannot verbalize pain, they can express pain by crying.
The nurse is assessing a patient who has sustained severe injuries in a motor vehicle accident. The patient is in severe pain and is diaphoretic. On assessment, the patient's heart rate is increased, pupils are dilated, and blood pressure is decreased. Which finding is caused by the stimulation of the parasympathetic nervous system? 1 Diaphoresis 2 Dilation of pupils 3 Increased heart rate 4 Decrease in blood pressure
4 Superficial pain or mild-to-moderate pain stimulates the sympathetic nervous system. The parasympathetic nervous system is stimulated by continuous, deep, or severe pain involving visceral organs. Stimulation of the parasympathetic nervous system has an inhibitory effect on the body systems and causes a decrease in blood pressure. The sympathetic nervous system prepares the body for a fight-or-flight response. Diaphoresis, dilation of pupils, and increased heart rate are caused by the stimulation of the sympathetic system.
When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information should the nurse include? 1 TENS works by causing distraction. 2 TENS therapy does not require a health care provider's order. 3 A TENS unit must remain plugged in at all times 4 TENS electrodes are applied near or directly on the site of pain.
4 TENS involves stimulation of the skin with a mild electrical current passed through external electrodes. The therapy requires a health care provider order. The TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. Place the electrodes directly over or near the site of pain.
13. When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? 1. TENS works by causing distraction. 2. TENS therapy does not require a health care provider's order. 3. TENS requires an electrical source for use. 4. TENS electrodes are applied near or directly on the site of pain.
4 TENS units act on both the central and peripheral nervous systems. The peripheral effect occurs through activation of the neuroreceptors at or near the source of pain; therefore the electrodes should be placed near the site.
6. A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1. Opioid toxicity. 2. Opioid tolerance. 3. Opioid addiction. 4. Opioid withdrawal.
4 The common symptoms of opioid withdrawal that are associated with physical dependence may develop when an opioid is withdrawn rapidly. Symptoms include shaking chills, abdominal cramps, and joint pain.
The registered nurse is evaluating the performance of a student nurse who is performing a back massage for a patient with back pain. Which action by the student nurse needs correction? 1 Using long, gliding strokes along the muscles of the spine 2 Beginning at the sacral area and massaging in a circular motion 3 Kneading the skin by gently grasping tissue between the thumb and fingers 4 Kneading downward along one side of the spine from the shoulders to the buttocks
4 The nurse should knead upward along one side of the spine from buttocks to shoulders, not downward from the shoulders to the buttocks. The nurse should massage each body part for at least 10 minutes and use long, gliding strokes along the muscles of the spine. The massage should begin at the sacral area and progress in a circular motion while moving upward from the buttocks to the shoulders. The nurse should knead the skin by gently grasping tissue between the thumb and fingers.
A nurse administers epidural anesthesia to a patient in the terminal stages of cancer for pain relief. Which nursing intervention is then necessary? 1 Administering supplemental doses of opioid 2 Assessing vitals once every hour after administering the first dose 3 Administering anticoagulant medications with the epidural 4 Notifying the health care provider if the patient develops pain at the epidural insertion site
4 The nurse should notify the health care provider if the patient develops pain at the epidural insertion site, because it may indicate development of an epidural hematoma. Administering supplemental opioids could lead to dangerous additive central nervous system adverse effects. The nurse should monitor vital signs and respiratory rate once every 15 minutes after the administration of epidural anesthesia to ensure stable vitals; once every hour is not enough. Anticoagulants and antiplatelet drugs should not be administered to the patient, because they may increase the risk of hematoma formation.
A patient with diabetes who is on metformin has been taking morphine and nortriptyline for the past week to treat neuropathic pain. The patient is diagnosed with an upper respiratory tract infection and is prescribed antibiotics. Which drug taken by the patient is an adjuvant pain medication? 1 Antibiotic 2 Morphine 3 Metformin 4 Nortriptyline
4 The primary purpose of an adjuvant drug such as an antiepileptic, muscle relaxant, sedative, or anxiolytic is to treat conditions other than pain. Some of these drugs have analgesic properties and reduce pain effectively when used with or without pain medications. The diabetic patient takes nortriptyline, which is an antidepressant. It is also used as an adjuvant analgesic to morphine, which is an opioid analgesic in pain management. Morphine is the primary drug that provides pain relief. Antibiotics and metformin do not have an analgesic affect. Antibiotics are used to treat infections and do not have an analgesic effect. Metformin is an oral hypoglycemic drug and does not have any effect on pain relief.
After assessing pain in a 9-year-old child using a numeric rating scale (NRS), the nurse documents the score as 5. What does the nurse interpret from this score? 1 The child has no pain. 2 The child has mild pain. 3 The child has severe pain. 4 The child has moderate pain.
4 The score range of 4 to 6 indicates moderate pain. A score of 0 indicates that the child is relaxed and comfortable without any pain. The score range of 1 to 3 indicates that the child has mild pain. The score range of 7 to 10 indicates that the child has severe pain.
Which pain management method is considered a nonpharmacological complementary and alternative intervention? 1 Distraction 2 Biofeedback 3 Guided imagery 4 Therapeutic touch
4 Therapeutic touch is a nonpharmacological complementary and alternate pain management intervention. Distraction, biofeedback, and guided imagery, music are nonpharmacological, but considered cognitive-behavioral, not alternative and complementary, interventions.
The nurse has conducted an informative session on discouraging pseudoaddiction to a group of people in a community. Which group of patients should be the main target for the nurse's teachings? 1 Patients with a history of taking over-the-counter medicines 2 Patients with a history of drinking coffee for more than 5 years 3 Patients who say that heroin increases concentration 4 Patients who repeatedly seek multiple medical opinions for chronic pain relief
4 When a patient with chronic pain seeks pain medication from multiple primary health care providers, the patient is called a drug seeker but not an illicit drug abuser. This kind of addiction is called pseudoaddiction. Such drug seekers should be referred to pain specialists. Pseudoaddiction is not related to a history of taking over-the-counter medicines or the history of drinking coffee for more than 5 years. The patients who say that heroin increases concentration do not have pseudoaddiction.
The nurse is teaching pain management to a group of caregivers. Which information should be included? Select all that apply. 1 Chronic pain is often psychological. 2 Only hospitalized patients experience severe pain. 3 Psychogenic pain is not real. 4 Regular administration of analgesics will not lead to addiction. 5 Patients with minor illnesses may also experience severe pain.
4, 5 Misconceptions about pain often lead to poor nursing care. Therefore, it is important to know these misconceptions in order to promote appropriate pain management in patients. Regular administration of analgesics does not lead to addiction. Therefore, analgesics should be administered whenever the need arises. Although a patient may suffer from minor illness, he or she may experience severe pain that should not be ignored. A common misconception is that chronic pain is often psychological. However, chronic pain may have a pathological origin. Another misconception is that only hospitalized patients experience pain. Patients who are not hospitalized may also experience pain that needs to be addressed. Another misconception is that psychogenic pain is not real.
5. The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. a. A patient cradles a wrist that was injured in a car accident. b. A child is moaning and crying due to a stomachache. c. A patient's pulse is increased following a myocardial infarction. d. A patient in pain strikes out at a nurse who attempts to bathe him. e. A patient who has chronic cancer pain is depressed and withdrawn. f. A child pulls away from a nurse trying to give him an injection.
4. A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? a. Transient pain b. Superficial pain c. Phantom pain d. Referred pain d. Referred pain 5. The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. a. A patient cradles a wrist that was injured in a car accident. b. A child is moaning and crying due to a stomachache. c. A patient's pulse is increased following a myocardial infarction. d. A patient in pain strikes out at a nurse who attempts to bathe him. e. A patient who has chronic cancer pain is depressed and withdrawn. f. A child pulls away from a nurse trying to give him an injection. a. A patient cradles a wrist that was injured in a car accident. b. A child is moaning and crying due to a stomachache. f. A child pulls away from a nurse trying to give him an injection.
It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." Correct
4. A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? • "Older patients often have difficulty determining what is causing their pain." • "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." • "As adults age, their ability to perceive pain decreases." • "Patients who have dementia probably experience pain, and their pain is not always well controlled."
What should be the maximum 24-hour dose of acetaminophen for an adult patient whose liver and kidney function tests are normal? Record your answer using a whole number, and please note that no comma is needed. ___ mg
4000 Acetaminophen is one of the safest analgesics available. However, its mode of action is unknown. The maximum 24-hour dose given to an adult with no kidney or liver diseases is 4000 mg.
Meaning of pain Correct
5. The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? • Neurological factors • Competency of the surgeon • Meaning of pain • Postoperative support personnel
A 50-year-old patient with prostate cancer Correct
6. The nurse anticipates administering an opioid fentanyl patch to which patient? • A 15-year-old adolescent with a broken femur • A 30-year-old adult with cellulitis • A 50-year-old patient with prostate cancer • An 80-year-old patient with a broken hip
Labeling the tubing that leads to the epidural catheter Correct
7. What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? • Keeping the reversal agent in a syringe in the patient's bedside table • Applying a gauze dressing to the epidural catheter insertion site • Labeling the tubing that leads to the epidural catheter • Asking the nursing assistive personnel to check on the patient at least once every 2 hours
Relaxation and guided imagery Correct
8. A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? • Relaxation and guided imagery • Transcutaneous electrical nerve stimulation (TENS) • Herbal supplements with analgesic effects • Pudendal block
"I feel less anxiety about the possibility of overdosing."
9. Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? • "This is the only pain medication I will need to be on." • "I can administer the pain medication as frequently as I need to" • "I feel less anxiety about the possibility of overdosing." • "I will need the nurse to notify me when it is time for another dose."
Assessment Questions for Pain
> When a patient is in pain, conduct a focused physical and neurological examination and observe for nonverbal responses to pain. Examine the painful area to see if palpation or manipulation of the site increases pain. > Ask questions to determine the onset, duration, and time sequence of pain. Ask a patient to describe or point to all areas of discomfort in order to assess pain location. To localize the pain specifically, have the patient trace the area from the most severe point outward.
Gate-control theory of pain (Melzack and Wall)
>> Pain has emotional and cognitive components, in addition to a physical sensation. >> Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses. >> Pain impulses pass through when a gate is open and are blocked when a gate is closed. >> Closing the gate is the basis for nonpharmacological pain relief interventions.
Pain assessment of the toddler
>Loud cry or screaming >Verbal expressions of pain >Thrashing of extremities >Attempt to push away or avoid stimulus >Noncooperation >Clinging to significant person >Behaviors occur in anticipation of painful stimulus
Pain management - Pharmacological interventions
>Optimal dosage of medications will control pain without causing severe AE >Select the least traumatic route for medication administration >Give medications routinely, vs PRN, to manage pain that is expected to last for an extended period of time >Combine adjuvant medications (steroids, antidepressants, sedatives, antianxiety medications, muscle relaxants, anticonvulsants) with other analgesics >Use nonopioid & opioid medications - Acetaminophen (Tylenol) & NSAIDs for mild - moderate pain - Opioids for moderate - severe pain (morphine sulfate, oxycodone (OxyContin), & fentanyl (Duragesic) - Combining a nonopioid & an opioid medication treats pain peripherally & centrally. This offers greater analgesia with less AE (respiratory depression, constipation, nausea) >IM injections are not recommended for pain control in children >Intranasal medications are not recommended for children younger than 18 yrs >Rectal medications have variable absorption rates, & children dislike them >Intradermal medications are used for skin anesthesia prior to procedures
Pain management - Interventions
>Reassess pain level >Nonpharmacological, pharmacological, or both >Assess child for AE to pain medications >Review lab reports >Assess child's physical functioning following pain management intervention >Assess for negative affect or distress r/t to the pain - anxiety, withdrawal, fear, depression, or unhappiness
Pain assessment of the school-aged child
>Stalling behavior >Muscular rigidity >Any behaviors of the toddler, but less intense in the anticipatory phase & more intense with painful stimulus
3. A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when: A. you compare assessed pain w/baseline pain. B. body language is incongruent with reports of pain relief. C. family members report that pain has subsided. D. vital signs have returned to baseline.
A
A. encourage expression of fears on past experiences This client has strong beliefs and emotions related to the issue of sibling addiction. First, encourage expression. This indicated to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, bearing in mind that their beliefs about drug addiction may be similar to those of the client.
A client appears upset and tearful, but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." what is the priority intervention for this client? A. encourage expression of fears on past experiences B. provide accurate information about use of pain meds C. explain that addiction is unlikely among acute care clients D. Seek family assistance in resolving this problem
naloxone in a overly sedated client
A client in the post-operative period that is unresponsive to painful stimuli is likely still under the effects of medications used during anesthesia. Using the opioid antagonist naloxone (Narcan) will temporarily reverse the effects of any opioid medications. Unfortunately, the half-life of naloxone is much shorter than most opioid medications, wearing off in 1-2 hours. The nurse should make repeat assessments of the post-surgical client's respiratory rate and administer prescribed oxygen for respiratory support. The health care provider should be notified and a second dose of naloxone should be prepared and administered as prescribed (either as a one-time dose or a continuous drip, depending on the prescription). An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause harm to the client, it is not necessary and may result in overuse of personnel resources. If additional information indicates a more serious situation (eg, respiratory rate <8 breaths/min, oxygen saturation <90%), it may be appropriate to initiate the emergency response system.
D. Have a conference with the nurses responsible for the care of this client As charge nurse, you must assess for the performance and attitude of the staff in relation to this client. After gathering data from the nurses, additional information from the records and the client can be obtained as necessary. The educator may be of assistance if knowledge deficit or need for performance improvement is the problem.
A client with chronic pain reports to you, the charge nurse, that the nurse have not been responding to requests for pain medication. What is your initial action? A.Check the MARs and nurses' notes for the past several days. B. Ask the nurse educator to give an in-service about pain management. C. Perform a complete pain assessment and history on the client. D. Have a conference with the nurses responsible for the care of this client
A. amitriptyline Antidepressants such as amitriptyline can be given for diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Methylphenidate is given to counteract sedation if the client is on opioids. Lorazepam is an anxiolytic
A client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is not responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of pain? A. amitriptyline B. corticosteroids C. methylphenidate D. lorazepam
D. Assess the pain for location, quality, and intensity Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps.
A first day postoperative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take? A. Deliver the bolus dose per standing order. B. Contact the physician to increase the dose. C. Try non-pharmacological comfort measures. D. Assess the pain for location, quality, and intensity
type of IV fluid for increased ICP
A hypertonic, rather than isotonic, solution would be infused in clients with ICP. Increasing circulating volume would only further increase ICP.
nasoenteric tube with crackles and productive cough
A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is in the client's airway and must be removed immediately.
paracentesis positioning
A paracentesis requires the client to be upright (semi- to high Fowler) so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it
what factors can manipulate the accuracy of o2 pulse monitor readings
A pulse oximeter is a noninvasive device that estimates the arterial blood saturation (SaO2) by using a sensor attached to the adult client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains both light-emitting and light-sensing components and measures the amount of light absorbed by hemoglobin in the arterial blood. Because the sensor estimates the value at a peripheral site, the oximeter reports the value as SpO2. The sensor relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SpO2 readings. Conditions associated with low blood flow or decreased perfusion states include cardiac dysrhythmias, heart failure, peripheral vascular disease, edema, hypotension, hypovolemic shock, and vasoconstriction (eg, hypothermia, smoking, drugs). Other factors affecting accuracy of the reading include improper positioning or fit of the sensor, excessive movement, smoke inhalation, and carbon monoxide poisoning.
A first day postoperative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take?
A. Deliver the bolus dose per standing order. B. Contact the physician to increase the dose. C. Try non-pharmacological comfort measures. D. Assess the pain for location, quality, and intensity Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps.
When titrating an analgesic to manage pain, what is the priority goal? A. administer smallest dose that provides relief with the fewest side effects B. titrate upward until the client is pain free C. tirate downwards to prevent toxicity D. ensure that the drug is adequate to meet the clients subjective needs
A. administer smallest does that provides relief with the fewest side effects the goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until pain is controlled. Downward titration occurs when the pain begins to subside. Adequate dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs.
A client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is not responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of pain? A. amitriptyline B. corticosteroids C. methylphenidate D. lorazepam
A. amitriptyline Antidepressants such as amitriptyline can be given for diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Methylphenidate is given to counteract sedation if the client is on opioids. Lorazepam is an anxiolytic
In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant? A. assist the client with preparation of a sits bath B. monitor the client for signs of discomfort while ambulating C. coach the client to deep breathing during painful procedures D. evaluate relief after applying a cold application
A. assist the client with preparation of aa sits bath The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities.
A client appears upset and tearful, but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." what is the priority intervention for this client? A. encourage expression of fears on past experiences B. provide accurate information about use of pain meds C. explain that addiction is unlikely among acute care clients D. Seek family assistance in resolving this problem
A. encourage expression of fears on past experiences This client has strong beliefs and emotions related to the issue of sibling addiction. First, encourage expression. This indicated to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, bearing in mind that their beliefs about drug addiction may be similar to those of the client.
Prescribing analgesics on a PRN basis for chronic pain is ineffective and causes more suffering; thus patients with chronic pain need to take analgesics ______ even when their pain subsides.
ATC= around the clock
what is the best non-pharmalogical treatment for chronic lower back pain related to inflammation
Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacologic intervention to treat the inflammation includes rest from pain-aggravating activities which may continue to promote inflammation and delay healing. Applying heat to the injured area can promote the inflammatory process (via vasodilation); therefore, this is NOT the best intervention at this time. However, after the acute inflammation has resolved (usually within a few days) heat application would be appropriate to reduce pain and muscle spasms.
post cardiac cauterization via femoral artery client positioning
After cardiac catheterization via femoral entry, place clients flat or in low Fowler position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma.
communicating with a client with alzheimer's
Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function (dementia) in older individuals (most commonly age >60). Conversation becomes progressively more difficult, and the client experiences word-finding difficulty. The best way for the nurse to obtain information and communicate is to use simple statements and questions. Facing the client allows the client to visualize the speaker's face and helps reduce distraction. Providing a quiet environment (eg, turning off the television, closing the door) removes competing or distracting stimuli.
when an an oxymizer appropriate to use
An oxymizer is a nasal reservoir cannula-type device that conserves on oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen (eg, 3 L/min nasal cannula is equivalent to 1 L/min oxymizer device) to reach the same saturation. It is not the best choice in an unstable COPD client with varying TVs as the inspired oxygen concentration is not guaranteed.
dealing with an angry client
Anger is often a sign of psychological distress stemming from anxiety, fear, or loss of control. This elderly veteran has likely had life-long control. Now, with worsening health issues and an acute illness, the client has lost control, causing anger. The feelings are probably accentuated by hospitalization and by staff such as the UAP trying to do things for the client that the client could do alone. A client who is angry should be given the opportunity to express concerns openly. It is important to approach the conversation with an open, accepting, nonjudgmental attitude. The nurse can show the UAP how to deal with these issues. The UAP plays an important role in developing an interdisciplinary plan of care for hygiene and activities of daily living (ADLs) that the client will accept. Therefore, the nurse and the UAP should go together to learn about the client's concerns. They can then work with the client to create a plan for hygiene and ADLs that will allow the client more control while ensuring safety and quality care
anorexia during end of life care
Anorexia is an expected complication in clients nearing the end of life and is exacerbated by many variables, including medications, stress, and progression of disease. Caregivers can implement strategies to manage these factors, including the following: 1. Administering prescribed analgesia, antiemetic medications, and appetite stimulants (eg, dexamethasone, megestrol acetate) to enhance client comfort and increase intake (Option 1) 2. Involving the client in meal planning to encourage autonomy and a sense of purpose 3. Promoting foods that are preferred and well tolerated, regardless of nutritional value, to stimulate appetite and increase intake 4. Providing meals with friends/family outside of the "sick room," if possible, to promote stimulation and enjoyment 5. Providing frequent oral care, especially after eating, and using topical treatments to minimize oral discomfort and dry mouth 6. Offering adequate fluid and fiber intake and implementing a bowel regimen to help prevent constipation
17. The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? • Age and gender • Anxiety and fear • Culture • Previous pain experience
Anxiety and fear
21. A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action? • Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. • Ask the health care provider to verify the dosage and frequency of the medication. • Ask the health care provider for an order for a nonsteroidal anti-inflammatory drug (NSAID). • Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.
Ask the health care provider to verify the dosage and frequency of the medication.
30. The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? • Call the rapid response team. • Ask the patient to rate and describe the pain. • Raise the head of the bed. • Administer pain relief medications.
Ask the patient to rate and describe the pain.
1. What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? • Assess the patient's body language. • Observe cardiac monitor for increased heart rate. • Ask the patient to rate the level of pain. • Ask the patient to describe the effect of pain on the ability to cope.
Ask the patient to rate the level of pain. Correct
aspirin
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastrointestinal (GI) bleeding by decreasing the production of prostaglandins, which protect the lining of the stomach and intestines from digestive acids. NSAIDs (especially aspirin) also decrease platelet aggregation and thereby inhibit blood clotting. Coffee-ground emesis and black tarry stools (melena) are signs of GI bleeding. Bruising can occur due to the decreased platelet aggregation. TINNITUS (ringing in the ears) is the earliest sign of ASPIRIN TOXICITY. aspirin will cause tachycardia and hypotension. when aspirin toxicity occurs, bradycardia and hypertension will occur secondary to nausea, vomiting and dehydration
what is the priority assessment when bladder retention is suspected
Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications.
asthma exacerbation with shortness of breath after administration of albuterol
Asthma exacerbation may require repeat nebulization every 20 minutes or continuous nebulization for 1 hour to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the inflammation
1. When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage.
B
Which client(s) would be appropriate to assign to a newly graduated RN, who has recently completed orientation? Choose all that apply. A. An anxious, chronic pain client who frequently uses the call button B. A client second day post-op who needs pain medication prior to dressing changes C. A client with HIV who reports headache and abdominal and pleuritic chest pain D. A client who is being discharged with a surgically implanted catheter
B. A client second day post-op who needs pain medication prior to dressing changes A second day postoperative client who needs medication prior to dressing changes has predictable and routine care that a new nurse can manage. Although clients with chronic pain can be relatively stable, the interaction with this client will be time consuming and may cause the new nurse to fall behind. The client with HIV has complex complaints that require expert assessment skills. The client pending discharge will need special and detailed instructions.
Which client(s) are appropriate to assign to the LPN/LVN, who will function under the supervision of the RN or team leader? (Choose all that apply.) A. A client who needs pre-op teaching for use of a PCA pump B. A client with a leg cast who needs neurologic checks and PRN hydrocodone C. A client post-op toe amputation with diabetic neuropathic pain D. A client with terminal cancer and severe pain who is refusing medication
B. A client with a leg cast who needs neurologic checks and PRN hydrocodone C. A client post-op toe amputation with diabetic neuropathic pain The clients with the cast and the toe amputation are stable clients and need ongoing assessment and pain management that are within the scope of practice for an LPN/LVN under the supervision of an RN. The RN should take responsibility for pre-operative teaching, and the terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication.
For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? A. Closely assess for nonverbal signs such as grimacing or rocking. B. Obtain baseline behavioral indicators from family members. C. Look at the MAR and chart, to note the time of the last dose and response. D.Give the maximum PRS dose within the minimum time frame for relief
B. Obtain baseline behavioral indicators from family members. Complete information from the family should be obtained during the initial comprehensive history and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.
In educating clients about non-pharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function under your continued support and supervision? A. therapeutic touch B. use of heat and cold applications C. meditation D. transcutaneous electrical nerve stimulation (TENS)
B. use of heat and cold applications Use of heat and cold applications is a standard therapy with guidelines for safe use and predictable outcomes, and an LPN/LVN will be implementing this therapy in the hospital, under the supervision of an RN. Therapeutic touch requires additional training and practice. Meditation is not acceptable to all clients and an assessment of spiritual beliefs should be conducted. Transcutaneous electrical stimulation is usually applied by a physical therapist.
Place the examples of drugs in the order of usage according to the World Health Organization (WHO) analgesic ladder. a. Morphine, hydromorphone, acetaminophen and lorazepam b. NSAIDs and corticosteroids c. Codeine, oxycodone and diphenhydramine
BCA 1. NSAIDs and corticosteroids 2. codeine, oxycodone and diphenhydramine 3.morphine, hydromorphone, acetaminophen and lorazepam Step 1 includes non-opioids and adjuvant drugs. Step 2 includes opioids for mild pain plus Step 1 drugs and adjuvant drugs as needed. Step 3 includes opioids for severe pain (replacing Step 2 opioids) and continuing Step 1 drugs and adjuvant drugs as needed.
What is the Non-communicating children's pain checklist?
Behaviors are observed for 10 minutes >6 subcategories are scored on a scale 0 to 3 >Subcategories are vocal, social, facial, activity, body & limbs, & physiological, each with observable behaviors to be scored - 0 = not at all - 1 = just a little - 2 = fairly often - 3 = very often >Cutoff scores - 11 or more indicates moderate to severe pain - 6 to 10 indicates mild pain
A family member asks you, "Why can't you give more medicine? He is still having a lot of pain." What is your best response? A. "The doctor ordered the medicine to be given every 4 hours." B. "If the medication is given too frequently he could suffer ill effects." C. "Please tell him that I will be right there to check of him." D. "Let's wait about 30-40 minutes. If there is no relief I'll call the doctor."
C. "Please tell him that I will be right there to check of him." directly ask the client about the pain and do a complete pain assessment. This information will determine which action to take next.
A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? A. fever B. nausea C. diaphoresis D. abdominal cramps
C. diaphoresis Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours.
In caring for a young child with pain, which assessment tool is the most useful? A. simple description pain intensity scale B. 0-10 numeric pain scale C. faces pain-rating scale D. McGill-Melzack pain questionnaire
C. faces pain-rating scale The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and use of advanced vocabulary.
Which route of administration is preferred if immediate analgesia and rapid titration are necessary A. intraspinal B.patient-controlled analgesia (PCA) C. intravenous D. sublingual
C. intravenous the IV route is preferred as the fastest and most amenable to titration. A PCA bolus can be delivered; however, the pump will limit the dosage that can be delivered unless the parameters are changed. Intraspinal administration requires special catheter placement and there are more potential complications with this route. Sublingual is reasonably fast, but not a good route for titration, medication variety in this form is limited.
Which non-pharmacological measure is particularly useful for a client with acute pancreatitis A. Diversional therapy, such as playing cards or board games B. Massage of back and neck with warmed lotion C. Side-lying position with knees to chest and pillow against abdomen D. Transcutaneous electrical nerve stimulation (TENS)
C. side lying position with knees to chest and pillow against abdomen The side-lying, knee-chest position opens retroperitoneal space and provides relief. The pillow provides a splinting action. Diversional therapy is not the best choice for acute pain, especially if the activity requires concentration. TENS is more appropriate for chronic muscular pain. The additional stimulation of massage may be distressing to the client.
For a client who is taking aspirin, which laboratory value should be reported to the physician? A. Potassium 3.6 mEq/L B. Hematocrit 41% C.PT 14 seconds D. BUN 20 mg/dL
C.PT 14 seconds When a client takes aspirin, monitor for increases in PT (normal range 11.0-12.5 seconds in 85%-100%). Also monitor for possible decreases in potassium (normal range 3.5-5.0 mEq/L). If bleeding signs are noted, hematocrit should be monitored (normal range male 42%-52%, female 37%-47%). An elevated BUN could be seen if the client is having chronic gastrointestinal bleeding (normal range 10-20 mg/dL).
Common Opioid Side Effects
Central Nervous System (CNS) Toxicity • Drowsiness • Cognitive impairment • Confusion • Hallucinations • Myoclonic jerks • Euphoria • Sedation • Sleep disturbances • Dizziness Ocular • Pupil constriction Respiratory • Bradypnea • Hypoventilation Cardiac • Hypotension • Bradycardia • Peripheral edema Gastrointestinal • Constipation • Nausea • Vomiting • Delayed gastric emptying Genitourinary • Urinary retention Endocrine • Hormonal and sexual dysfunction Skin • Pruritus Immunological • Immune system impairment possible with chronic use Tolerance • Over time, increased doses needed to obtain analgesic effect Withdrawal Syndrome • Rapid or sudden cessation or marked dose reduction may cause rhinitis, chills, pupil dilatation, diarrhea, "gooseflesh"
dysphagia and techniques for eating
Clients with dysphagia are at risk for aspiration and aspiration pneumonia. Dietary modifications and swallowing rehabilitation measures can reduce the risk of aspiration in clients who can tolerate oral feedings. Specific techniques include the following: 1. Modification of food consistency (pureed, mechanically altered, soft) 2. Thickened liquids 3. Having the client sit upright at a 90-degree angle 4. Placing food on the stronger side of the mouth to aid in bolus formation 5. Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis NO STRAWS OR THINNING FOODS. Using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass.
right sided stroke and impulsiveness
Clients with right-sided cerebrovascular accidents tend to be impulsive and unaware of deficits. Teaching the client's family to expect disinhibition and emotional outbursts helps family members cope with the behavioral changes and reduces frustration during interactions
sickle cell crisis and pain management
Clients with sickle cell crisis often have excruciating pain related to the occlusion from the sickling and resulting ischemia. These individuals usually need large doses of narcotics as prior treatment has led to drug tolerance; they may also metabolize the drugs differently. Using only external cues to judge a client's pain is invalid as these clients have often learned how to distract themselves from focusing on the pain. Use of continuous PCA is recommended for relief rather than prn administration.
ways to improve sleep habits
Clients with trouble sleeping should be encouraged to keep good sleep habits, which include the following: 1. Reducing stimuli in the bedroom (eg, reading, television). Reading in bed is not recommended. 2. A client wanting to read before bed should do so in a different setting and then go to bed when ready to sleep. 3. Avoiding naps later in the day. 4. Keeping the bedroom slightly cool, quiet, and dark for comfort. 4. Avoiding caffeine, nicotine, and alcohol (stimulants) within 6 hours of sleep. 5. Avoiding exercise or strenuous activity within 6 hours of going to bed to avoid brain stimulation. 6. Avoiding going to bed hungry. 7. Practicing relaxation techniques if stress is causing insomnia.
non pharm coining
Coining is believed by some cultures (eg, Chinese, Vietnamese) to remove illness from the body. A rounded surface (eg, coin, spoon) is firmly stroked on the lubricated skin of the back and can produce weltlike linear lesions. This is appropriate to include in a culturally competent care in-service.
Parasympathetic Nervous System Reaction to pain
Continous, severe or deep pain typically involving the visceral organs (ex: with a myocardial infarction or colic from gallbladder or renal stones) activates the parasympathetic nervous system. Responses: • Pallor= causes blood supply to shift away from periphery • Nausea and Vomiting: vagus nerve sends impulses to chemoreceptor trigger zone in the brain • Decreased HR & BP= results from vagal stimulation • Rapid, irregular breathing= causes body defenses to fail under prolonged stress of pain
what blood products do clients of the Jehovah Witness faith unable to receive
Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products
non pharm cupping
Cupping is used by many cultures to remove illness from the body. The mouth of a steam-filled cup is placed on the skin, causing circular, bruised blemishes. This is appropriate to include in a culturally competent care in-service.
2. A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be: A. adjunctive therapy. B. nonopioids. C. NSAIDs. D. PCA pain management.
D
A client with chronic pain reports to you, the charge nurse, that the nurse have not been responding to requests for pain medication. What is your initial action? A.Check the MARs and nurses' notes for the past several days. B. Ask the nurse educator to give an in-service about pain management. C. Perform a complete pain assessment and history on the client. D. Have a conference with the nurses responsible for the care of this client
D. Have a conference with the nurses responsible for the care of this client As charge nurse, you must assess for the performance and attitude of the staff in relation to this client. After gathering data from the nurses, additional information from the records and the client can be obtained as necessary. The educator may be of assistance if knowledge deficit or need for performance improvement is the problem.
What is the best way to schedule medication for a client with constant pain? A. PRN at the client's request B. Prior to painful procedures C. IV bolus after pain assessment D. Around-the-clock
D. around the clock IF the pain is constant, the best schedule is around-the-clock, to provide steady analgesia and pain control. The other options may actually require higher doses to achieve control
The physician has ordered a placebo for a chronic pain client. You are newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? A. prepare the medication and hand it to the physician B. check the hospital policy regarding use of the placebo C. follow a personal code of ethics and refuse to give it D. contact the charge nurse for advice
D. contact the charge nurse for advice the charge nurse is a resource person who can help locate and review the policy. If the physician is insistent, he or she could give the placebo personally, but delaying the administration does not endanger the health or safety of the client. While following one's own ethical code is correct, you must ensure that the client is not abandoned and that care continues.
as the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The Rn correctly charted dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. what action should you take first? A. make a note in the nurse's file and continue to observe clinical performance B. refer the new nurse to the in-service education department C. quiz the nurse about knowledge of pain management D. give praise for the correct dose and time and discuss the deficits in charting
D. give praise for the correct dose and time and discuss the deficits in charting In supervising the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service might be considered if the problem persists.
what is the priority intervention in fecal incontinence
Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin. Clean, dry linens and clothing should be provided.
Pain management - Nonpharmacological interventions
Distraction >Play, radio, computer game, movie >Tell jokes or a story to the child Relaxation >Hold or rock infant or young child >Assist older children into a comfortable position >Assist with breathing techniques Guided imagery >Assist the child in an imaginary experience >Have child describe the details Positive self-talk >Have child say positive things during a procedure or through a painful episode Behavioral contracting >Use stickers or tokens as rewards >Give time limits for the child to cooperate >Reinforce cooperation with a reward Containment >Swaddle the infant >Place rolled blankets around the child >Maintain proper positioning Nonnutritive sucking >Offer pacifier with sucrose before, during, & after painful procedures >Offer nonnutritive sucking during episodes of pain Kangaroo care - skin-to-skin contact between infants & parents Complementary & alternative medicine >Offer foods, vitamins, or supplements >Offer massage or chiropractic option >Review energy based tx such as magnets >Discuss mind-body techniques - hypnosis, homeopathy, naturopathy
disulfiram (Antabuse) for alcoholism and teaching point
Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist
steps for ear irrigation
Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure: Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). Place the client in a side-lying or sitting position with the head tilted toward the affected ear. Place a towel and an emesis basin under the ear Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal. Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled. Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching
what is the first thing a nurse should do when an enteral feeding tube becomes blocked
Enteral feeding tubes are more likely to become obstructed if the tube is not flushed frequently enough, medications are not adequately crushed or diluted before administration, a thick feeding formula is used, or a small-bore feeding tube is required. Interventions to unclog a feeding tube are more successful if they are initiated immediately. The nurse should first attempt to dislodge the clogged contents by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube If a feeding tube cannot be unclogged with warm water, the nurse may then attempt to use a digestive enzyme solution. These commercial declogging kits contain prefilled syringes of enzymatic solution that must be added to the tube and dwell in it for a period of time (usually 30 minutes to 1 hour) before flushing and aspiration are attempted.
aspirin toxicity reversal
FIRST - Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those who are asymptomatic. Activated charcoal binds to available salicylates, thus limiting further absorption in the small intestine and enhancing elimination. SECOND - IV sodium bicarbonate is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate.
Oucher Pain Scale
Facial pictures for kids.
C. Sociocultural The family is part of the sociocultural dimension of pain. They are influencing the client and should be included in the teaching sessions about the appropriate use of narcotics and about the adverse effects of pain on the healing process. The other dimensions should be included to help the client/family understand overall treatment plan and pain mechanism
Family members are encouraging your client to "tough it out" rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family's wishes. Priority nursing interventions for this client should target which dimension of pain? A.Sensory B.Affective C.Sociocultural D.Behavioral E.Cognitive
B. Obtain baseline behavioral indicators from family members. Complete information from the family should be obtained during the initial comprehensive history and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.
For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? A. Closely assess for nonverbal signs such as grimacing or rocking. B. Obtain baseline behavioral indicators from family members. C. Look at the MAR and chart, to note the time of the last dose and response. D.Give the maximum PRS dose within the minimum time frame for relief
muslim culture and care
For the observant Muslim client, maintaining modesty is an important moral value. Covering up the body is essential when a Muslim woman is in the presence of a man who is not related to her, even if the man is a health care provider. Special provision should be made for female health care workers to provide care and examine Muslim women. If a female health care provider is not available, a female nurse or clinical staff person should be present. In addition, privacy screens should be used and room doors should be kept closed consistently.
heat exhuastion
Heat exhaustion is the result of prolonged exposure to excessive heat. Heat exhaustion manifests with elevated body temperature (hyperthermia), intravascular volume depletion, and electrolyte imbalance. Manifestations include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping. If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports drink, another electrolyte-containing beverage (eg, Gatorade), or water. The priority is to lower the body temperature to prevent heat stroke, a potentially fatal condition associated with mental status changes (ie, indicating brain damage) and additional organ damage (eg, kidney injury, rhabdomyolysis). If the client's temperature continues to rise after moving to cooler temperatures, ice packs placed on the axilla and groin may help to dissipate heat; further medical help may be necessary.
evaluation of pain management
How is patient tolerating pain? Is treatment plan working? Do we need to change plan of care? Through the patient's eyes: • Patients help decide the best times to attempt pain treatments • They are the best judge of whether a pain-relief intervention works Patient outcomes: • Evaluate for change in the severity and quality of the pain
hydromorphone and narcan
Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to wane at 20-40 minutes after administration, and its duration of action is approximately 90 minutes. Therefore, depending on the hydromorphone dose, its duration of action can continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary.
contraindication for erythropoietin
Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin
mal de ojo in Mexican culture
In Latin American culture, an illness called "mal de ojo" ("evil eye") is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The "illness," or "curse," is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child or immediately afterward. Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets. If a child is believed to be afflicted with mal de ojo, the parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse.
C. faces pain-rating scale The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and use of advanced vocabulary.
In caring for a young child with pain, which assessment tool is the most useful? A. simple description pain intensity scale B. 0-10 numeric pain scale C. faces pain-rating scale D. McGill-Melzack pain questionnaire
A. assist the client with preparation of aa sits bath The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities.
In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant? A. assist the client with preparation of a sits bath B. monitor the client for signs of discomfort while ambulating C. coach the client to deep breathing during painful procedures D. evaluate relief after applying a cold application
B. use of heat and cold applications Use of heat and cold applications is a standard therapy with guidelines for safe use and predictable outcomes, and an LPN/LVN will be implementing this therapy in the hospital, under the supervision of an RN. Therapeutic touch requires additional training and practice. Meditation is not acceptable to all clients and an assessment of spiritual beliefs should be conducted. Transcutaneous electrical stimulation is usually applied by a physical therapist.
In educating clients about non-pharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function under your continued support and supervision? A. therapeutic touch B. use of heat and cold applications C. meditation D. transcutaneous electrical nerve stimulation (TENS)
28. The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? • Increasingly higher doses of opioid are needed to control pain. • The patient needed a substantial dose of naloxone (Narcan). • The patient asks for pain medication close to the time it is due around the clock. • The patient no longer experiences sedation from the usual dose of opioid.
Increasingly higher doses of opioid are needed to control pain. Correct
additional kosher diet information for jewish culture
Individuals who practice Orthodox Judaism follow Kosher dietary laws. These regulations are strict regarding the consumption of certain animal products (eg, no pork, shellfish, fish without scales) and the separation of meat/poultry from dairy. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product is consumed. Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be consumed at any time. Hard-boiled eggs and blueberries are nondairy foods and would be an appropriate snack. This choice also provides a combination of carbohydrates and protein, which would help in regulating blood glucose.
34. The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient? • Infants cannot tolerate analgesics owing to an underdeveloped metabolism. • Infants have an increased sensitivity to pain when compared with older children. • Pain cannot be accurately assessed in infants. • Infants respond behaviorally and physiologically to painful stimuli.
Infants respond behaviorally and physiologically to painful stimuli. Correct
Interventions to prevent abdominal wound dehiscence
Interventions to prevent abdominal wound dehiscence include: 1. Administering stool softeners (eg, docusate) to prevent straining and constipation from postoperative immobility and opioid pain medications 2. Administering antiemetics (eg, ondansetron) as needed for nausea to prevent straining that can occur with vomiting 3. Applying an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving 4. Monitoring blood sugar to maintain tight glycemic control (<140 mg/dL [7.8 mmol/L] fasting glucose; <180 mg/dL [10 mmol/L] random glucose) to decrease infection risk and promote wound healing 5. Splinting the abdomen by holding a pillow or folded blanket against the wound for support when coughing and moving
Chronic/persistent noncancer pain
Is not protective, has no purpose, may or may not have an identifiable cause •Chronic noncancerous pain may include arthritis, headache, low back pain, or peripheral neuropathy. • The goal of chronic noncancer pain is to improve functional status with a multimodality plan. • Chronic noncancer pain may be viewed as a disease since it has a distinct pathology that causes changes throughout the nervous system which may worsen over time.
4. A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? • "Older patients often have difficulty determining what is causing their pain." • "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." • "As adults age, their ability to perceive pain decreases." • "Patients who have dementia probably experience pain, and their pain is not always well controlled."
It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." Correct
7. What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? • Keeping the reversal agent in a syringe in the patient's bedside table • Applying a gauze dressing to the epidural catheter insertion site • Labeling the tubing that leads to the epidural catheter • Asking the nursing assistive personnel to check on the patient at least once every 2 hours
Labeling the tubing that leads to the epidural catheter Correct
orthodox jewish faith and kosher diet
Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill.
side effects of nausea, vomiting and diarrhea during enteral feedings and SOLUTION
Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra- and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting. SLOWING down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate.
_____ is the physiologic process by which information about tissue damage is communicated to the central nervous system (CNS).
Nociception
What are nociceptors?
Nociceptors are neurons that respond to pain and are stimulated by a mechanical, thermal, or chemical stimuli.
what medications can cause bladder retention
Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions.
opioids and orthostatic hypotension
Opioids, including morphine sulfate, DILATE peripheral blood vessels and can cause HYPOTENSION. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client's priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider.
What is the Numeric Pain Scale?
Pain rated on a scale of 0 to 10 >Explain to the child that 0 means "no pain" & 10 means "worst pain" >Have child verbally report a number or point on a visual scale their pain level
What is the FLACC tool?
Pain rated on a scale of 0 to 10 Assess behaviors of the child (F)ace - 0 = smile or no expression - 1 = occasional frown or grimace, withdrawn - 2 = frequent or constant frown, clenched jaw, quivering chin (L)egs - 0 = relaxed or normal position - 1 = uneasy, restless, tense - 2 = kicking or legs drawn up (A)ctivity - 0 = lying quietly, moves easily, normal position - 1 = squirming, shifting, tense - 2 = arched, ridged, or jerking (C)ry - 0 = no cry - 1 = moans or whimpers, occasional complaints - 2 = crying, screaming, sobbing, frequent complaints (C)onsolability - 0 = content or relaxed - 1 = reassured by occasional touching, or hugging. able to distract - 2 = difficult to console or comfort
What is the OUCHER tool?
Pain rated on a scale of 0 to 5 using six photographs >Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale >Have child organize the photographs in order of no pain to the worst pain - 0 = no hurt - 1 = hurts a bit - 2 = hurts a little more - 3 = hurts even more - 4 = hurts a whole lot - 5 = hurts worst >Ask child to choose a face that best describes how they are feeling
Deep or Visceral
Pain resulting from stimulation of internal organs Pain is diffuse, and radiates in several directions. Duration varies, but it usually lasts longer than superficial pain. Pain is sharp, dull, or unique to organ involved. Example of Causes: Crushing sensation, like angina. Burning sensation, like a gastric ulcer.
Superficial or Cutaneous Pain
Pain resulting from stimulation of skin Pain is short, and localized. It is usually a sharp sensation. Example of Causes: needle stick; small cut or laceration
End-of-dose failure pain
Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic
Somatic Pain
Pain that originates from skeletal muscles, ligaments, or joints.
palliative care
Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan. This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder. The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment.
29. A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? • Patient drinks 1 to 2 glasses of wine every night. • Patient smokes 2 packs of cigarettes a day. • Patient occasionally smokes marijuana. • Patient takes antianxiety medications.
Patient drinks 1 to 2 glasses of wine every night. Correct
eye contact in Indian and Asian-American culture
People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration.
when should peripheral IVs be changed
Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client's IV line will likely be discontinued at discharge and is not the highest priority.
phlebitis
Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs (eg, vancomycin), catheter movement within the vein (eg, inadequate stabilization), or bacteria (eg, poor aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection.
BCA 1. NSAIDs and corticosteroids 2. codeine, oxycodone and diphenhydramine 3.morphine, hydromorphone, acetaminophen and lorazepam Step 1 includes non-opioids and adjuvant drugs. Step 2 includes opioids for mild pain plus Step 1 drugs and adjuvant drugs as needed. Step 3 includes opioids for severe pain (replacing Step 2 opioids) and continuing Step 1 drugs and adjuvant drugs as needed.
Place the examples of drugs in the order of usage according to the World Health Organization (WHO) analgesic ladder. a. Morphine, hydromorphone, acetaminophen and lorazepam b. NSAIDs and corticosteroids c. Codeine, oxycodone and diphenhydramine
positioning of a client with left lobe pneumonia
Pneumonia decreases gas exchange in the affected areas of the lung. This client is experiencing ventilation to perfusion (V/Q) mismatch, because the affected area is receiving adequate perfusion from the pulmonary artery, but lung infiltrates are obstructing effective gas exchange. Arterioles in the affected area compensate by vasoconstricting, which re-directs blood flow away from the hypoxic alveoli and toward better-ventilated areas of the lung. This is known as hypoxic pulmonary vasoconstriction. This client with left lobar pneumonia should be positioned with the GOOD LUNG DOWN. If the client is positioned on the left side, because of gravity, blood flow will be directed to the area of pulmonary vasoconstriction, V/Q mismatch will increase, and saturation can drop significantly. Positioning the good lung down also promotes re-expansion (of atelectasis) and drainage of the bad lung.
how to prevent pressure ulcer injuries
Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries (using the Braden scale) upon admission and at least once daily during hospitalization. To prevent pressure injuries: -Use EMOLLIENTS and BARRIER CREAMS to hydrate, protect, and strengthen the skin -Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences -Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin -Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur.
proper fit of crutches to prevent injury
Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad. Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously. The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating.
Epidural analgesia
Regional Administered into epidural space treats: acute postoperative pain, rib fracture pain, labor and delivery pain, and chronic cancer pain. The health care provider administers epidural analgesia into the spinal epidural space by inserting a blunt-tip needle into the level of the vertebral interspace nearest to the area requiring analgesia. The health care provider advances the catheter into the epidural space, removes the needle, and secures the remainder of the catheter with a dressing while ensuring the catheter is taped securely.
what is more important to intervene with, hyperkalemia or elevated blood urea nitrogen
Serum potassium may increase in clients in progressive shock as a result of metabolic acidosis, which can cause a shift of potassium from the intracellular to extracellular compartments. Because the most significant manifestation of hyperkalemia is a disturbance in cardiac conduction and the development of cardiac dysrhythmias, correction of the imbalance requires immediate action. Although a blood urea nitrogen level of 44.4 mg/dL (15.9 mmol/L) is elevated, it does not require immediate action. It can increase in clients in a shock state as the result of decreased perfusion to the kidneys (pre-renal azotemia) or extra-renal factors such as dehydration, fever, or gastrointestinal bleed.
13. A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? • Frequently reassesses the patient's pain scores • Reassures the patient that the provider will come to the emergency department soon • Softly plays music that the patient finds relaxing • Teaches the patient how to do yoga
Softly plays music that the patient finds relaxing
hobbies to avoid during neutropenia
Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand-washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask. The client with neutropenia is allowed to consume cooked vegetables. However, raw or unwashed vegetables should be avoided due to possible contamination with pathogens as this can increase the risk of infection. A healthy diet containing vegetables is encouraged to increase consumption of necessary nutrients. Protein is a necessary component in the diet of a client receiving chemotherapy. Protein aids in the healing process of the body. As long as the meat or seafood is fully cooked, it is safe for the client with neutropenia to consume. Raw or undercooked meat/seafood is to be avoided due to possible exposure to pathogens. Clients with neutropenia are encouraged to bathe daily to remove pathogens that could cause infection. Moisturizer should be applied to prevent dry skin. If the skin becomes dry or cracked, pathogens could use these openings as portals of entry; this can lead to infection in the host.
why should the nurse follow up after a spiritual needs preference
Spirituality and religious beliefs are often integral parts of a client's life and can be therapeutic in the management of illness. Some studies have found that clients who engage in regular spiritual or religious practices have shorter recovery times, better coping mechanisms, and improved health outcomes. Spiritual, cultural, or religious needs should be accommodated within the plan of care. During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care
caring for a dying client who is muslim
Spirituality, religious beliefs, and traditions are important to include in client care. Aspects of care for Muslim clients include: Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer - Ritual daily prayers occur 5 times a day, and dying clients may pray more often. Modesty - Care providers should be the same sex as the client whenever possible. The female client may require a hijab (traditional head covering) and/or gown to cover most of the body. Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) - Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable. During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly. Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day in Islam, the family is the most important unit, and family presence brings strength to the individual. Multiple visitors should be accommodated unless they interfere with care.
35. The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.) • Past medical history of gastric ulcer Correct • Patient states last bowel movement was 4 days ago • Stated allergy to aspirin • Patient states has 2/10 intermittent joint pain • Patient experienced respiratory depression after administration of an opioid medication
Stated allergy to aspirin Correct
subcutaneous emphysema by chest tube insertion site
Subcutaneous emphysema is air that leaks into the tissue surrounding the chest tube insertion site. The amount is usually small and reabsorbs spontaneously. The nurse should auscultate for lung sounds, assess for a popping sound, and palpate the site for a crackling sensation. However, this client does not have the most urgent need.
the Beers criteria
The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list include antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales.
what is the most appropriate oxygen delivery device for a client with COPD
The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased TV, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD.
what is the most reliable indicator of a client's pain
The client's self-report of symptoms is always the most reliable indicator of the client's pain. The nurse does not have the ability to determine the extent of pain the client is experiencing—only the client can report this. In the nonverbal client, the nurse may use nonverbal pain scales such as the Wong-Baker pain rating scale.
dying client and artificial hydration via IV
The decision about providing artificial nutrition to a dying client is complex. Although certain situations involving terminal illness, such as a terminally ill client who wants to attend an important family function, can justify the decision to provide IV fluids, providing artificial hydration in other situations may not be justified and may even be harmful. Ethical principles dictate that client preferences should be respected and that clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life. Artificial hydration does not seem to help dying clients feel more comfortable, and IV fluids could cause distressful symptoms such as respiratory distress, vomiting and diarrhea, and the need for urinary catheterization. The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration. There is no evidence that withholding artificial hydration at the end of life speeds up the dying process. Research indicates that dying clients who do not receive artificial hydration live just as long as those who do receive IV fluids.
tetracycline teaching points
The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): 1. Take on an empty stomach - for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals 2. Avoid antacids or dairy products - tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption 3. Take with a full glass of water - tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion 4. Photosensitivity - severe sunburn can occur with tetracycline. The client should use sunblock
when is nasal cannula appropriate
The nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal vital signs. It is not the best choice in an unstable COPD client with varying TVs because the inspired oxygen concentration is not guaranteed.
when is the non-rebreathing reservoir mask appropriate
The non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client in this situation.
teaching strategies for the elderly client with low literacy
The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: Using pictures and simplified text is beneficial to the older adult with low literacy. Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language.
Safety Guidelines:
The patient is the only person who should press the button to administer the pain medication when PCA is used. Monitor the patient for signs and symptoms of oversedation and respiratory depression. Monitor for potential side effects of opioid analgesics.
16. A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? • The patient is sleeping and is difficult to arouse. • The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. • Sufficient medication is left in the PCA syringe. • The patient presses the control button to deliver pain medication.
The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. Correct
26. The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding? • "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." • "When patients say they don't need pain medication, they aren't in pain." • "The patient who is experiencing 8/10 pain and has a STAT order for pain medication • "A patient's behavior is more reliable than the patient's report of pain."
The patient who is experiencing 8/10 pain and has a STAT order for pain medication Correct
27. The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? • The patient who needs to take a scheduled dose of maintenance pain medication • The patient who needs to be premedicated before walking • The patient with a PCA running who needs to have the syringe replaced • The patient who is experiencing 8/10 pain and has a STAT order for pain medication
The patient who is experiencing 8/10 pain and has a STAT order for pain medication Correct
11. A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior and response to surgery? • The surgery successfully cured the patient's pain. • The patient's culture is possibly influencing the patient's experience of pain. • The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain. • The nurse is allowing personal beliefs about pain to influence pain management at this time.
The patient's culture is possibly influencing the patient's experience of pain. Correct
18. The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient's pain during dressing changes? • The patient's need for analgesic medication decreases during the dressing changes. • The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. • The patient's facial expressions are stoic during the procedure. • The patient can tolerate more pain, so dressing changes can be performed more frequently.
The patient's need for analgesic medication decreases during the dressing changes. Correct
D. contact the charge nurse for advice the charge nurse is a resource person who can help locate and review the policy. If the physician is insistent, he or she could give the placebo personally, but delaying the administration does not endanger the health or safety of the client. While following one's own ethical code is correct, you must ensure that the client is not abandoned and that care continues.
The physician has ordered a placebo for a chronic pain client. You are newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? A. prepare the medication and hand it to the physician B. check the hospital policy regarding use of the placebo C. follow a personal code of ethics and refuse to give it D. contact the charge nurse for advice
what clients cannot leave against medical advice (AMA)
To leave against medical advice (AMA), the client must be legally competent to make an educated decision to stop treatment. Disqualifications for legal competency include altered consciousness, mental illness (ie, a danger to self or others), and being under chemical influence (eg, drugs or alcohol). The client who drank a 1 L bottle of vodka is intoxicated. The client who hears voices has psychotic symptoms and is potentially homicidal. The manic client who has not eaten in 5 days is a potential danger to self and cannot leave AMA For a competent client to leave AMA, the health care provider must explain the risks of discontinuing treatment. The nurse must witness and document the discussion on risks of leaving AMA and the client's understanding of these risks ("informed refusal"). A client leaving AMA can, and should, receive discharge instructions and the option to return at any time.
Arab culture and bathing
To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not allowed to be alone with a woman other than his wife. It may also be inappropriate for a female health care worker to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third party is present.
Types of Pharmacological Pain Therapies
Topical analgesics: >>Creams, ointments, patches Local anesthesia: >>Local infiltration of an anesthetic medication to induce loss of sensation to a body part >>Regional anesthesia >> Perineural local anesthetic infusion >> Epidural analgesia
What are examples of a chemical stimulus?
Toxic substances or a blockage in a coronary artery
Describe transmission.
Transmission is the process by which pain signals are relayed from the periphery to the spinal cord and then to the brain.
water intoxication
Water intoxication (water overload) resulting in hyponatremia may occur in infants when formula is diluted to "stretch" the feeding to save money. Hyponatremia may also result from ingestion of plain water (eg, caregiver attempting to rehydrate an infant who has been ill). Infants have immature renal systems with a low glomerular filtration rate, which decreases their ability to excrete excess water and makes them susceptible to water intoxication. Symptoms of hyponatremia include irritability, lethargy, and, in severe cases, hypothermia and seizure activity. Breast milk and/or formula are the only sources of hydration an infant needs for the first 6 months of life. Formula should be prepared per the manufacturer's instructions.
D. around the clock IF the pain is constant, the best schedule is around-the-clock, to provide steady analgesia and pain control. The other options may actually require higher doses to achieve control
What is the best way to schedule medication for a client with constant pain? A. PRN at the client's request B. Prior to painful procedures C. IV bolus after pain assessment D. Around-the-clock
If patient outcomes are not met, ask the patient:
What is your current pain level? How far away is your pain level from your goal? What side effects are you experiencing from your pain medication? What have you done to help manage your pain? Describe limitations in function you are experiencing related to uncontrolled pain. How is your pain limiting or altering your rest and sleep?
teaching clients of middle age
When teaching clients and caregivers, the nurse must keep in mind several principles of adult learning. These include the learner's: Need to know Readiness to learn Prior experiences Motivation to learn Orientation to learning Self-concept Adults learn best when teaching provides information that the client views as being needed immediately. Readiness to learn is increased if the client perceives a need, has the belief that the change in behavior has value, or perceives the learning activity as new and stimulating. The client's age and occupation may help to determine the vocabulary the nurse uses during teaching. Sitting down with the client to assist with the choice of items on the menu that are low in sodium actively involves the client and provides immediately applicable information. The primary nurse or the nurse case manager can refer the client to be seen by a dietician before leaving the hospital or to follow up with one when discharged. This will be helpful to the client, but the opportunity to teach when the information is immediately applicable is preferred.
A. administer smallest does that provides relief with the fewest side effects the goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until pain is controlled. Downward titration occurs when the pain begins to subside. Adequate dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs.
When titrating an analgesic to manage pain, what is the priority goal? A. administer smallest dose that provides relief with the fewest side effects B. titrate upward until the client is pain free C. tirate downwards to prevent toxicity D. ensure that the drug is adequate to meet the clients subjective needs
C. a client with progressive pancreatic cancer Cancer pain generally worsens with disease progression and the use of opioids is more generous. Fibromyalgia is more likely to be treated with non-opioid and adjuvant medications. Trigeminal neuralgia is treated with anti-seizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins.
Which client is most likely to receive opioids for extended periods of time? A. a client with fibromyalgia B. a client with phantom limb pain C. a client with progressive pancreatic cancer D. a client with trigeminal neuralgia
B. A client with a leg cast who needs neurologic checks and PRN hydrocodone C. A client post-op toe amputation with diabetic neuropathic pain The clients with the cast and the toe amputation are stable clients and need ongoing assessment and pain management that are within the scope of practice for an LPN/LVN under the supervision of an RN. The RN should take responsibility for pre-operative teaching, and the terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication.
Which client(s) are appropriate to assign to the LPN/LVN, who will function under the supervision of the RN or team leader? (Choose all that apply.) A. A client who needs pre-op teaching for use of a PCA pump B. A client with a leg cast who needs neurologic checks and PRN hydrocodone C. A client post-op toe amputation with diabetic neuropathic pain D. A client with terminal cancer and severe pain who is refusing medication
B. A client second day post-op who needs pain medication prior to dressing changes A second day postoperative client who needs medication prior to dressing changes has predictable and routine care that a new nurse can manage. Although clients with chronic pain can be relatively stable, the interaction with this client will be time consuming and may cause the new nurse to fall behind. The client with HIV has complex complaints that require expert assessment skills. The client pending discharge will need special and detailed instructions.
Which client(s) would be appropriate to assign to a newly graduated RN, who has recently completed orientation? Choose all that apply. A. An anxious, chronic pain client who frequently uses the call button B. A client second day post-op who needs pain medication prior to dressing changes C. A client with HIV who reports headache and abdominal and pleuritic chest pain D. A client who is being discharged with a surgically implanted catheter
C. side lying position with knees to chest and pillow against abdomen The side-lying, knee-chest position opens retroperitoneal space and provides relief. The pillow provides a splinting action. Diversional therapy is not the best choice for acute pain, especially if the activity requires concentration. TENS is more appropriate for chronic muscular pain. The additional stimulation of massage may be distressing to the client.
Which non-pharmacological measure is particularly useful for a client with acute pancreatitis A. Diversional therapy, such as playing cards or board games B. Massage of back and neck with warmed lotion C. Side-lying position with knees to chest and pillow against abdomen D. Transcutaneous electrical nerve stimulation (TENS)
C. intravenous the IV route is preferred as the fastest and most amenable to titration. A PCA bolus can be delivered; however, the pump will limit the dosage that can be delivered unless the parameters are changed. Intraspinal administration requires special catheter placement and there are more potential complications with this route. Sublingual is reasonably fast, but not a good route for titration, medication variety in this form is limited.
Which route of administration is preferred if immediate analgesia and rapid titration are necessary A. intraspinal B.patient-controlled analgesia (PCA) C. intravenous D. sublingual
You have been assigned to care for a postoperative patient who has been switched from patient-controlled analgesia with meperidine (Demerol) to morphine sulfate after experiencing restlessness and agitation. The caregiver asks why the change has been made. Which of the following replies is most appropriate? a. "Restlessness and agitation are symptoms of meperidine toxicity." b. "Meperidine is not controlling the surgical pain effectively." c. "Meperidine has caused the respiratory rate to drop too low." d. "Meperidine can only be used for 24 hours postoperatively."
a. "Restlessness and agitation are symptoms of meperidine toxicity." Confusion, restlessness, and agitation are signs of toxicity from normeperidine, a toxic metabolite of meperidine.
Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his pain medication. What would be a priority nursing diagnosis for this patient? a. Acute Pain related to fear of taking prescribed postoperative medications b. Impaired Physical Mobility related to surgical procedure c. Anxiety related to outcome of surgery d. Risk for Infection related to surgical incision
a. Acute Pain related to fear of taking prescribed postoperative medications
A patient with osteoarthritis has been taking ibuprofen (Motrin) 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on knowledge of which of the following? a. Another NSAID may be indicated because of individual variations in response to drug therapy. b. The patient is probably not compliant with the drug therapy and therefore the nurse must initially assess the patient's knowledge base and initiate appropriate teaching. c. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. d. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective.
a. Another NSAID may be indicated because of individual variations in response to drug therapy. Patients vary in their response to medications so when one NSAID does not provide relief, another should be tried. There is no evidence in the stem of the question to ascertain any noncompliance to drug therapy.
Before administering celecoxib (Celebrex), the nurse will assess the patient's medical record for which of the following medications that would increase the risk of adverse effects? a. Aspirin b. Scopolamine c. Theophylline d. Acetaminophen
a. Aspirin Celecoxib is a nonsteroidal antiinflammatory drug (NSAID) of the cyclooxygenase-2 (COX-2) inhibitor type. Although celecoxib does not inhibit COX-1 and thus has a decreased risk of bleeding, bleeding is still of concern as an adverse effect. For this reason, the drug should not be taken with other drugs that increase risk of bleeding, such as aspirin.
The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? a. CRIES scale b. COMFORT scale c. FLACC scale d. FACES scale
a. CRIES scale
A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. You should assess for which of the following common adverse reactions to this medication? a. Constipation b. Agitation c. Diarrhea d. Urinary incontinence
a. Constipation Morphine sulfate is an opioid analgesic that can lead to constipation as a side effect. It is very important to use countermeasures, such as increased fiber and fluids in the diet, whenever possible, to prevent this side effect.
An elderly patient is confined to bedrest following cervical spine surgery to treat nerve pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to prevent the formation of pressure ulcers. What type of agent is the stimulus for pressure ulcers? a. Mechanical b. Thermal c. Chemical d. Electrical
a. Mechanical
You are caring for a patient receiving morphine sulfate 10 mg IV push prn for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8. Which of the following medications would you prepare to administer to treat these symptoms? a. Naloxone (Narcan) b. Atropine sulfate c. Protamine sulfate d. Neostigmine bromide (Prostigmin)
a. Naloxone (Narcan) Naloxone is the antidote or reversal agent for opioid analgesics, such as morphine. Excessive sedation and respiratory depression are symptoms of overdose and/or severe adverse effects that must be reversed for patient safety.
You are caring for a postoperative patient receiving epidural fentanyl for pain relief. For which of the following common side effects will you monitor the patient (select all that apply)? a. Nausea b. Itching c. Urinary retention d. Ataxia
a. Nausea, and b. Itching Common side effects of intraspinal opioids include nausea, itching, and urinary retention. Ataxia is a common side effect of intraspinal clonidine.
To reduce the risk of adverse effects, you should do which of the following when caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA)? a. Teach the caregiver not to push the button for the patient. b. Instruct the patient not to push the button too frequently. c. Ask the patient to do deep breathing exercises every hour. d. Administer medications to prevent the occurrence of diarrhea.
a. Teach the caregiver not to push the button for the patient. It is important to teach the caregiver not to push the button for the patient because it is only the patient who can determine the need for the medication. If the caregiver pushes the button, the patient could receive more of a dose than is actually needed, and this increases the risk of adverse effects.
local anesthesia
anesthesia used to numb a specific area without causing loss of consciousness Health care providers often use local anesthesia during brief surgical procedures such as removal of a skin lesion or suturing a wound by applying local anesthetics topically on skin and mucous membranes or by injecting them subcutaneously or intradermally to anesthetize a body part.
Adjuvants and co-analgesics
are drugs used to treat other conditions, but they also have analgesic qualities (tricyclic antidepressants and anticonvulsants).
D. give praise for the correct dose and time and discuss the deficits in charting In supervising the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service might be considered if the problem persists.
as the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The Rn correctly charted dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. what action should you take first? A. make a note in the nurse's file and continue to observe clinical performance B. refer the new nurse to the in-service education department C. quiz the nurse about knowledge of pain management D. give praise for the correct dose and time and discuss the deficits in charting
When assessing a patient receiving a continuous opioid infusion, the nurse immediately notifies the physician when the patient has: a. A respiratory rate of 10/min with normal depth b. A sedation level of 4 c. Mild confusion d. Reported constipation
b. A sedation level of 4 sedation level of 4: somnolent, minimal or no response to verbal & physical stimulation. nursing intervention: unacceptable. stop opioid & consider administering naloxone, call RRT code blue. stay w pt. and monitor respiratory status & sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory.
After administering acetaminophen and oxycodone (Percocet) for complaints of pain, which of the following interventions would be of highest priority for the nurse to complete before leaving the patient's room? a. Leave the overbed light on at low setting. b. Ensure that the upper two side rails are raised. c. Offer to turn on the television to provide distraction. d. Ensure that documentation of intake and output is accurate.
b. Ensure that the upper two side rails are raised. Percocet has acetaminophen and oxycodone (a class III controlled substance) as ingredients. Since the medication contains an opioid analgesic with sedative properties, the nurse must ensure patient safety before leaving the room, such as leaving the top two bedrails raised. This will help prevent the patient from falling from bed, while not restraining the patient (as four side rails would do).
A patient asks you why a dose of morphine sulfate by IV push is given before starting the medication via PCA. Which of the following responses is most appropriate? a. "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim." b. "The IV push dose will enhance the effects of the PCA for the next 8 hours." c. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." d. "PCA will never be effective unless a loading dose is given first."
c. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off.
When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate would drop down to or below which of the following parameters? a. 16 Breaths/min b. 14 Breaths/min c. 12 Breaths/min d. 10 Breaths/min
c. 12 breaths/min To protect the patient from adverse effects of respiratory depression from this medication, the nurse should alert the physician as soon as the respiratory rate drops down to or below 12 breaths/min.
When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? a. On a PRN (as needed) basis b. Conservatively c. Around the clock (ATC) d. Intramuscularly
c. Around the clock (ATC)
You should teach a patient to avoid which of the following medications while taking ibuprofen? a. Morphine sulfate (generic) b. Nitroglycerin (Nitro-Bid) c. Aspirin d. Furosemide (Lasix)
c. Aspirin The patient should not take aspirin while taking ibuprofen because the combination could increase the risk of GI bleeding.
A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in her legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? a. Prostaglandins b. Substance P c. Endorphins d. Serotonin
c. Endorphins
Which of the following assessments is of highest priority for you to complete before administration of morphine? a. Pain rating b. Blood pressure c. Respiratory rate d. Level of consciousness
c. Respiratory rate Decreased respirations below a rate of 12/min are a sign of opioid toxicity. Using the ABC approach in prioritization of care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine.
An important nursing responsibility related to pain is a. leave the patient alone to rest. b. help the patient appear to not be in pain. c. believe what the patient says about the pain. d. assume responsibility for eliminating the patient's pain.
c. believe what the patient says about the pain. Pain is a subjective experience, and patients need to feel confident the nurse will believe their reports of pain.
A patient is receiving a PCA infusion following surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths per minute. The most appropriate nursing action in this situation is to a. stop the PCA infusion. b. obtain an oxygen saturation level. c. continue to closely monitor the patient. d. administer naloxone and contact the physician.
c. continue to closely monitor the patient. Close monitoring is indicated for this patient with a sedation score of 3 and respiratory rate of 8 breaths/minute. If the respirations fall below 8 breaths/minute and the sedation level is 5 or greater, the nurse should vigorously stimulate the patient and try to keep the patient awake.
Unrelieved pain is a. expected after major surgery. b. expected in a person with cancer. c. dangerous and can lead to many physical and psychologic care needs. d. an annoying sensation, but it is not as important as other physical care needs.
c. dangerous and can lead to many physical and psychologic care needs. Consequences of untreated pain include unnecessary suffering, physical and psychosocial dysfunction, impaired recovery from acute illness and surgery, immunosuppression, and sleep disturbances. In the acutely ill patient, unrelieved pain can result in increased morbidity as a result of respiratory dysfunction, increased heart rate and cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal motility and transit, and increased breakdown of body energy stores (i.e., catabolism).
Providing opioids to a dying patient who is experiencing moderate to sever pain a. may cause addiction. b. will probably be ineffective. c. is an appropriate nursing action. d. will likely hasten the person's death.
c. is an appropriate nursing action. Opioids are an appropriate intervention for moderate to severe pain experienced by a dying patient, and they may be titrated upward many times over the course of therapy to maintain adequate pain control.
A cancer patient who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes a. is probably exaggerating pain. b. should be referred for surgical treatment of his pain. c. should be receiving both a long-acting and a short-acting opioid. d. should receive regularly scheduled short-acting opioids plus acetaminophen.
c. should be receiving both a long-acting and a short-acting opioid. Moderate to severe pain usually requires an opioid analgesic. Constant, moderate pain is treated with a long-acting opioid; procedural severe pain is treated with a short-acting opioid.
Pain is a. subjective. b. objective. c. usually subjective, but may be primarily objective in some circumstances.
c. usually subjective, but may be primarily objective in some circumstances. Although understanding the patient's experience and relying on his or her self-report is essential, this view is problematic in many patients. For example, patients who are comatose or who suffer from dementia, patients who are mentally disabled, and patients with expressive aphasia (disturbance in formulation and comprehension of language) possess varying ability to report pain. In these instances, you must incorporate nonverbal information such as behaviours into your pain assessment.
Behavioral responses to pain
clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction Some patients choose not to report pain if they believe that it inconveniences others or if it signals loss of self-control. Others endure severe pain without asking for assistance
Multimodal Analgesia
combines drugs with at least two different mechanisms of action so pain control can be optimized - Benefit is that the use of different agents allows for the lower-than usual dosing of each medication, so it lowers the risk of side effects while providing pain relief that is as good or even better than could be obtained from each med alone.
the difference between acute and chronic pain involves the ___________ of harm. Acute pain is protective, thus preventing harm. Chronic pain is no longer protective and does not provide any benefit.
concept
Visual Analog Scale (VAS) for Pain
consists of a straight line without labeled subdivisions. The strait line shows a continuum of intensity was has labeled end points. The patient indicates pain by marking the appropriate point on the line.
A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? a. "It's not a good idea to ask for pain medication regularly as it can be addictive." b. "It is better to wait until the pain gets unbearable before asking for pain medication." c. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." d. "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."
d. "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."
The nurse should instruct a patient receiving NSAIDs to report which of the following adverse effects? a. Blurred vision b. Nasal stuffiness c. Urinary retention d. Black or tarry stools
d. Black or tarry stools Black, tarry stools could indicate GI bleeding, which is a risk associated with NSAIDs. For this reason, the patient should be taught to report this sign and other signs of bleeding immediately.
Which of the following words is most likely to be used to describe neuropathic pain? a. Dull b. Mild c. Aching d. Burning
d. Burning Neuropathic pain is caused by damage to peripheral nerves or structures in the central nervous system (CNS). Typically described as numbing, hot or burning, shooting, stabbing, sharp, or electric shock-like in nature, neuropathic pain can be sudden, intense, short lived, or lingering.
The patient is receiving fentanyl (Duragesic) for control of chronic cancer pain. Which of the following should you observe for as a potential adverse effect of this medication? a. Pupillary dilation b. Hypertension c. Urinary incontinence d. Decreased respiratory rate
d. Decreased respiratory rate Respiratory depression is a potentially life-threatening adverse effect of fentanyl (Duragesic), which is an opioid analgesic.
Which of the following clinical manifestations would you attribute to adverse effects of morphine sulfate administered via PCA? a. Urinary incontinence b. Increased blood pressure c. Diarrhea d. Nausea and vomiting
d. Nausea and vomiting Morphine sulfate promotes nausea and vomiting by directly stimulating the chemoreceptor trigger zone in the medulla. Other common side effects include constipation, sedation, respiratory depression, and pruritus.
A nurse believes that patients with the same type of tissue injury should have the same amount of pain. This statement reflects a. a belief that will contribute to appropriate pain management. b. an accurate statement about pain mechanisms and an expected goal of pain therapy. c. a premise that this belief will have no effect on the type of care provided to people in pain. d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management.
d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management. Genetic makeup and variability among individuals affects the plasticity of the central nervous system; this phenomenon helps to explain individual differences in responses to pain. Poor knowledge of pain mechanisms often leads to poor pain management.
Noxious stimuli cause the release of numerous chemicals, which make up a "biologic soup," into the damaged tissues, and includes:
hydrogen ions, substance P, adenosine triphosphate (ATP); chemicals released from mast cells (serotonin, histamine, bradykinin, and prostaglandins); and chemicals released from macrophages (bradykinin, interleukins, and tumor necrosis factor [TNF]). Hydrogen ions Substance P Adenosine triphosphate (ATP) Serotonin Histamine Bradykinin Prostaglandins Bradykinin Interleukin Tumor necrosis factor (TNF)
Nonopioids
include acetaminophen and NSAIDs. Acetaminophen has no anti-inflammatory or antiplatelet effects. NSAIDs (aspirin and ibuprofen) provide mild to moderate pain relief. Most NSAIDs work on peripheral nerve receptors to reduce transmission of pain stimuli. Long-term use is associated with gastrointestinal (GI)bleeding and renal insufficiency.
ChlorpheniraMINE (ChlorTrimeton)
is a sedating histaMINE H1 antagonist used to treat allergy symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly
Amitriptyline (Elavil)
is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias
Perception
is the point at which a person is aware of pain. Gives awareness, and meaning to pain, resulting in a reaction. Somatosensory cortex identifies the location and intensity of the pain. Association cortex (primarily limbic) determines how a person feels about it. There is no single pain center.
Meperidine (Demerol)
narcotic to treat moderate to severe pain. Meperidine (Demerol) is contraindicated for a sickle cell crisis as large frequent doses can result in normeperidine (toxic metabolite) accumulation. Symptoms start with tremors and can result in a seizure.
normal absolute neutrophil count
normal: 2200-7700 cells/mm3 [2.2-7.7 ×109/L])
Incident Pain
occurs predictably after specific movements
Neuropathic Pain
pain from damage to neurons of either the peripheral or central nervous system
Spontaneous Pain
pain in the absence of stimulation
Chronic Pain
pain that lasts for 3 months or longer; may be intermittent or continuous Chronic pain affects a patient's activity (eating, sleeping, socialization), thinking (confusion, forgetfulness), or emotions (anger, depression, irritability) and quality of life and productivity.
The _____ of pain will influence the ways in which a person responds to pain and must be incorporated into a comprehensive treatment plan.
perception or meaning Examples: A woman who is in labor and is experiencing pain but views the pain as "with a purpose" and self-limiting versus a patient who is experiencing unrelieved pain for an unknown reason but fears she may have done something to cause.it.
(Table 10-1, p. 128) In the acutely ill patient, unrelieved pain can cause increased morbidity due to:
respiratory dysfunction, increased heart rate and cardiac workload, increased muscular contraction and spasm, decreased gastric motility and transit, and increased breakdown of energy stores (catabolism).
One of the concerns related to the use of peripheral and epidural anesthetic techniques is the:
risk of bleeding and subsequent hematoma formation near the injection/insertion site. Safe placement or removal of these injections and catheters is based on knowledge of the patients' coagulation status as well as the timing of administration of anticoagulant or antiplatelet medications. Because the epidural space is a highly vascular area, patients with epidural catheters are at risk for the development of epidural hematomas, which may lead to ischemia of the spinal cord, and if unaddressed, serious neurological complications.
Pain management
should be patient centered, with nurses practicing patient advocacy, patient empowerment, compassion, and respect. Caring for patients in pain requires recognition that pain can and should be relieved.
Key Points: pain is purely a ____________ physical and psychosocial experience
subjective
The emotional distress of pain can cause _____, which is the state of distress associated with loss.
suffering Suffering can result in a profound sense of insecurity and lack of self control. Suffering is not the same as pain.
WHO Analgesic Ladder
three step approach in treating cancer pain 1= Nonopoid ± adjuvant (pain persisting or increasing) 2= Opoid for mild to moderate pain ± Nonopioid ± Adjuvant (pain persisting or increasing) 3= Opioid for moderate to sever pain ± Nonopioid ± Adjuvant (Freedom from Cancer pain)
transmucosal fentanyl
to treat breakthrough pain in opioid-tolerant clients, the unit is placed in the mouth and dissolved, not chewed - Allow to absorb for over a 15 min period, delaying swallowing as long as possible. - Use no more than 2 units per breakthrough pain episode. - If the patients pain is not relieved after 2 units, call the health care provider.
C oral If the gastrointestinal system is function, the oral route is preferred for routine analgesics because of lower cost and ease of administration. Oral route is also less painful and less invasive than the IV, IM, subcutaneous, or PCA routes. Transdermal route is slower and medication availability is limited compared to oral forms.
which route of administration is preferable for administration of daily analgesics? A. IV B. IM or subcutaneous C. Oral D. Transdermal E. PCA
Nursing Knowledge Base: Pain
• A nurse must accept a patient's report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and evidence-based research findings. • Nurses' assumptions about patients in pain seriously limit their ability to offer pain relief. Biases based on culture, education, and experience influence everyone. Too often nurses allow misconceptions about pain to affect their willingness to intervene
Nursing Diagnosis for Pain
• Activity intolerance • Anxiety • Fatigue • Insomnia • Impaired social interaction • Ineffective coping • Impaired physical mobility
Physiological Factors for Pain
• Age, fatigue, genes, neurological function • Fatigue increases the perception of pain and can cause problems with sleep and rest * pain is not an inevitable part of aging, likewise pain perception does not decrease with age. Age-related changes and increased frailty may lead to a less predictable response to analgesics, increased sensitivity to medications and potential harmful drug effects.
Psychological Factors for Pain
• Anxiety • Coping Style * Pain is a lonely experience that often causes patients to feel a loss of control. Coping style influences the ability to deal with pain.
Social Factors for Pain
• Attention, previous experiences, family and social support, spiritual • Spirituality includes active searching for meaning in situations, with questions such as "Why am I suffering?"
Assessment: Errors
• Bias • Vague or unclear assessment questions • Use of pain assessment tools that are not evidence based • Use of medical terms with patients with low health literacy • Patients do not always provide complete, relevant or accurate information • Cognitively impaired patients
Nonpharmacological pain-relief interventions
• Cognitive and behavioral approach • Relaxation and guided imagery • Distraction (directs a patient's attention to something other than pain and thus reduces awareness of it.) • Music (may be useful in treating acute or chronic pain, stress, anxiety, and depression.) • Cutaneous stimulation (Stimulation of the skin through a massage, warm bath, cold application, and TENS may be helpful in reducing pain perception.) • Cold and heat application (relieve pain and promote healing. ) • Transcutaneous electrical nerve stimulator (TENS) • Herbals (Many patients use herbals and dietary supplements such as echinacea, ginseng, ginkgo biloba, and garlic despite conflicting research evidence supporting their use in pain relief. ) • Reducing pain perception and reception
Transduction
• Converts energy produced by these stimuli into electrical energy. • Begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential. • Once transduction is complete, transmission of the pain impulse begins.
Achieving Adequate Pain Management
• Effective communication among the patient, family, and professional caregivers is essential to achieve adequate pain management. • Recognition of the subjective nature of pain and respect for the patient in pain is demonstrated when a nurse accepts McCaffery's classic definition: "Pain is whatever the experiencing person says it is, existing whenever he says it does."
Pain in Infants
• Infants have the anatomical and functional requirements for pain processing by mid-to-late gestation • Term neonates have the same sensitivity to pain as older infants/children. Preterm neonates have a greater sensitivity to pain than term neonates or older children. • Pain requires no prior experience, infants do not need to learn it from earlier painful experience. It occurs within the first insult • You use behavioral cues (facial expression/body movements/cry) and physiological indicators of pain (changes in vital signs) to reliably assess pain in infants. • Infants are very sensitive to drugs, response to drugs is intense and prolonged. Absorption is faster than expected. Dosages of drugs excreted by the kidneys need to be reduced. Prescribers carefully select the medication, dosage, administration, route, and time. Nurses monitor frequently for desired and undesired effects. They also follow medication orders to titrate and wean medications to minimize adverse effects.
Modulation
• Inhibits pain impulse • A protective reflex response occurs with pain reception >>Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as endorphins (endogenous opioids), serotonin, norepinephrine, and gamma-aminobutyric acid (GABA), which hinder the transmission of pain and help produce an analgesic effect.
Nature of Pain
• Involves physical, emotional, and cognitive components •Pain is subjective and individualized • Reduces quality of life • Not measurable objectively • May lead to serious physical, psychological, social, and financial consequences
Cultural Factors for Pain
• Meaning of pain: affects the experience of pain and how one adapts to it; associated with a person's cultural background, including age, ethnicity, education, race, and familial factors. • Ethnicity: Cultural beliefs and values affect how individuals cope with pain. Individuals learn what is expected and accepted by their culture, including how to react to pain. Health care providers often mistakenly assume that everyone responds to pain in the same way. Different meanings and attitudes are associated with pain across various cultural groups.
Pain in Older Adults
• Older adults are at greater risk (2x) than younger adults for many painful conditions • Pain is not an inevitable result of aging. • Older adults commonly underreport pain. Reasons include: expecting to have pain with increasing age, not wanting to alarm love ones, being fearful of losing their independence, believing caregivers know they have pain and are doing all they can to relieve it. The absence of a report of pain does not mean the absence of pain • Older patients often believe that it is unacceptable to show pain, and learned a variety of ways to cope with it. • Opoids are safe to use in older adults, except if they're opioid-naive they're more sensitive to opioids. Slow titration prevents potentially dangerous opioid-induced side effects.
Nursing implications for local and regional anesthesia
• Provide emotional support • Protect patient from injury • Patient education • Invasive interventions for pain relief • Procedure pain management • Cancer pain and chronic noncancer pain management
Transmission
• Sending of impulse across a sensory pain nerve fiber (nociceptor) • Nerve impulses • Pain impulses
Nursing Implications
• You maintain responsibility for providing emotional support to patients receiving local or regional anesthesia. • After administration of a local anesthetic, protect the patient from injury until full sensory and motor function return. • Nursing implications for managing epidural analgesia are numerous. • Patient education.
Pain
• is purely subjective. No two people experience pain in the same way, and no two painful events create identical responses or feelings in a person. • Nurses are legally and ethically responsible for managing pain and relieving suffering • Pain can be categorized by duration (chronic or acute) or pathology (cancer or neuropathic).
