Hinkle Ch. 9: Pain Management

A client is receiving morphine sulfate intravenously (IV) every 4 hours as needed for the relief of pain related to a surgical procedure the client had 3 days previously. The physician is discontinuing the IV and will be starting the client on oral pain medication. What would provide the client with optimal pain relief when discontinuing the IV dose? - Administer a lower dose so the client does not get addicted to the medication. - Administer an equianalgesic dose. - The client should be ordered the medication to be administered intramuscularly (IM) instead of by mouth. - Administer a higher dose of the medication by mouth.

- Administer an equianalgesic dose. Explanation: When changing from a parenteral to an oral route, it is best to administer an equianalgesic dose, an oral dose that provides the same level of pain relief as when the drug is given by a parenteral route. Administering a lower dose of the medication will not provide the client with an adequate pain relief. Administering an IM dose may decrease the absorption and not provide the client with adequate relief. Administering a higher dose may cause side effects that would be detrimental to the client.

A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain? - Administer oral opioids as needed. - Provide patient-controlled analgesia. - Administer pain medication through a transdermal patch. - Administer analgesics around the clock.

- Administer analgesics around the clock. Explanation: Because assessing pain medication needs in a client with end-stage dementia is difficult, analgesics should be administered around the clock. Clients at this stage of dementia typically can't request oral pain medications when needed. They're also unable to use patient-controlled analgesia devices. Transdermal patches are used to manage chronic pain; not postoperative pain.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client? - Administering the analgesics on a regular basis - Administering the analgesics intravenously - Administering the analgesics on an as-needed per client request - Administering analgesics with increased dosage

- Administering the analgesics on a regular basis Explanation: Routine scheduling of the administration of analgesics, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician.

A female client with sickle-cell disease is hospitalized for pain management. The client's BUN is 24 mg/dL and creatinine is 1.6 mg/dL. To assist with management of the pain, the nurse - Applies warm soaks to the extremities - Administers meperidine (Demerol) intravenously - Obtains cold packs to place on the joints - Places the lower extremities in a dependent position

- Applies warm soaks to the extremities Explanation: Warm soaks may help to alleviate pain in the client with sickle-cell disease. Meperidine is not recommended in clients experiencing renal dysfunction. This client's renal studies show some dysfunction. Cold will cause the blood cells to lump even more and constrict blood vessels, increasing pain. Lowering the extremity to a dependent position will encourage blood to pool, particularly in the joints, increasing pain.

Prior to starting a peripheral intravenous line on a patient, what intervention can the nurse provide to decrease the pain from the needle puncture? - Give an oral opioid analgesic 30 minutes before the procedure. - Apply diclofenac gel over the site 1 hour before the procedure. - Apply eutectic mixture of local anesthetic cream 30 minutes prior to the procedure. - Inject lidocaine 2% with epinephrine locally around the potential procedure site.

- Apply eutectic mixture of local anesthetic cream 30 minutes prior to the procedure. Explanation: The topical route of administration is used for both acute and chronic pain. For example, the nonopioid diclofenac is available in patch and gel formulations for application directly over painful areas. Local anesthetic creams, such as EMLA (eutectic mixture or emulsion of local anesthetics) and L.M.X.4 (lidocaine cream 4%), can be applied directly over the injection site prior to painful needle stick procedures, and the lidocaine patch 5% is often used for well-localized types of neuropathic pain, such as postherpetic neuralgia.

A client with a terminal illness grimaces and begins to cry when being turned and repositioned in bed. Which action will the nurse take at this time? - Ask the client to rate the pain. - Coach the client with guided imagery. - Support the body area that is painful. - Stay with the client until pain from activity eases.

- Ask the client to rate the pain. Explanation: A client who is obviously experiencing pain should be asked to rate the pain as part of the assessment. Nonpharmacologic methods are used to supplement pharmacologic interventions. Therefore, pain medication should be provided to the client before coaching through guided imagery, supporting the body area that is painful, or staying with the client until the pain from the activity eases.

A client recovering from hip surgery is receiving morphine through a patient-controlled analgesia (PCA) infusion pump with a set basal rate. What action is most important for the nurse to implement? - Assess the client's respiratory status - Instruct the client about bolus doses - Ask the client about pain status - Obtain consent for PCA by proxy

- Assess the client's respiratory status Explanation: A basal rate is a continuous infusion of the medication. Assessment of the client's respiratory status is a major nursing responsibility and the most important one listed per Maslow's hierarchy of needs. The nurse will instruct the client about bolus doses for increased pain or painful activities and assess pain status. There is no information in the stem of the question to support the need for consent for PCA by proxy.

The client takes naproxen for arthritic pain and is now prescribed warfarin for persistent atrial fibrillation. Due to the interactions of the medications, what is the nurse's best response? - Assess the client's stool for color - Teach the client to ingest foods high in vitamin K - Administer both medications with food to increase absorption - Inform the client to decrease alcohol to one glass each day

- Assess the client's stool for color Explanation: Clients who take NSAIDs, such as naproxen (Aleve), with warfarin (Coumadin) may experience gastrointestinal bleeding. The nurse will need to monitor for this. Clients are to ingest a consistent level of vitamin K. Administering the medications with food does not increase absorption. Ingesting food with the medications may decrease gastrointestinal upset. Clients are instructed to not ingest alcohol.

When administering a fentanyl patch, the last dose of sustained-release morphine should be administered at what point? - Immediately after the morning shower - Before respiratory assessment - At the same time the first patch is applied - There are no administration requirements

- At the same time the first patch is applied Explanation: Because it takes 12 to 18 hours for the fentanyl concentrations to increase gradually from the first patch, the last dose of sustained-release morphine should be administered at the same time the first patch is applied. The skin must be clean and dry before applying the patch; no shower is required. Respiratory assessment must be conducted before applying the fentanyl patch.

The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for? - Asystole - Hypertension - Bradypnea - Tachycardia

- Bradypnea Explanation: Most patients experience sedation at the beginning of opioid therapy and whenever the opioid dose is increased significantly. If left untreated, excessive sedation can progress to clinically significant respiratory depression (bradypnea, or reduced breathing rate).

When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use? - Burning - Chronic - Intermittent - Severe

- Burning Explanation: When asking the patient to describe how the pain feels, the nurse should suggest to the patient descriptors such as "sharp," "shooting," or "burning," which may help identify the presence of neuropathic pain.

When taking a client history, the nurse notes that the client has been taking herbal remedies in addition to acetaminophen for several years. Based on the admission history, the nurse understands that the client is experiencing which type of pain? - Breakthrough pain - Chronic pain - Acute pain - Neuropathic pain

- Chronic pain Explanation: Chronic pain persists over a course of time, in this case several years. Acute pain has a relatively short duration. Breakthrough pain is acute exacerbations of pain periodically experienced by clients with a normally controlled pain management regimen.

A client comes to the outpatient clinic to receive cortisone injections in the neck for pain that has been occurring consistently for 8 months. What type of pain is this client experiencing? - Referred pain - Neuropathic pain - Acute pain - Chronic pain

- Chronic pain Explanation: The characteristics of chronic pain, discomfort that lasts longer than 6 months, are almost totally opposite from those of acute pain. Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located. An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Acute pain is a discomfort that has a short duration (from a few seconds to less than 6 months). It is associated with tissue trauma, including surgery, or some other recent identifiable etiology.

Which of the following nursing interventions contributes to achieving a client's goal for pain relief? - Minimize the client's description of pain or need for pain relief. - Collaborate with the client about his or her goal for a level of pain relief. - Use all forms of available pain management techniques. - Prevent the client from self-administering analgesics.

- Collaborate with the client about his or her goal for a level of pain relief. Explanation: The nurse should collaborate with each client about his or her goal for a level of pain relief; this helps implement interventions for achieving the goal. The client's description of pain or need for pain relief should never doubted or minimized. The client need not refrain from self-administering analgesics; providing a client with equipment to self-administer analgesics promotes a more consistent level of pain relief. The nurse should also inform the client of available pain management techniques and incorporate any preferences or objections to interventions for pain management that the client may have when establishing a plan of care; using all forms of available pain management techniques is not necessary.

Which of the following nursing interventions contributes to achieving a client's pain relief? - Minimize the client's description of pain or need for pain relief. - Collaborate with the client about the goal of a level of pain relief. - Use all forms of available pain management techniques. - Prevent the client from self-administering analgesics.

- Collaborate with the client about the goal of a level of pain relief. Explanation: The nurse should collaborate with each client about the goal of a level of pain relief; this helps implement interventions for achieving the goal. The client's description of pain or need for pain relief should never doubted or minimized. The client need not refrain from self-administering analgesics; providing a client with equipment to self-administer analgesics promotes a more consistent level of pain relief. The nurse should also inform the client of available pain management techniques and incorporate any preferences or objections to interventions for pain management that the client may have when establishing a plan of care; using all forms of available pain management techniques is not necessary.

Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain? - Avoid caffeine or other stimulants, such as decongestants - Monitor weight, vital signs, and serum glucose concentration - Do not administer if respirations are less than 12 breaths per minute - Monitor blood counts and liver function tests

- Do not administer if respirations are less than 12 breaths per minute Explanation: The nurse should not administer the prescribed opiate therapy if respirations are less than 12 breaths per minute. The nurse should instruct a client who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose concentration when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests.

Which substance reduces the transmission of pain? - Endorphins - Acetylcholine - Serotonin - Substance P

- Endorphins Explanation: Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment? - Ensure the client knows to taper down the dose if it is discontinued by the care provider. - Educate the client about the need to avoid grapefruit and grapefruit juice during treatment. - Teach the client the signs and symptoms of gastrointestinal bleeding. - Educate the client about the difference between tolerance and dependence.

- Ensure the client knows to taper down the dose if it is discontinued by the care provider. Explanation: Corticosteroids must be tapered slowly in order to prevent an adrenal crisis. These medications do not normally cause dependence and they do not pose a risk for GI bleeding. Grapefruit is not contraindicated.

The nurse is caring for a client with traumatic injuries. Which action will the nurse perform to conduct a comprehensive pain assessment for this client? - Identify pertinent medical history, including comorbidities. - Review results from diagnostic studies and laboratory tests. - Evaluate the effect of pain on ability to perform recovery activities. - Match a face from the FACES scale to the client's facial expression.

- Evaluate the effect of pain on ability to perform recovery activities. Explanation: A comprehensive pain assessment is the foundation of developing and evaluating the effectiveness of the pain treatment plan. Evaluating the effect of pain on the client's ability to perform recovery activities is an important aspect of the comprehensive pain assessment. Identifying pertinent medical history, including comorbidities, and reviewing results from the diagnostic studies and laboratory tests would need to be considered when establishing the treatment plan, but would not be part of the comprehensive pain assessment. The FACES tool is a self-report tool, in which the client picks a face that they feel represents the pain level they are feeling; the nurse should not attempt to match a face to the client's facial expression.

The nurse is administering a narcotic analgesic for the control of a newly postoperative client's pain. What medication will the nurse administer to this client? - Midazolam - Ibuprofen - Acetaminophen - Fentanyl

- Fentanyl Explanation: Opioid and opiate analgesics such as morphine and fentanyl are controlled substances referred to as narcotics. The other medications are not opioid analgesics and should not be given for a newly postoperative client.

An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client? - Exercise regularly. - Avoid harsh sunlight. - Follow a bowel regimen. - Reduce fiber intake.

- Follow a bowel regimen. Explanation: The nurse should ensure that a bowel regimen to prevent constipation is started when any older adult is treated with opioids. A high-fiber diet along with increased fluids should be encouraged. The client should not reduce fiber intake because this increases the risk for constipation. The client need not exercise regularly or avoid harsh sunlight because these have no effects on the drug therapy.

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe? - Tramadol - Ketamine - Gabapentin - Hydromorphone

- Gabapentin Explanation: The anticonvulsant gabapentin is a first-line analgesic agent for neuropathic pain. Tramadol is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine is used as a third-line analgesic agent for refractory acute pain. Hydromorphone is a first-line opioid not used as an analgesic agent for neuropathic pain.

When taking a client history, the nurse notes that the client is taking herbal remedies in addition to acetaminophen. Which herb, when taken in conjunction with acetaminophen, enhances the risk of bleeding? - Echinacea - Ginkgo - Willow - Kava

- Ginkgo Explanation: Ginkgo, when taken with acetaminophen, enhances the risk of bleeding. Echinacea, willow, and kava, when taken with acetaminophen, increase the potential for hepatotoxicity and nephrotoxicity.

A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling? - Warm compresses - Ice bag - Elevation of the extremity - Injection of a steroid into the joint space

- Ice bag Explanation: Pain associated with injury is best treated initially with cold applications such as an ice bag or chemical pack. The cold decreases vasodilation which reduces localized swelling, which may be useful for minor or moderate pain. Heat will increase vasodilation. Elevation of the extremity will not decrease vasodilation. It is beyond the scope of practice for the nurse to inject steroids into the joint space.

When evaluating a patient's response to acute pain, the nurse assesses for the presence of physiologic responses associated with the pain experience. Select all that apply: - Increased cardiac output - Lowered production of cortisol - Bradycardia and hypotension - Increased metabolic rate - Hyperglycemia - Decreased urinary output

- Increased cardiac output - Increased metabolic rate - Hyperglycemia - Decreased urinary output Explanation: The physiological response to pain activates a series of endocrine and metabolic reactions that cause increased cardiac output and metabolic rate, hyperglycemia, and decreased urinary output. Under stress, the patient would be expected to have hypertension, tachycardia, and increased levels of cortisol. Refer to Box 7-2.

About which issue should the nurse inform clients who use pain medications on a regular basis? - Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. - Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. - Minimize fiber intake during the therapy. - Consume the medications just before or along with meals.

- Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. Explanation: Clients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the client to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Clients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

A client is recovering from abdominal surgery and sleeping. The client had received an opioid medication 3 hours ago. The client's son requests pain medication for the client, stating "I do not want her to wake up in pain." The first nursing action is - Refuse to administer the pain medication. - Administer the prescribed medication. - Instruct the son about lack of client consent. - Wake the client and ask about her pain rating.

- Instruct the son about lack of client consent. Explanation: One of the client's rights is to participate in management of his or her own care. The nurse follows the nursing process by assessing the client's perception of pain but does not awaken the client to do this. The nurse can administer the pain medication only after assessment. The nurse does not administer the pain medication but does take the opportunity to educate the son.

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain. - A migraine headache - Intervertebral disk herniation - Angina - Appendicitis

- Intervertebral disk herniation Explanation: Chronic pain is found with degeneration or traumatic conditions and can sometimes be the cause of the patient's primary disorder. The other three choices refer to acute pain. Migraines could be chronic pain but are not the best example here.

The patient develops respiratory depression after the nurse administers fentanyl for pain. What medication can the nurse anticipate administering to counteract the effects of the fentanyl? - Nubain - Morphine - Narcan - Lidocaine

- Narcan Explanation: Antagonists (e.g., naloxone [Narcan], naltrexone) are drugs that also bind to opioid receptors but produce no analgesia. If an antagonist is present, it competes with opioid molecules for binding sites on the opioid receptors and has the potential to block analgesia and other effects. They are used most often to reverse adverse effects, such as respiratory depression.

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing? - Breakthrough pain - Neuropathic pain - Visceral pain - Referred pain

- Neuropathic pain Explanation: An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Chronic pain sufferers may have periods of acute pain, which is referred to as breakthrough pain. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located.

A client is reporting her pain as "8" on a 0-to-10 pain intensity scale. Then, the client states the pain is "3." Before the nurse leaves the room, the client states her pain is "6." The best action of the nurse is to - Obtain a pain scale with faces for the client to measure her pain. - Average the numbers and report that number as the client's level of pain. - Medicate the client for pain based on the highest number of "8." - Record each of the numbers the client stated for her pain.

- Obtain a pain scale with faces for the client to measure her pain. Explanation: Various scales are helpful to clients trying to describe pain intensity. If the client cannot use one scale, such as the numeric pain intensity scale, the nurse uses another pain intensity scale that the client finds easy to understand and use. The nurse does not average the numbers, medicate based on the highest number, nor record each of the numbers the client stated.

Opioid analgesics are effective pain management tools for many clients. A significant portion of a nurse's practice is older adults who suffer from chronic pain. What impact does a client's age have on initial dosing? - Older clients should receive a reduced dose. - Older clients should receive an increased dose. - Opioid analgesics should not be used to treat older adults. - Age has no impact on dosing.

- Older clients should receive a reduced dose. Explanation: A reduced dose of analgesics, especially opioid analgesics, may be prescribed for the older adult initially because older adults experience a higher peak effect and longer duration of pain relief from an opioid. An increased dose is not generally recommended for older adults. Opioid analgesics can be used to treat older adults, but there are special dosing considerations.

The nurse is administering an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully? - Older people metabolize drugs more rapidly. - Older people have increased hepatic, renal, and gastrointestinal function. - Older people are more sensitive to drugs. - Older people have lower ratios of body fat and muscle mass.

- Older people are more sensitive to drugs. Explanation: Older adults are often sensitive to the effects of the adjuvant analgesic agents that produce sedation and other CNS effects, such as antidepressants and anticonvulsants. Therapy should be initiated with low doses, and titration should proceed slowly with systematic assessment of patient response.

The nurse is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient? - Older people are expected to experience chronic pain. - Older people have a decreased pain threshold. - Older people experience reduced sensory perception. - Older people have increased sensory perception.

- Older people experience reduced sensory perception. Explanation: Pain affects individuals of every age, sex, race, and socioeconomic class (American Geriatrics Society, 2009; Johannes, Le, Zhou, et al., 2010; Walco, Dworkin, Krane, et al., 2010).

Which phase of pain transmission occurs when the one is made aware of pain? - Transmission - Modulation - Transduction - Perception

- Perception Explanation: Perception is the pain process where one becomes aware of the pain as a result of neural activity. Modulation involves the response to noxious stimuli. Transduction refers to the processes by which noxious stimuli activate primary afferent neurons called nociceptors. Transmission describes the action potential that is created by transduction being transmitted along fibers.

The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective? - Consult with the health care prescriber to include hydroxyzine with the opioid. - Provide the client with a fresh gown. - Position the client for comfort. - Encourage the client to eat crackers.

- Position the client for comfort. Explanation: The nurse should provide a comfort level with positioning first. Hydroxyzine may be given with opioid analgesics. However, elderly clients are more susceptible to adverse reactions of this medication, and alternative measures should be tried first. Providing a fresh gown will not make the medication more effective. Ingesting food with an opioid medication does not make the medication more effective.

A client who is watching television with a visitor reports severe pain and wants pain medication. Which action will the nurse take? - Prepare a dose of pain medication as prescribed. - Watch the client's actions to determine pain level. - Encourage client to use distraction techniques to manage pain. - Wait until the visitor leaves before providing pain medication.

- Prepare a dose of pain medication as prescribed. Explanation: The client's report of pain is the undisputed standard of pain assessment. Since the client reported severe pain, a dose of pain medication should be prepared. Watching the client's actions to determine pain level is inappropriate, as personal and cultural differences yield different demonstrations of pain levels and behaviors are not as reliable of indicators as the client's report of pain. Encouraging the client to use distraction techniques to manage their pain would not be indicated in this scenario, as the client is already using these techniques and still reporting severe pain, indicating the need for medication. There is no reason to wait for the visitor to leave before providing the client with the pain medication.

A client is being taught to self-administer a narcotic analgesic by means of an intravenous PCA pump system. Which of the following would help prevent accidental overdosage? - Reducing the dosage of the narcotic analgesic - Reducing the frequency of administration of the narcotic analgesic - Programming the dosage and time interval into the device - Drawing up a schedule chart for the client

- Programming the dosage and time interval into the device Explanation: When the client is being taught to self-administer a narcotic analgesic, the dosage and time interval between doses are programmed into the PCA intravenous pump system to prevent accidental overdosage. The frequency or dosage of the narcotic analgesic need not be reduced. Although a schedule chart is useful to the client, it does not effectively prevent accidental overdosage.

A new surgical patient has been prescribed an opioid analgesic intravenously for pain control. The nurse should be aware of which most serious adverse effect of this medication? - Respiratory depression - Nausea and vomiting - Constipation - Pruritus

- Respiratory depression Explanation: Respiratory depression is the most serious adverse effect of opioid analgesic agents administered by IV, subcutaneous, or epidural routes. The other side effects can occur with administration of opioids but are not the most serious.

Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy? - Risk for injury - Risk for impaired gas exchange - Diarrhea - Altered mobility

- Risk for impaired gas exchange Explanation: Problems that may develop with opioid and opiate therapy include risk for impaired gas exchange related to respiratory depression, constipation related to slowed peristalsis, and risk for injury related to drowsiness and unsteady gait.

A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client - About activities that would distract him from pain - That the nurse will notify the surgeon of his fear - How anxiety could increase his pain perception - That medication will be prescribed for pain relief

- That medication will be prescribed for pain relief Explanation: Pain is expected postoperatively, and the client should be reassured that medication will be prescribed to relieve pain. The client may have less pain knowing that measures will be taken to reduce it. Diversional activities may be used in addition to analgesics. Anxiety about pain could increase the client's perception of pain. Another nursing activity is being an advocate for the client and notifying his surgeon of the client's fear.

A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses - That the client's past experiences with pain may influence her perception of current pain - That based on her past experiences the client's perception of pain should be less - That the client has become dependent on drugs from her previous experience of burns - That the client is experiencing pain relating to the burn injuries from several years ago

- That the client's past experiences with pain may influence her perception of current pain Explanation: Clients who have had previous experiences with pain are usually more frightened about subsequent painful events, as in the client who experienced partial-thickness burns to more than 60% of her body. The clients in these situations are less able to tolerate pain. Insufficient data in the stem support that the client is dependent on drugs or that this current pain is related to the client's previous burn injuries.

The nurse informs the patient that a preventive approach for pain relief will be used, involving nonsteroidal anti-inflammatory drugs. What will this mean for the patient? - The pain medication will be administered before the pain becomes severe. - The pain medication will be administered before the pain is experienced. - The pain medication will be administered when the pain is at its peak. - The pain medication will be administered when the level of pain tolerance has been exceeded.

- The pain medication will be administered before the pain is experienced. Explanation: Two basic principles of providing effective pain management are preventing pain and maintaining a pain intensity that allows the patient to accomplish functional or quality-of-life goals with relative ease (Pasero, Quinn et al., 2011). Accomplishment of these goals may require the mainstay analgesic agent to be administered on a scheduled around-the-clock (ATC) basis, rather than PRN (as needed) to maintain stable analgesic blood levels.

When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress? - The pump will deliver a preset amount of medication. - The client should wait until the pain is severe to push the button to prevent overdose. - Teach the client to avoid pushing the button multiple times because additional doses will be given. - Chance of sedation is rare when using a PCA pump.

- The pump will deliver a preset amount of medication. Explanation: A client experiencing pain can administer small amounts of medication directly into the IV, subcutaneous, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The client should not wait until the pain is severe to push the button. Even if the client pushes the button multiple times in rapid succession, no additional doses are released because of the preset lock-out time. Sedation can occur with the use of the PCA pump. Assessment of respiratory status remains a major nursing role.

The nurse is caring for a client with kidney stones who reports severe pain. What type of pain does the nurse understand this client is experiencing? - Somatic pain - Visceral pain - Neuropathic pain - Chronic pain

- Visceral pain Explanation: Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Somatic pain is caused by mechanical, chemical, thermal, or electrical injuries or disorders affecting bones, joints, muscles, skin, or other structures composed of connective tissue. Neuropathic pain is pain that is processed abnormally by the nervous system. Chronic pain is discomfort that lasts longer than 6 months and is almost totally opposite from those of acute pain.

Regarding tolerance and addiction, the nurse understands that - although clients may need increasing levels of opioids, they are not addicted. - tolerance to opioids is uncommon. - addiction to opioids often develops. - the nurse must be primarily concerned about the development of addiction by a client in pain.

- although clients may need increasing levels of opioids, they are not addicted. Explanation: Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.

The client is taking oxycodone (Oxycontin) for chronic back pain and reports decreased pain relief when he began taking a herb to improve his physical stamina. The nurse asks if the herb is - valerian - kava-kava - chamomile - ginseng

- ginseng Explanation: Ginseng may inhibit the analgesic effects of an opioid, such as oxycodone. The other herbs listed (valerian, kava-kava, and chamomile) may increase central nervous system depression.

A nurse is caring for a client with pain. What should the nurse monitor for when administering intravenous acetaminophen? - hepatotoxicity - renal toxicity - bleeding - gastrointestinal effects

- hepatotoxicity Explanation: The nurse will need to monitor the client receiving acetaminophen for hepatotoxicity. Intravenous acetaminophen should not cause renal toxicity, bleeding, and gastrointestinal effects.

A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends - ingesting up to 6 glasses of fluids per day - increasing the amount of bran and fresh fruits and vegetables - using milk of magnesia 30 mL every day - inserting a bisacodyl (Dulcolax) rectal suppository every morning

- increasing the amount of bran and fresh fruits and vegetables Explanation: Constipation is a common problem with the use of opioid medications, such as methadone. Activities to prevent constipation include increasing bran and fresh fruits and vegetables in the diet. The client should ingest 8 to 10 glasses of fluids per day. Milk of magnesia may be used if no bowel movement is produced in 3 days. Milk of magnesia is not to be used daily. A glycerin suppository, not bisacodyl, may be used to make the bowel movement less painful.

According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment? - location, onset, alleviating factors, and aggravating factors - quality, location, intensity, and family history - nutritional deficiencies, onset, duration, and effects of pain - intensity, variations, range of motion, and the client's goal for pain control

- location, onset, alleviating factors, and aggravating factors Explanation: Location, onset, alleviating factors, and aggravating factors are all essential components of a comprehensive pain assessment according to The Joint Commission's standards. Family history is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Nutritional deficiencies are not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Range of motion is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards.

A client is on a second round of radiation therapy for an inoperable tumor, and asks the nurse for medication to help with pain. The nurse suspects that the client's pain is the result of nerve damage from the radiation. Which type of pain is the client likely experiencing? - neuropathic pain - somatic pain - visceral pain - referred pain

- neuropathic pain Explanation: Neuropathic pain can affect cancer patients due to nerve damage from chemotherapy or radiation therapy. Somatic pain is caused by damage or disorders that affect bones, joints, muscles, skin, or other structures. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is pain felt in the body in a location that is different from the actual source of the pain.

A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about? - the limits on dose and frequency that are programmed into the PCA - the fact that naloxone will be kept readily available at all times - the use of non-pharmacologic pain interventions to minimize use of the PCA - the importance of limiting the use of the PCA to no more than twice per hour

- the limits on dose and frequency that are programmed into the PCA Explanation: Patient-controlled analgesia (PCA) devices allow clients to self-administer their own narcotic analgesic using an intravenous pump system and pressing a handheld button. The dose and time intervals between doses are programmed into the device to prevent accidental overdose. Dosing may or may not be more than twice per hour. Naloxone treats overdoses, but this will not likely alleviate the client's concerns about overdosing in the first place. The client may benefit from non-pharmacologic pain measures, but should not be encouraged to minimize the use of the PCA or to endure pain.

A nurse observes the anesthesiologist administer single-dose, extended-release morphine through an epidural catheter for a client undergoing a major surgical procedure. What is the duration the nurse should assess the client for drug effectiveness? - 2 to 4 hours - 8 to 10 hours - 24 hours - 48 hours

- 48 hours Explanation: Morphine sulfate has an extended-release injectable medication that may administered via an epidural catheter and produce analgesia for up to 48 hours for acute pain management.

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain? - Diaphoresis - Bradycardia - Hypotension - Decreased respiratory rate

- Diaphoresis Explanation: Observe behavioral signs, e.g., facial expressions, crying, restlessness, diaphoresis (sweating), and changes in activity. A pain behavior in one patient may not be in another. Try to identify pain behaviors that are unique to the patient ("pain signature"). Increased heart rate, blood pressure, and respiratory rate would be more likely to be associated with pain rather than decreased levels of these measures.

The nurse's major area of assessment for a patient receiving patient-controlled analgesia is assessment of what system? - Cardiovascular - Integumentary - Neurologic - Respiratory

- Respiratory Explanation: Essential to the safe use of a basal rate with PCA is close monitoring by nurses of sedation and respiratory status and prompt decreases in opioid dose (e.g., discontinue basal rate) if increased sedation is detected (Pasero, Quinn et al., 2011).

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse? - "You are so brave to not take your pain medication when the dressing change will hurt." - "If you need pain relief, I can give you some medication when I have completed the dressing change." - "I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication." - "You are so right to not take your pain medication. You can become dependent on the medication."

- "I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication." Explanation: The nurse needs to explore the reason a client denies pain when pain is expected during a treatment, as with a dressing change to burns, and when the client grimaces during the dressing change. The nurse needs to educate clients about effects of pain on recovery. The nurse also cannot ignore that pain relief will hasten recovery. The nurse should not allow the client to associate pain with his dressing changes.

A client informs the nurse of having taken ibuprofen every 6 hours for 3 weeks to help alleviate the pain of arthritis. The client has a history of a gastric ulcer and is taking a proton pump inhibitor for the treatment of this disorder. What should the nurse instruct the client about the use of the ibuprofen? - "You should never take ibuprofen; it can cause considerable problems." - "Ibuprofen is contraindicated when taking a proton pump inhibitor." - "It would be best to contact the health care provider before taking any over-the-counter medications." - "Don't you know that you can cause bleeding when you take that medication so often?"

- "It would be best to contact the health care provider before taking any over-the-counter medications." Explanation: Clients should not use an over-the-counter analgesic agent, such as aspirin, ibuprofen, or acetaminophen, consistently to treat chronic pain without first consulting a physician. Ibuprofen is not contraindicated when taking a proton pump inhibitor. Asking "Don't you know that you can cause bleeding when you take that medication so often?" implies accusation and is not a therapeutic response.

The client is taking continuous-release oxycodone for chronic pain and now reports constipation. What should be the first question the nurse asks the client? - "What do you usually take for constipation?" - "When was your last bowel movement?" - "Can you take bisacodyl?" - "Are you able to increase fluids and fiber in your diet?"

- "When was your last bowel movement?" Explanation: Constipation is a common side effect of opioids. The nurse needs to assess the situation first before intervening. Asking about date of last bowel movement is most important. Once the history of constipation is completed, it would then be appropriate for the nurse to ask about effectiveness of past interventions and begin teaching about interventions, such as increasing fluids and fiber.

A nurse is caring for a client diagnosed with depression in the mental health unit. The nurse understands that therapeutic effects of tricyclic antidepressants occur at which time point? - 1 week - 2 weeks - 3 weeks - 4 weeks

- 3 weeks Explanation: Patients need to know that a therapeutic effect may not take effect until they have taken the medication for 3 weeks. The other time points are incorrect.

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission? - A child quickly removing a hand when touching a hot object - A surgeon making an incision to perform surgery - A mother in labor utilizing imagery to reduce pain - A patient taking tramadol to enhance pain management

- A child quickly removing a hand when touching a hot object Explanation: Transduction, the first process involved in nociception, refers to the processes by which a noxious stimulus, such as a burn, releases of a number of excitatory compounds, which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual-mechanism analgesic agent, such as tramadol, involves many different neurochemicals as in the process of modulation.

The nurse has assessed a client's pain subsequent to a broken ankle. How would the nurse categorize and document the client's pain? - Acute - Chronic - Intermittent - Visceral

- Acute Explanation: Acute pain is of early onset and associated with an injury. Pain decreases as healing occurs. Chronic pain is constant or intermittent and persists beyond the healing time.

Acute pain can be distinguished from chronic pain by assessing which characteristic? - Acute pain responds poorly to drug therapy. - Chronic pain diminishes with healing. - Acute pain is specific and localized. - Chronic pain is symptomatic of primary injury.

- Acute pain is specific and localized. Explanation: Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury.

The nurse is obtaining data regarding medications the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving? - Adjuvant drug therapy - Replacement drug therapy - Alternate drug therapy - Withdrawal therapy

- Adjuvant drug therapy Explanation: Adjuvant drugs are medications that are ordinarily administered for reasons other than treating pain. Duloxetine is used to treat depression but is being used for neuropathic pain for this client.

The nurse sees an order for a lidocaine 5% patch. What use is approved for by the US Food and Drug Administration for this patch? - postherpetic neuralgia - epidural anesthesia - general anesthesia - diabetic neuropathy

- postherpetic neuralgia Explanation: A lidocaine 5% patch has been shown to be effective in postherpetic neuralgia. Lidocaine 5% patch has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply. - "How long have you experienced this pain?" - "Please point to where you are experiencing pain." - "You've never had this pain before, have you?" - "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." - "What aggravates your chest pain?"

- "How long have you experienced this pain?" - "Please point to where you are experiencing pain." - "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." - "What aggravates your chest pain?" Explanation: The nurse needs to assess pain as to intensity, timing, location, and aggravating factors. Assessing frequency is important, but the statement "You've never had this pain before, have you" is leading and nontherapeutic.

When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose? - Confusion - Hyperalertness - Hyperventilation - Insomnia

- Confusion Explanation: Patients should be informed about signs and symptoms of fentanyl overdose such as shallow or difficulty breathing, extreme sleepiness, confusion, sedation. Hyperalertness, hyperventilation, and insomnia would not occur.

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced how often? - Every 12-24 hours - Every 24-36 hours - Every 36-60 hours - Every 48-72 hours

- Every 48-72 hours Explanation: Fentanyl patches should be replaced every 48-72 hours, depending on client response. The other time frames are incorrect.

A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing? - visceral - neuropathic - deeper somatic - chronic

- visceral Explanation: Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Visceral pain usually is diffuse, poorly localized, and accompanied by autonomic nervous system symptoms such as nausea, vomiting, pallor, hypotension, and sweating. Neuropathic pain is pain that is processed abnormally by the nervous system. Deeper somatic pain such as that caused by trauma produces localized sensations that are sharp, throbbing, and intense. Chronic pain has a duration longer than 6 months.

A physician orders morphine sulfate 1 mg IV stat for chest pain. The drug is available in 2 mg per 1 mL syringe. How many mL does the nurse administer?

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