LEWIS : Chapter 10: Pain
19. A patient with cancer-related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? a. Administer the prescribed PRN immediate-acting morphine. b. Suggest the use of alternative therapies such as heat or cold. c. Utilize distraction by talking about things the patient enjoys. d. Consult with the doctor about increasing the MS Contin dose.
a. Administer the prescribed PRN immediate-acting morphine. The patient's pain requires rapid treatment and the nurse should administer the immediate-acting morphine. Increasing the MS Contin dose and use of alternative therapies also may be needed, but the initial action should be to use the prescribed analgesic medications.
21. A patient who is using a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? a. Remove the fentanyl patch. b. Notify the health care provider. c. Continue to monitor the patient's status. d.Give the prescribed PRN naloxone (Narcan).
a. Remove the fentanyl patch. The assessment data indicate possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring also are needed, but the patient's data indicate that more rapid action is needed.
14. A patient who uses extended-release morphine sulfate (MS Contin) for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone (Vicodin) tablets, but the patient is asleep when the nurse returns with the medication. Which action is best for the nurse to take? a. Wake the patient and administer the hydrocodone. b. Wait until the patient wakes up and reassess the pain. c. Consult with the health care provider about changing the MS Contin dose. d. Suggest the use of nondrug therapies for pain relief instead of additional opioids.
a. Wake the patient and administer the hydrocodone. Since patients with chronic pain frequently use withdrawal and decreased activity as coping mechanisms for pain, the patient's sleep is not an indicator that she is pain free. The nurse should wake the patient and administer the hydrocodone.
18. A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic pain complains of nausea and abdominal fullness. The best initial action by the nurse is to a. administer the ordered antiemetic medication. b. tell the patient that the nausea will subside in about a week. c. order the patient a clear liquid diet until the nausea decreases. d. consult with the health care provider about using a different opioid
a. administer the ordered antiemetic medication. Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics usually are prescribed to treat this expected side effect. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops and the nausea will subside in about a week, it is not appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea, but the best choice would be to administer the antiemetic medication and allow the patient to eat.
5. A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse's reply is based on the information that these strategies a. impact the cognitive and affective components of pain. b. increase the modulating effect of the efferent pathways. c. prevent transmission of nociceptive stimuli to the cortex. d. slow the release of transmitter chemicals in the dorsal horn.
a. impact the cognitive and affective components of pain. Cognitive therapies impact on the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn.
1. When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient's pain? a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How much medication do you take for the pain?" d."How many times a day do you medicate for pain?"
b. "How would you describe your pain?" Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain is likely to elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning "How would you describe your pain?" is the best initial question.
20. Which nursing action should the nurse delegate to nursing assistive personnel (NAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? a. Assess the skin under the heating pad. b. Check the respiratory rate every 2 hours. c. Monitor sedation using the sedation assessment scale. d. Ask the patient about whether pain control is effective.
b. Check the respiratory rate every 2 hours. Obtaining the respiratory rate is included in NAP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice.
13. The nurse is caring for a diabetic patient who has chronic burning leg pain even when taking oxycodone (OxyContin) twice daily. Which of these prescribed medications is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain? a. aspirin (Ecotrin) b. celecoxib (Celebrex) c. amitriptyline (Elavil) d. acetaminophen (Tylenol)
c. amitriptyline (Elavil) The patient's pain symptoms are consistent with neuropathic pain and the tricyclic antidepressants are effective for treating this type of pain. The other medications are more effective for nociceptive pain.
1. The health care provider plans to titrate a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which of the following nursing actions regarding opioid administration are appropriate at this time (select all that apply)? a. Assessing for signs that the patient is becoming addicted to the opioid b. Monitoring for therapeutic and adverse effects of opioid administration c. Emphasizing that the risk of some opioid side effects increases over time d. Educating the patient about how analgesics improve postoperative activity level e. Teaching about the need to decrease opioid doses by the second postoperative day
b. Monitoring for therapeutic and adverse effects of opioid administration d. Educating the patient about how analgesics improve postoperative activity level Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain. Although postoperative patients usually need decreasing amount of opioids by the second postoperative day, each patient's response is individual. Tolerance may occur, but addiction to opioids will not develop in the acute postoperative period. The patient should use the opioids to achieve adequate pain control, and so the nurse should not emphasize the adverse effects.
16. The nurse assesses a postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). Which information is most important to report to the health care provider? a. The patient complains of nausea after eating. b. The patient's respiratory rate is 10 breaths/minute. c. The patient has not had a bowel movement for 3 days. d. The patient has a distended bladder and has not voided.
b. The patient's respiratory rate is 10 breaths/minute. The patient's respiratory rate indicates a need to decrease the PCA dose or change the medication in order to avoid further respiratory depression. The other information also may require intervention, but is not as urgent to report as the respiratory rate.
8. A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. The most appropriate action by the nurse is to a. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. consult with the health care provider about using a different treatment protocol to control the patient's pain. c. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.
b. consult with the health care provider about using a different treatment protocol to control the patient's pain. PCAs are best for controlling acute pain; this patient's history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.
15. These medications are prescribed by the health care provider for a patient who uses long-acting morphine (MS Contin) for chronic back pain, but still has ongoing pain. Which medication should the nurse question? a. morphine (Roxanol) b. pentazocine (Talwin) c. celecoxib (Celebrex) d. dexamethasone (Decadron)
b. pentazocine (Talwin) Opioid agonist-antagonists can precipitate withdrawal if used in a patient who is physically dependent on mu agonist drugs such as morphine. The other medications are appropriate for the patient.
9. When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication? a. The patient has cramping abdominal pain. b. The patient becomes restless and agitated. c. The patient has not voided for over 10 hours. d. The patient complains of a "pounding" headache.
c. The patient has not voided for over 10 hours. Urinary retention is a common side effect of epidural opioids. Headache is not an anticipated side effect of morphine, although if there is a cerebrospinal fluid leak, the patient may develop a "spinal" headache. Sedation (rather than restlessness or agitation) would be a possible side effect. Hypotonic bowel sounds and constipation (rather than abdominal cramping) are concerns.
12. Which of these prescribed therapies should the nurse use first when caring for a patient with cancer pain that the patient describes as at "level 8 (0 to 10 scale), deep, and aching." a. fentanyl (Duragesic) patch b. ketorolac (Toradol) tablets c. hydromorphone (Dilaudid) IV d. acetaminophen (Tylenol) suppository
c. hydromorphone (Dilaudid) IV The patient's pain level indicates that a rapidly-acting medication such as an IV opioid is needed. The other medications also may be appropriate to use, but will not work as rapidly or as effectively as the IV hydromorphone.
3. A postoperative patient asks the nurse how the prescribed ibuprofen (Motrin) will control the incisional pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the a. modulating effect of descending nerves. b. sensitivity of the brain to painful stimuli. c. production of pain-sensitizing chemicals. d. spinal cord transmission of pain impulses.
c. production of pain-sensitizing chemicals. Nonsteroidal anti-inflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by the NSAIDs.
7. A patient with chronic back pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Can you describe the quality of your pain?" b. "Has there been a change in the pain location?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does the pain keep you from doing things you enjoy?"
d. "Does the pain keep you from doing things you enjoy?" The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions also are appropriate to ask, but information about patient function is more useful in evaluating effectiveness.
4. A patient with chronic cancer pain is receiving imipramine (Tofranil) in addition to long-acting morphine for pain control. Which information is the best indicator that the imipramine is effective? a. The patient sleeps 8 hours every night. b. The patient has no symptoms of anxiety. c. The patient states, "I feel much less depressed since I've been taking the imipramine." d. The patient states, "The pain is manageable, and I can accomplish my desired activities.
d. The patient states, "The pain is manageable, and I can accomplish my desired activities. Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication also is prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level.
17. A patient who has chronic musculoskeletal pain tells the nurse, "I feel depressed because I ache too much to play golf." The patient says the pain is usually at a level 7 (0 to 10 scale). Which patient goal has the highest priority when the nurse is developing the treatment plan? a. The patient will exhibit fewer signs of depression. b. The patient will say that the aching has decreased. c. The patient will state that pain is at a level 2 of 10. d. The patient will be able to play 1 to 2 rounds of golf.
d. The patient will be able to play 1 to 2 rounds of golf. For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse also should assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play 1 or 2 rounds of golf is the most appropriate.
10. When the nurse visits a hospice patient, the patient has a respiratory rate of 8 breaths/minute and complains of severe pain. Which action is best for the nurse to take? a Inform the patient that increasing the morphine will cause the respiratory drive to fail. b. Administer a nonopioid analgesic, such as a nonsteroidal anti-inflammatory drug (NSAID), to improve patient pain control. c. Tell the patient that additional morphine can be administered when the respirations are 12. d. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.
d. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief. The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient's respiratory rate.
22. These medications are ordered for an 86-year-old patient with arthritis in both hips who is complaining of level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse use as initial therapy? a. aspirin (Bayer) 650 mg orally b. naproxen (Aleve) 200 mg orally c. oxycodone (Roxicodone) 5 mg orally d. acetaminophen (Tylenol) 650 mg orally
d. acetaminophen (Tylenol) 650 mg orally Acetaminophen is the best first-choice medication. The principle of "start low, go slow" is used to guide therapy when treating elderly adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Nonopioid analgesics are used first for mild to moderate pain, although opioids may be used later. Aspirin and the NSAIDs are associated with a high incidence of gastrointestinal bleeding in elderly patients.
6. A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which of these prescribed medications will be best for the nurse to administer? a. lorazepam (Ativan) 1 mg orally b. amitriptyline (Elavil) 10 mg orally c. ibuprofen (Motrin) 400 to 800 mg orally d. immediate-release morphine 30 mg orally
d. immediate-release morphine 30 mg orally The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. The Motrin and Elavil may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of anti-anxiety agents for pain control is inappropriate because this patient's anxiety is caused by the pain.
11. A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patient's home medications, which of these will be of most concern to the admitting nurse? a. amitriptyline (Elavil) 50 mg at bedtime b. oxycodone (OxyContin) 80 mg twice daily c. ibuprofen (Advil) 800 mg 3 times daily d. meperidine (Demerol) 25 mg every 4 hours
d. meperidine (Demerol) 25 mg every 4 hours Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management.
2. A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." The nurse will document this as a. somatic pain. b. referred pain. c. neuropathic pain. d.breakthrough pain.
d.breakthrough pain. Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.