PP1 Pain EAQ

Which methods qualify as alternative therapies for pain? **Select all that apply** - Prayer - Hypnosis - Medication - Aromatherapy - Guided imagery

- Prayer - Hypnosis - Aromatherapy - Guided imagery

After interacting with a client, the nurse thinks that client is in the prodromal phase of a migraine. Which statements made by the client led the nurse to reach this conclusion? **Select all that apply** - "I feel drowsy all the time" - "I feel severe pain over my ear" - "I feel a throbbing pain in my head" - "I feel confused at this point in time" - "I feel weakness in the left side of my body"

- "I feel drowsy all the time" - "I feel confused at this point in time" - "I feel weakness in the left side of my body"

Twenty-four hours after receiving spinal anesthesia during childbirth, a client tells the nurse she has a headache. Which statement indicates the nurse that the headache is a reaction to anesthesia? **Select all that apply** - "My ears are ringing" - "It gets better when I lie down" - "Bright lights really bother my eyes" - "It gets better as soon as a walk a while" - "My head hurts more when I'm sitting watching television" - "My head hurts more when I'm lying on my side breast-feeding"

- "My ears are ringing" - "It gets better when I lie down" - "Bright lights really bother my eyes" - "My head hurts more when I'm sitting watching television"

Which information would the nurse include in the client's medication teaching on the administration of aspirin 650mg every 6 hours as needed for arthritic pain? **Select all that apply** - "Report persistent abdominal pain" - " Do not chew enteric-coated tablets" - " Take the aspirin with meals or a snack" - " See a dentist if bleeding gums develop" - "Switch to acetaminophen if tinnitus occurs"

- "Report persistent abdominal pain" - " Do not chew enteric-coated tablets" - " Take the aspirin with meals or a snack"

Which assessment finding of a client with chronic pain who has been prescribed opioid treatment includes the need for a priority nursing intervention? **Select all that apply** - Pruritus - Constipation - Level 3 sedation - Nausea and vomiting - Respiratory rate of 8 breaths per minute

- Level 3 sedation - Respiratory rate of 8 breaths per minute

Which therapeutic outcome is expected after administering ibuprofen? **Select all that apply** - Diuresis - Pain relief - Temperature reduction - Bronchodilation - Anticoagulation - Reduced inflammation

- Pain relief - Temperature reduction - Reduced inflammation

Which nursing interventions would the nurse implement for a child undergoing treatment with opioid analgesics? **Select all that apply** - Assessing the child's level of pain - Administering oral medications with meals or snacks - Assessing the child's verbal and nonverbal behaviors - Documenting the child's age, weight, and height before treatment - Monitoring and documenting the child's vital signs before the start of therapy

- Assessing the child's level of pain - Administering oral medications with meals or snacks - Assessing the child's verbal and nonverbal behaviors - Documenting the child's age, weight, and height before treatment

Which benefit would be provided by administering patient-controlled analgesia (PCA) to a client after surgery? **Select all that apply** - Client is able to self administer pain-relieving medications as necessary - Amount of mediation received is determined by the client - Decreases client dependency - Relieves the nurse fo monitoring the client - Increases client sense of autonomy

- Client is able to self administer pain-relieving medications as necessary - Decreases client dependency - Increases client sense of autonomy

Which action is the nurse's responsibility when administering prescribed opioid analgesics? **Select all that apply** - Count the client's respirations - Document the intensity of the client's pain - Withhold the medication if the client reports pruritus - Verify the number of doses in the locked cabinet before administering the prescribed dose - Discard the medication in the client's toilet before leaving the room if the medication is refused

- Count the client's respirations - Document the intensity of the client's pain - Verify the number of doses in the locked cabinet before administering the prescribed dose

Which action would the nurse take before administering each dose in a client who takes oxycodone every 3 hours for pain after surgery? **Select all that apply** - Count the client's respiratory rate - Examine the client for petechiae - Observe the client for movement disorders - Ask the client to rate the level of pain - Assess the client's level of consciousness

- Count the client's respiratory rate - Ask the client to rate the level of pain - Assess the client's level of consciousness

Which factors would the nurse consider when administering opioids to a child with severe pain? **Select all that apply** - Diet modification - Dosing calculations - Body mass index - Appropriate dosage form - Presence of other symptoms

- Dosing calculations - Appropriate dosage form - Presence of other symptoms

Which nursing concern is a priority when a 6-year-old child with sickle cell disease is admitted with a vasoocclusive crisis (pain episode) **Select all that apply** - Nutrition - Hydration - Pain management - Prevention of infection - Oxygen supplementation

- Hydration - Pain management - Oxygen supplementation

An adolescent is admitted with partial-and full-thickness burns of the arms and upper torso. Which are the primary purposes of administering pain mediation via the intravenous route, rather than the intramuscular route? **Select all that apply** - Adolescents are afraid of injections - It decreases the risk of tissue irritation - Severe pain is reduced more effectively - Impaired peripheral circulation is bypassed - It provides for more prolonged relief of pain

- It decreases the risk of tissue irritation - Severe pain is reduced more effectively - Impaired peripheral circulation is bypassed

A child is administered fentanyl during outpatient surgery. The nurse understands which criteria must be met before the child can be discharged? **Select all that apply** - The child is alert and active - The child's pain is at baseline levels - The child's body temperature is 102F (38.9C) - The child's vital signs have remained stable - The child's oxygen saturation is 65% on room air

- The child is alert and active - The child's pain is at baseline levels - The child's vital signs have remained stable

After undergoing minor surgery, a postoperative child has recovered from anesthesia. Which observation alter the nurse the child may be ready for discharge? **Select all that apply** - Vital signs are stable - Temperature is 101F/38C - Pain rate is at baseline level - The child is alert and oriented - Oxygen saturation is 75% on room air

- Vital signs are stable - Pain rate is at baseline level - The child is alert and oriented

When providing comfort to a client during the last hours of life, which would be the nurse's primary concern? **Select all that apply** - Pain - Nutrition - Elimination - Respiratory status - Cardiovascular status

- pain - respiratory status

The nurse is caring for a child with an exacerbation of leukemia. The nurse would plan to administer the prescribed analgesic for bone pain at which time? A. At scheduled intervals B. When the child asks for it C. When pain becomes severe D. Before the pain becomes severe

A. at scheduled intervals

A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature 101F (38.3C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, which clinical finding is a primary nursing concern for this client? A. Acute pain B. Inadequate nutrition C. Electrolyte imbalance D. Distributed self-concept

A. Acute pain

Which intervention would the nurse incorporate into the plan of care for older adult experiencing chronic pain? A. Exercise B. Distractions C. Heat therapy D. Trigger point massage

A. Exercise

The nurse understands which anesthetic medication is commonly used for short procedures on pediatric clients? A. Fentanyl B. Morphine C. Meperidine D. Hydromorphone

A. Fentanyl

After obtaining vital sign data of blood pressure 90/60 mmHg, pulse 96 beats/minute, and respiratory rate 10 breaths/minute for a postoperative client receiving hydromorphone by a patient-controlled analgesia (PCA) pump, which priority action would the nurse take? A. Give naloxone intravenously per protocol B. Assess the client's pain level on a 10-point scale C. Document the vital signs in the client record D. Notify the hospital rapid response team

A. Give naloxone intravenously per protocol

After an amputation of a limb, a client reports extreme discomfort in the area where the limb once was. Which goal would the nurse plan to focus interventions? A. Identifying actions to decrease pain in the lost limb B. Reversing feelings of hopelessness about the future C. Promoting mobility in the residual limb D. Facilitating the grieving process for the lost limb

A. Identifying actions to decrease pain in the lost limb

A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take? A. Instruct the client to splint the wound with a pillow when coughing B. Place the client in the supine position and inspect the site of the incision C. Assess the intensity of the pain and administer the prescribed analgesic D. Notify the health care provider immediately and then check for wound dehiscence

A. Instruct the client to splint the wound with a pillow when coughing

Which pain relief medication would the nurse expect to find in the plan of care of a client with a myocardial infraction admitted to the cardiac intensive care unit? A. Morphine B. Diazepam C. Midazolam D. Oxycodone

A. Morphine

Six hours after major abdominal surgery, a client reports severe abdominal pain and faintness. The nurse identifies a thready, rapid pulse. The nurse checks the medication administration record (MAR) and determines that the client can receive another injection of pain medication in an hour. Which action would the nurse take? A. Notify the health care provider about the client's symptoms B. Explain to the client that it is too early to have an injection for pain C. Reposition the client for greater comfort and turn on the television as a distraction D. Prepare the injection to administer it to the client early because of the severe pain

A. Notify the health care provider about the client's symptoms

Which nursing action is beneficial for the client who has pain due to muscle spasm? A. Providing heat compresses at the site B. Providing a massage to the affected area C. Encouraging the client to perform isometirc exercises D. Encouraging the client to do active range-of-motion (ROM) exercises

A. Providing heat compresses at the site

Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline? A. Remove the IV catheter and restart the saline lock in another site B. Document the findings per protocol and reassess the site in 8 hours C. Flush the IV catheter and saline lock again vigorously with normal saline D. Change the dressing and apply a new clean dressing per IV care protocol

A. Remove the IV catheter and restart the saline lock in another site

Which intervention is the priority nursing care for a client in the coronary care unit who develops "viselike" chest pain radiating to the neck with a blood pressure of 124/64 mmHg, an irregular apical pulse of 64 beats per minutes, and diaphoresis who is prescribed morphine sulfate 4mg intravenous (IV) push stat and cardiac monitoring? A. Relief of pain B. Client teaching C. Cardiac monitoring D. Maintenance of bed rest

A. relief of pain

A client with a known history of opioid addiction has a surgical repair of multiple stab wounds to the abdomen. After surgery, the client's pain is not relieved by the prescribed morphine injections. Which phenomenon is the client experiencing when they fail to achieve pain relief? A. Tolerance B. Habituation C. Physical addiction D. Psychological dependence

A. tolerance

Which situation would the nurse address FIRST according to Maslow's hierarchy? A. Has history of being injured from sudden falls B. Complains of sleeplessness due to pain postsurgery C. Reports that they feel lonely and socially isolated D. Conveys to the nurse that they want to become the manager of the company

B. Complains of sleeplessness due to pain postsurgery

Which is the most reliable indicator of a 2.5-year-old child's pain? A. Crying and sobbing B. Changes in behavior C. Verbal exclamations of pain D. Changes in pulse and respiratory rate

B. Changes in behavior

At which time would the nurse plane to administer morphine 2mg by mouth every 2 hours as needed to a client who has burns on 55% of the body surface and requires dressing changes? A. 15 minutes before the dressing change B. 60 minutes before the dressing change C. Along with a stool softener each time it is administered D. Only if the client rates pain between 8 and 10 on the pain scale

B. 60 minutes before the dressing change

The nurse completes an admission assessment of a child with sickle cell anemia who is experiencing a painful vasco-occlusive crisis. Which nursing action would be a priority for the nurse to implement. A. Provide oxygen therapy B. Administer an analgesic C. Initiate a blood transfusion D. Monitor intravenous fluids

B. Administer an analgesic

Which client would be triaged under emergency severity index (ESI)-1 based on threat to life and stability of vital functions? A. Chest pain results from ischemia B. Cardiac arrest C. Simple laceration D. Hip fracture

B. Cardiac arrest

Which physiological response will occur if a client being treated for myocardial infarction experiences the intended therapeutic effect of morphine? A. Increased respiratory rate B. Decreased workload of the heart C. Dilation of coronary arteries D. Diminished metabolites within the ischemic heart muscle

B. Decreased workload of the heart

Which action would the nurse take when caring for a client using a patient-controlled analgesia (PCA) pump who identifies attempts to self-administer the analgesic 10 times because the client is still experiencing pain? A. Monitor the client's pain level for another hour B. Determine the integrity of the intravenous delivery system C. Reprogram the pump to deliver a bolus dose every 8 minutes D. Arrange for the client to be evaluated by the health care provider

B. Determine the integrity of the intravenous delivery system

Which action would the nurse take while giving an injection to a preschooler? A. Ask the parent to restrain the child B. Distract the child with conversation C. Avoid awakening the child if sleep D. Avoid using lidocaine ointment over the injection site

B. Distract the child with conversation

Which route would a nurse expect to administer morphine sulfate prescrbed for pain in a client admitted to the ER with burns to the anterior trunk, entire right arm, and anterior left arm? A. Orally B. Intravenously C. Subcutaneously D. Intramuscularly

B. Intravenously (preferred route for a client with impaired peripheral circulation)

Which action would be taken by a nurse when caring for a client prescribed transdermal fentanyl 25mcg/h every 72 hours during the first 24 hours after starting the fentanyl? A. Titrate the dose until pain is tolerable B. Manage pain with an analgesic by a different route C. Assess the client for anticholinergic side effects D. Instruct the client to take the medication with food

B. Manage pain with an analgesic by a different route

An adolescent client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. Which action would the nurse implement? A. Turning on the television for diversion B. Placing the prescribed as-needed warm, wet compress on the elbow C. Calling the primary health care provider for another analgesic prescription D. Informing the client gently that they must wait until the pump reactivates to get more medication

B. Placing the prescribed as-needed warm, wet compress on the elbow

Which factor would the nurse recognize as a cause of neck pain in a client? A. Headache B. Poor posture C. Low body weight D. Sedentary lifestyle

B. Poor posture

Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain? A. Ambulation B. Repositioning C. Purse-lipped breathing D. Deep breathing and coughing

B. Repositioning

Which conclusion would the nurse make regarding the client's response to pain medication when a client using a pain scale of 1 to 10 rates the pain as an 8 before receiving an analgesic and a 7 after being medicated? A. The client has a low pain tolerance B. The medication is not adequately effective C. The medication has sufficiently decreased the pain level D. The client needs more education about the use of the pain scale

B. The medication is not adequately effective

The primary nurse, leaving the unit for lunch, provides a verbal report for the covering nurse. The report included one client's prescription for morphine: 2mg intravenously (IV) every 3 hours for abdominal pain secondary to major abdominal surgery that morning. During the primary nurse's lunch, the client complains of pain at a level 8 out of 10 on the pain scale. Which action would the covering nurse perform first? A. Determine the documented time of the last administration of pain medication B. Verify that the written prescription matches the administration record C. Encourage nonpharmacological measures initially to relieve the pain D. Explain that the primary nurse will be back from lunch in a few minutes

B. Verify that the written prescription matches the administration order

A school-aged child with end-stage cancer has a continuous infusion of morphine to manage their pain. Breakthrough pain occurs and a fentanyl "lollipop" is prescribed. Which instruction would the nurse give the child regarding the use of the lollipop when pain occurs? A. "Chew it and then swallow every 4 hours" B. "Suck of it for half an hour every 6 hours" C. "Hold it in your cheek only until the pain is relieved" D. "Place it in your mouth and suck on it until it dissolves"

C. "Hold it in your cheek only until the pain is relieved"

Which response would the nurse give to a client newly diagnosed with multiple sclerosis who asks the nurse, "Will I experience pain?" A. "Tell me about your fears regarding pain" B. "Analgesics will be prescribed to control the pain" C. "Pain is not a characteristic symptom of this condition" D. "Let's make a list of things to ask your primary health care provider"

C. "Pain is not a characteristic symptom of this condition"

Which response by the nurse asked "How will they 'knock me out' for this colonoscopy?" described the route of administration for conscious sedation? A. "The medicine will be injected into your spine" B. "You will receive the anesthesia through a face mask" C. "You will receive medication through an intravenous (IV) catheter" D. "We will give you an oral medication about 1 hour before the procedure"

C. "You will receive medication through an intravenous (IV) catheter"

Which pain description would the nurse expect a client to report when describing pain associated with a suspected duodenal peptic ulcer? A. An ache radiating to McBurney point B. An intermittent, colicky right-flank pain C. A gnawing sensation in the epigastric area D. A generalized abdominal pain intensified by movement

C. A gnawing sensation in the epigastric area

A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? A. Maintain the settings programmed by the health care provider B. Turn the machine on several times a day for 10 to 20 minutes C. Adjust the dial on the unit until the client states that the pain is relieved D. Apply the color-coded electrodes on the client where they are most comfortable

C. Adjust the dial on the unit until the client states that the pain is relieved

Which order would the nurse identify as a priority nursing action after reviewing the prescriptions for the newly admitted ER client with urolithiasis? A. Strain the client's urine B. Place the client in the high-Flower position C. Administer the prescribed morphine D. Collect a urine specimen for culture and sensitivity

C. Administer the prescribed morphine

Which action would the nurse take FIRST for a postsurgical client who is still intubated but becoming restless, with an increased pulse rate and blood pressure, when it has been 4 hours since the last dose of pain medications? A. Notify the provider B. Perform a full physical assessment C. Administer the prescribed pain medication D. Play soft, relaxing music to help calm the client

C. Administer the prescribed pain medication

Which property would the nurse understand that the medication is being used primarily for when aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis? A. Analgesics B. Antipyretic C. Anti-inflammatory D. Antiplatelet

C. Anti-inflammatory

A client has been receiving oxycodone for moderate pain associated with multiple injuries sustained in a motor vehicle collision. Which assessment finding, in addition to the client's slurred speech, leads the nurse to suspect opioid intoxication? A. Mood liability B. Hypervigilance C. Constricted pupils D. Increased respirators

C. Constricted pupils

The nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun to care for the client. Which is the best nursing intervention in preparing for the client's discharge? A. Contact the client's health care provider to ask to substitute a liquid form of medications for the pill form B. Teach the client and family members to crush the pills and administer them with applesauce C. Contact the client's health care provider to discuss use of transdermal medications for pain control D. Teach the client and family members about addiction that may occur as a result of regular opioid use

C. Contact the client's health care provider to discuss use of transdermal medications for pain control

A child is experiencing pain after abdominal surgery and is given an opioid analgesic. Which statement is correct regarding children in pain and their response to opioid analgesics when they are prescribed? A. Addiction to opioids is more of a risk for children than adults B. Analgesics are not needed as frequently because pain is not as strongly felt by children as it is by adults C. Even though children do not like taking medicines, analgesics will make them more comfortable D. Children do not need analgesics because they are easily distracted and will quickly return to play or sleep

C. Even though children do not like taking medicines, analgesics will make them more comfortable

A client with a history of osteoporosis and vertebral compression has been coming to the clinic more frequently for prescription refills of hydrocodone/acetaminophen. Which inference will the nurse make? A. The half-life of the medication has decreased B. An idiosyncratic reaction has occurred C. Higher doses are needed to achieve pain relief D. An emotional dependence on the medication has developed

C. Higher doses are needed to achieve pain relief

Which mode of medication administration is preferred for a client with deep partial-thickness burns who is receiving an opioid for pain management? A. Oral B. Rectal C. Intravenous D. Intramuscular

C. Intravenous

The nurse is planning the discharge of a 9-year-old child who has undergone tonsillectomy. In addition to the prescribed analgesic, which would the nurse recommend the parent use to ease their child's pain? A. Warm saline gargles B. Heating pad to the neck C. Light-colored ice pops D. Peppermint candy for sucking

C. Light-colored ice pops

For which involuntary physiologic response would the nurse monitor for development in a client experiencing pain? A. Crying B. Splinting C. Perspiring D. Grimacing

C. Perspiring

Which group of clients who were in a bus accident and admitted to the ER with injuries is considered urgent according to the three-tier triage system? A. Sprains B. Simple fractures C. Severe abdominal pain D. Chest pain with diaphoresis

C. Severe abdominal pain

An adolescent client has orders for morphine sulfate for severe pain and acetaminophen-codeine compound for moderate pain after a spinal fusion. The pain assessment reveals the client is rigid and crying in pain. Which information would influence the nurse's choice of analgesic? A. One dose of morphine may be given, but the drug should be restricted thereafter because it is addictive B. Adolescents tend to exaggerate their discomfort, particularly when they are immobilized by surgery or injury C. Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic D. The acetaminophen-codeine compound is preferred because morphine can cause respiratory depression or respiratory arrest

C. Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic

Which intervention is useful in promoting comfort for the client experiencing a headache? A. Massage B. Heat therapy C. Cold therapy D. Relaxation strategies

C. cold therapy

In which time frame would the nurse advise a client with a long leg cast for a fractured bone to take the prescribed as-needed oxycodone? A. Just as a last resort B. Before going to sleep C. As the pain becomes intense D. When the discomfort begins

D. When the discomfort begins

Which consideration is the nurse's concern when responding to the request of a hospice client who has severe pain and asks for another dose of oxycodone? A. Prevent addiction B. Determine why the medication is needed C. Provide alternative comfort measures D. Reduce the client's pain

D. reduce the client's pain

The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explains the analgesic properties of cold therapy? A. Promotes analgesia and circulation B. Numbs the nerves and dilates the blood vessels C. Promotes circulation and reduces muscle spasms D. Causes local vasoconstriction, preventing edema and muscle spasms

D. Causes local vasoconstriction, preventing edema and muscle spasms

Which recommendation would the nurse give to the client with trigeminal neuralgia? A. Drink iced liquids B. Avoid oral hygiene C. Apply warm compresses D. Chew on the unaffected side

D. Chew on the unaffected side

According to the nursing process, which action would the nurse take after administering pain medication to a postoperative client? A. Administer nonpharmacological comfort measures B. Inform the health care provider of the nursing action C. Create a care plan that addresses the client's pain level D. Determine whether the pain medicine relieved the client's pain

D. Determine whether the pain medicine relieved the client's pain

Assessment findings of a client who is admitted to the ER include cramping pain in the left lower quadrant, weakness, bloating, malaise, and a low-grade fever. The nurse suspects which condition? A. Pancreatitis B. Appendicitis C. Cholecystitis D. Diverticulitis

D. Diverticulitis

Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? A. Listening B. Spiritual caring C. Providing presence D. Relieving pain and suffering

D. Relieving pain and suffering

After orthopedic surgery, an adolescent reports pain and rates it a 5 on a scale of 0 to 10. The nurse administers the prescribed 5mg of oxycodone every 3 hours as needed. Two hours after having been given this medication, the adolescent reports pain and rates it a 10 of 10. Which action would the nurse take? A. Administer another dose of oxycodone within 30 minutes B. Report the adolescent's apparent idiosyncratic reaction to oxycodone C. Tell the adolescent that additional medication cannot be given for 1 more hour D. Request that the primary health care provider evaluate the need for additional medication

D. Request that the primary health care provider evaluate the need for additional medication

When, during the first 24 hours postoperatively, will analgesics be administered to a client who undergoes an abdominal cholecystectomy for gangrene of the gallbladder? A. If repositioning is ineffective B. When the pain becomes severe C. In gradually increasing dosages D. As prescribed by the health care provider

D. As prescribed by the health care provider