Ch.35 Comfort & Pain Management

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.

Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take?

Reposition the client and gently massage the client's back.

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

Respiratory

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

CRIES Pain Scale

When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should:

actively solicit information about the client's pain level.

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?

modulation

A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?

the client's pain based on a pain rating

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?

A chronic opioid therapy plan Opioids are not contraindicated in older adults but are rarely used in chronic pain prior to nonpharmacologic measures.

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action?

Avoid massaging this area and report the finding to the health care provider.

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?

Guarding of the chest area

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.)

Heat Massage Pressure

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

Naloxone

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered?

PRN order

Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?

Pain assessment may require multiple methods in order to ensure accurate pain data.

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?

Preventing constipation

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first?

Stop the PCA pump.

When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation, scoring a 4 on the Pasero & McCaffery Sedation Scale. What is the nurse's best action?

Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and naloxone.

An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug?

The client exhibits restless, uncharacteristic behavior after receiving the drug.

A student nurse is preparing a presentation on pain management. What information regarding nonpharmacologic interventions should he include? Select all that apply.

Use cold packs for muscle spasms and surgical site pain. Ice packs should not be left on longer than 20 minutes. Massage can stimulate circulation. Distraction is useful for short pain periods.

The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client?

Use massage and heat application to the lower back

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating?

1

The nurse is reviewing relaxation techniques with the client who has chronic back pain that radiates to the legs. What information does the nurse include?

Close your eyes while practicing the relaxation exercises. Closing the eyes will help the client focus on relaxation and not be distracted by visual cues. The client should assume a comfortable position. This may be in a chair or a bed. A straight back wood chair is unlikely to allow the client to assume a comfortable position that would promote relaxation. The client takes deep abdominal breaths, not shallow breaths; this promotes relaxation. The client would tighten and relax muscles, starting with the toes and working up towards the head.

The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action is an example of this type of intervention?

Closing the client's room door to reduce unnecessary noises

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?

Examine the effectiveness of the current pain regimen

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?

increased blood pressure

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?

"Can you describe the type of pain you are having?"

The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain?

"How long have you experienced this pain?"

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body." The client needs further instruction when they say they can use the TENS unit on other areas of the body. Such a statement would indicate that the client does not understand that the unit should be used as prescribed by the physician in the location defined by the physician. The TENS unit will decrease the amount of the pain medication used by the client as it increases the blood supply to the injured area and will not interfere with the activities of daily living.

The nurse has completed a preoperative teaching session with a client who will receive morphine via a patient-controlled analgesia (PCA) pump after surgery. Which statement by the client indicates the need for further teaching?

"I will remind my family member to push the PCA pump button for me if I doze off during the day." Sedation occurs before clinically significant respiratory depression. Thus, if the client is too sleepy to push the button (or ask that it be pushed), the button should not be pushed. The other answers are all correct.

Two hours after receiving a pain medication, the client reports still suffering from pain. Which response is most appropriate?

"Tell me more about your pain."

Which client would be the best candidate to receive epidural analgesia for pain management?

A client recovering from recent hip replacement surgery Epidural analgesia is being used more commonly to provide pain relief during the immediate postoperative phase and for chronic pain situations. Epidural pain management is also being used in children with terminal cancer and children undergoing hip, spinal, or lower-extremity surgery. Pain that is less severe or pain with an acute onset is not normally treated in this way. A brain tumor may or may not have manifestations that require an epidural analgesia.

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?

A client who has a sprained ankle

Which medical client is most likely to be experiencing diffuse pain?

A client with shingles affecting her entire torso

The nurse is caring for a client with chronic back pain due to inoperable spinal stenosis. Which strategies, suggested by the nurse, may help to decrease the client's back pain?

Adding the use of hot or cold packs for pain control Chronic, inoperable back pain is difficult to manage. Treatment response is individual. Adding hot or cold packs with other measures, such as anti-inflammatory agents, may help to reduce pain. Opioids should be avoided due to the tendency of developing tolerance over time, as well as addiction. Getting a surgical consultation may be helpful but will not help with the acute pain that the client is experiencing. Bed rest alone may worsen back symptoms.

A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action?

Administer naloxone Naloxone is an opioid antagonist that reverses the respiratory depressant effects of opioids. If stimulation is ineffective in arousing a client using opioids, naloxone can be used. When the client is alert and the respiratory rate is greater than 9 breaths/min, the opioids may be resumed. A code blue is not appropriate, as there is no indication that the client is without pulse or respiration. However, being prepared for this action is necessary. The nurse will contact the health care provider but first needs to take action to prevent further deterioration of the client's condition. The family must be notified but the most pressing matter is the care of the client.

The nurse manager hears a nurse and a nurse aide talking about a female client who reports pain of 8 out of 10 on a 1-10 scale after a Caesarean birth to deliver twins. The nurse states, "I don't believe this client has any pain at all. I'm sure she is just drug seeking." What is the appropriate nurse manager action?

Ask the nurse to speak privately for a moment, and educate about bias in pain treatment.

The nurse is performing assessments for an assigned client. Which methods are appropriate ways for the nurse to gather objective data related to a client's pain? Select all that apply.

By checking the vital signs By observing facial expressions By diagnostic tests and procedures

The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply.

Do not drive a vehicle while taking this medication. You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken.

How should the nurse position the head of the bed for a client receiving epidural opioids?

Elevated 30 degrees The nurse should position the head of the bed so that it is elevated 30 degrees unless contraindicated. Elevation of the client's head minimizes upward migration of the opioid in the spinal cord, thereby decreasing the risk for respiratory depression. The Trendelenburg position is when the feet are higher than the head. Reverse Trendelenburg position or supine position is when the head is higher than the feet.

Evelyn is a 90-year-old woman who just returned from the operating room to your medical unit. She is otherwise healthy and has a history of some mild arthritis. As you examine Evelyn, you know that all of the following are signs of pain EXCEPT which?

Elevated kidney function Kidney function would be temporarily suppressed by acute pain.

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress?

The nurse is caring for client prescribed morphine who is experiencing constipation. What intervention should the nurse recommend to the client? (Select all that apply.)

Increased fluids Increased fiber Stool softener Most side effects of morphine disappear with prolonged use, but if constipation persists, it usually responds to increased fluids and fiber and use of a mild laxative or stool softener. Increased protein will not help the client's constipation. An enema is not indicated at this time.

The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client?

Intractable

The nurse recognizes which statement is true of chronic pain?

It may cause depression in clients.

A nurse is assessing the pain of a client who has been diagnosed with a sprained ankle. The client describes the pain as aching and is able to identify the pain as occurring in his left ankle. The nurse identifies this as which type of pain?

Somatic

A PCA has been ordered for a client who is experiencing significant postoperative pain. To minimize the risk of adverse effects of this therapy, the nurse should perform what action?

Teach the client to perform deep-breathing and coughing exercises. While using PCA, the nurse should encourage the client to practice coughing and deep breathing to promote ventilation and prevent pooling of secretions. Compression stockings are not necessary, since PCA is not associated with an increased risk of venous thromboembolism. Changes to food and fluid intake are not warranted.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?

The client is actively involved in pain management.

A nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique?

The nurse gives the client a massage before bed.

The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate?

They bind to opioid receptor sites throughout the CNS.

A 5-year-old client reports abdominal pain. Which action(s) will the nurse take to assess the pain? Select all that apply.

Use the Wong-Baker FACES pain rating scale. Observe the client. Ask the client to describe the pain.

You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so?

When obtaining patient vital signs

At 1930 the client reports experiencing neuropathic pain in the legs. The client has a history of neuropathic pain following chemotherapy. The client describes the pain as burning and rates the pain as a 7 on the pain scale of 1 to 10. Based on the client's medication orders (above), which medication would the nurse administer to the client for a report of pain?

acetaminophen/codeine 1 tablet

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

biofeedback.

The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?

confused to time and place

Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy?

gabapentin

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client:

in the postoperative stage with occasional pain.

A client comes to the facility reporting acute pain. When assessing the client, the nurse understands that moderate, superficial acute pain can result in which sympathetic physiologic response(s)? Select all that apply.

increased blood pressure increased pulse increased respiratory rate

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Gate Control Theory?

providing temple massage when head hurts

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

referred pain

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?

reviewing and revising the pain management treatment plan

A nurse is caring for a client whose injured cells are releasing chemicals such as prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?

transduction

The nurse is caring for a client who has come to the emergency department reporting chest pain rated at 9 on a scale of 1 to 10. The pain shoots down the left arm and started 45 minutes ago. How will the nurse document this pain in the electronic health record? Select all that apply.

visceral referred acute

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing?

visceral pain

When asking an older adult client about abdominal pain, the client reports, "I don't want to be a bother because nothing hurts too much." The nurse notes that the client grimaces and splints the abdomen when moving. What is the appropriate nursing action?

Gently mention that the client appears to be experiencing pain that can be treated.

When implementing the gate-control theory of pain, which intervention will enhance the closing of the gate to the client's pain?

Give the client a back rub.

In which client would a back massage be contraindicated?

Client who has a fractured rib

The nurse is caring for a client who reports muscular and joint pain after an ankle sprain when playing soccer last week. How will the nurse document this type of pain? Select all that apply.

somatic acute

The client is a new admission who reports lower right quadrant abdominal pain. The client is scheduled for an emergency appendectomy. What question(s) will the nurse ask the client in relation to the pain? Select all that apply.

How do you rate your pain on a scale of 0 to 10? Does anything make the pain worse? How would you describe the pain? When did your pain begin? What medication have you taken to relieve the pain?

A 77-year-old woman is on the nurse's unit s/p left knee replacement. The client typically stools every morning but has not had a bowel movement in 3 days. The nurse knows that which medication places the client at increased risk for constipation?

Hydromorphone

A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse?

Administer the medication if respiratory rate is > 9.

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?

Assess for medication prescription for breakthrough pain.

The nurse is caring for a client who frequently comes to the emergency department (ED) reporting a headache that is an 8 or 9 on a pain scale of 1 to 10. The client is noted to be laughing while on the phone and chatting with staff after reporting a headache that is a 10. Which action will the nurse perform prior to initiating treatment?

Assess for nonverbal cues to pain

When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response?

Behavioral

A client is receiving opioid analgesia for pain control. The nurse is assessing the client for possible respiratory depression. Which method would be most reliable for the nurse to use to identify impending respiratory depression?

Capnography End tidal CO2 is considered a highly reliable measure of the quality of ventilation and, unlike pulse oximetry, is an early indicator of impending respiratory depression. Although respiratory rate and lungs sounds help evaluate the client's respiratory status, they are not reliable indicators of impending respiratory depression.

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

Cutaneous stimulation

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant?

FLACC scale

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

Endorphins

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

stool softeners and increased fluid intake The most common side effect of opioid use is constipation. Consequently, stool softeners and increased fluid intake may be indicated. Opioids may cause respiratory depression, but this fact in and of itself does not create a need for oxygen supplementation or chest physiotherapy. The use of opioids does not create a need for calorie restriction, supplements, frequent turns, or the use of skin emollients.

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?

"I should only take medication when my pain is intense." PCA pumps allow the client to control the amount and timing of pain medication by pushing a button when the sensation of pain occurs versus waiting until the pain becomes intense. The pump is programmed with a lockout period that limits the chance of clients overmedicating themselves.

What will the nurse place at the bedside of a client receiving epidural analgesia?

Ampule of 0.4 mg naloxone At the bedside of a client receiving epidural analgesia, the nurse should ensure that an ampule of 0.4 mg naloxone and a syringe are present. This medication reverses the respiratory depressing effects of opioids when needed and should be readily available. Epidural analgesia does not usually affect the neurotransmitter epinephrine and, therefore, is not needed at the bedside. A chest drainage system and a bottle of sterile saline would be at the bedside of a client with a chest tube but is not indicated for epidural analgesia.

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.

The nurse is assessing a client who is experiencing pain. The nurse notes the client is experiencing acute rather than chronic pain when the client makes which statement?

"The pain is really sharp in this one spot."

The nurse is providing instructions to a client who has been prescribed a patient-controlled analgesia (PCA) pump postoperatively. The nurse will include which information in the client's instructions? Select all that apply.

"You should be the only person pressing the button on this device." "The device is set up to deliver a predetermined dose each time you press the button." "You will be asked to rate your pain frequently to reassess your need for this device." "You will hear a bell sound when the infuser delivers the medication."

The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief?

Acknowledge the pain as the client reports it and administer pain medication as prescribed

The demonstration provided by the nurse is directed at helping the postsurgical client manage what type of pain?

Deep somatic

The nurse is performing an assessment for a client related to pain. To determine the need for pain medication, on what primary source will the nurse base the decision?

verbal report

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:

visceral pain.

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?

"The pump is programmed with safeguards to limit the possibility overmedication."

After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?

3

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety?

Administering an oral dose of morphine to treat the client's breakthrough pain It is unsafe to administer opioids or adjuvant drugs without the approval of the clinician responsible for the epidural injection. Suppositories, abdominal palpation, and feeding are not contraindicated when the client has an epidural in place.

A nurse observes a client that had a hysterectomy crying hysterically. What type of pain response is this client experiencing?

Affective

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.)

Encourage deep breathing. Play the client's favorite music. Promote a restful environment. Anxiety, lack of sleep, and muscle tension may all increase the client's perceived intensity of pain. Therefore, the client's plan of care should include measures to promote sleep and decrease anxiety and muscle tension. These include relaxation techniques, such as deep breathing, favorite music, and restful environment. Use of a sitter, someone to be paid to stay with the client in the room at all times, is not indicated and may cause the client's anxiety level to increase. Encouraging increased protein does not aid in the client's perceived intensity of pain.

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment?

Respiratory status, oxygen saturation, pain, and sedation level

The nurse is providing care to multiple clients. During which client interaction(s) will the nurse ask about the level of pain the client is experiencing? Select all that apply.

The nurse is completing the admission database with a newly admitted client. The nurse is assisting a client to a supine position following a lumbar puncture. The nurse is making rounds and taking a client's vital signs at the scheduled time. The nurse waits 30 minutes to evaluate response to an oral pain medication. Five minutes is not adequate or sufficient time for an oral medication to be absorbed and metabolized.