Chapter 1 Pain Nurs 250

17. The nurse is considering seeking clarification for several prescriptions of pain medication. Which patient circumstance is the priority concern? 1. A 35-year-old opioid-naïve adult will receive a basal dose of morphine via IV patient-controlled analgesia. 2. A 65-year-old adult will be discharged with a prescription for nonsteroidal antiinflammatory drugs (NSAIDs). 3. A 25-year-old adult is prescribed as-needed intramuscular (IM) analgesic for pain 4. A 45-year-old adult is taking oral fluids and foods and has orders for IV morphine.

1. A 35-year-old opioid-naïve adult will receive a basal dose of morphine via IV patient-controlled analgesia. . Ans: 1 The nurse would consider questioning all of the medication prescriptions, but the opioid-naïve adult has the greatest immediate risk because use of a basal dose has been associated with an increased incidence of respiratory depression in opioid-naïve patients. Older adults are frequently prescribed NSAIDs; however, they are used with caution, and the patient's history should be reviewed for potential problems, such as a history of gastrointestinal bleeding, cardiac disease, or renal dysfunction. Many medications such as anticoagulants, oral hypoglycemics, diuretics, and antihypertensives can also cause adverse drug-drug interactions with NSAIDs. IM injections cause pain, absorption is unreliable, and there are no advantages over other routes of administration. If a patient is able to tolerate oral foods and fluids, oral medications are preferred because the efficacy of the oral route is equal to the IV route.

33. The nurse is working with a health care provider who prescribes opioid doses based on a specific pain intensity rating (dosing to the numbers). Which patient circumstance is cause for greatest concern? 1. A 73-year-old frail female patient with a history of chronic obstructive pulmonary disease is prescribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10. 2. A 25-year-old postoperative male patient with a history of opioid addiction is prescribed one tablet of oxycodone and acetaminophen for pain of 4 to 5 on a scale of 0 to 10. 3. A 33-year-old opioid-naïve female patient who has a severe migraine headache is prescribed 5 mg IV morphine for pain of 7 to 8 on a scale of 0 to 10. 4. A 60-year-old male with a history of rheumatoid arthritis is prescribed one tablet of hydromorphone for pain of 5 to 6 on scale of 0 to 10.

1. A 73-year-old frail female patient with a history of chronic obstructive pulmonary disease is prescribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10. Ans: 1 According to the American Society for Pain Management Nursing, prescribing opioid medication based solely on pain intensity should be prohibited because there are many other factors to consider (e.g., age, health conditions, medication history, respiratory status). Age, small body mass, and underlying respiratory disease put the 73-year-old patient at greatest risk for overmedication and respiratory depression. Patients with a history of opioid addiction will have a different response to medication and may need higher doses to achieve relief. IV morphine may actually worsen migraine headaches, and other first-line drugs (e.g., nonsteroidal antiinflammatory drugs, nonopioid analgesics, acetaminophen, sumatriptan, corticosteroids) are more effective. Hydromorphone is a potent opioid that is not typically prescribed for the pain associated with chronic rheumatoid arthritis.

10. According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, which pain management strategies are important for postsurgical patients? Select all that apply. 1. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the patient has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies 5. IV administration of opioids, rather than oral opioids, for postoperative analgesia 6. Pain specialists to manage the postoperative pain for all surgical patients

1. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the patient has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies Ans: 1, 2, 3, 4 The recommendations of the American Pain Society, in collaboration with the American Society of Anesthesiologists, for postoperative patients include: acetaminophen and/or NSAIDs if there are no contraindications; surgical site- specific peripheral regional anesthetic for procedures; neuraxial analgesia (also known as epidural analgesia) for major thoracic and abdominal procedures, if patient has risk for cardiac complications or prolonged ileus; and multimodal therapy, which includes use of different types of medications and other therapies. Oral opioids are preferred in the postoperative period. Pain specialists should be consulted if patients have inadequately controlled postoperative pain.

23. In the care of patients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (AP)? 1. Assisting the patient with preparation of a sitz bath 2. Monitoring the patient for signs of discomfort while ambulating 3. Coaching the patient to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress

1. Assisting the patient with preparation of a sitz bath The AP can assist the patient with hygiene issues and knows the principles of safety and comfort for the sitz bath. Monitoring the patient, teaching techniques, and evaluating outcomes are nursing responsibilities.

21. A patient is crying and grimacing but denies pain and refuses opioid medication because "my brother is a drug addict and has ruined our lives." Which intervention is the priority for this patient? 1. Encourage expression of fears and past experiences. 2. Respect the patient's wishes and use nonpharmacologic therapies. 3. Explain that addiction is unlikely when opioids are used for acute pain. 4. Seek family assistance to support the prescribed therapy.

1. Encourage expression of fears and past experiences. 21. Ans: 1 This patient has strong beliefs and emotions related to the issue of the brother's addiction. First, encourage expression. This indicates to the patient that the feelings are real and valid. Listening is respectful and increases the likelihood of compliance with prescribed therapies. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, and their beliefs about drug addiction may be similar to those of the patient.

27. According to recent guidelines from the Center for Disease Control and Prevention for prescribing/using opioid medication for chronic pain, which prescriptions would the nurse question because of the increased risk for opioid overdose? Select all that apply. 1. Extended-release/long-acting (ER/LA) transdermal fentanyl for a patient with fibromyalgia 2. Time-scheduled ER/LA oxycodone for a patient with chronic low back pain 3. As-needed (PRN) morphine for arthritis pain for an elderly patient with sleep apnea 4. 90 morphine milligram equivalents/day for a patient who has a hip fracture 5. ER/LA methadone PRN for a patient with headache pain 6. Patient-controlled analgesia (PCA) morphine for a patient with postsurgical abdominal pain

1. Extended-release/long-acting (ER/LA) transdermal fentanyl for a patient with fibromyalgia 2. Time-scheduled ER/LA oxycodone for a patient with chronic low back pain 3. As-needed (PRN) morphine for arthritis pain for an elderly patient with sleep apnea 4. 90 morphine milligram equivalents/day for a patient who has a hip fracture 5. ER/LA methadone PRN for a patient with headache pain Ans 1, 2, 3, 4, 5 In general, opioids are not the first-line choice for fibromyalgia, chronic low back pain, arthritis, or headache. There are other therapies that are safer for long-term use. ER/LA opioids increase the risk for overdose and are not recommended for chronic pain; time scheduling does not reduce the risk of harm. Age and sleep apnea increase the risk for respiratory depression. Morphine for hip fracture would be acceptable, but 90 morphine milligram equivalents would be considered a high dose, and high doses are associated with greater risk for overdose. Headaches are treated with nonsteroidal antiinflammatory drugs (NSAIDs), nonopioid analgesics, acetaminophen, caffeinated analgesic combinations (triptans, dihydroergotamine), anticonvulsants (e.g., valproate sodium and topiramate), or corticosteroids. Methadone is prescribed with caution because of the cardiotoxic effects. PCA morphine for postsurgical pain is common and acceptable because of the acute nature of the pain, the low dose, and the controlled delivery.

38. The patient is prescribed a fentanyl patch for persistent severe pain. Which patient behavior most urgently requires correction? 1. Frequently likes to sit in the hot tub to reduce joint stiffness 2. Prefers to place the patch only on the upper anterior chest wall 3. Saves and reuses the old patches when he can't afford new ones 4. Changes the patch every 4 days rather than the prescribed 72 hours

1. Frequently likes to sit in the hot tub to reduce joint stiffness Ans: 1 All of these behaviors require correction; however, heat can increase the release of medication from the patch and result in a sudden overdose. The patient should be urged to rotate sites to prevent irritation of the skin. Reusing old patches and delaying the patch changes are likely to give less than optimal pain relief. Based on assessment of behaviors, the nurse would reeducate about use of the patch, help the patient seek financial resources, or develop a reminder system for patch change intervals

8. A patient with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal antiinflammatory drugs. Which medication will the nurse advocate for first? 1. Gabapentin 2. Corticosteroids 3. Hydromorphone 4. Lorazepam

1. Gabapentin Ans: 1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be prescribed as an adjuvant medication.

42. Which instruction would the nurse give to the unlicensed assistive personnel (AP) related to the care of a patient who has received ketamine for analgesia? 1. Keep the environment calm and quiet. 2. Watch for and report respiratory depression. 3. Offer frequent sips of noncaffeinated fluids. 4. Keep the bed flat and frequently turn patient.

1. Keep the environment calm and quiet. Ans: 1 A calm and quiet environment helps to reduce the psychomimetic effects (e.g., hallucinations/delusions, anxiety). Other side effects of ketamine include nausea, vomiting, and headaches; therefore giving fluids, keeping the patient flat, and frequent turning would not be advised. Ketamine is not associated with respiratory depression or sedation.

13. The nurse is caring for a postoperative patient who reports pain. Based on recent evidence-based guidelines, which approach would be best? 1. Multimodal strategies 2. Standing orders by protocol 3. Intravenous patient-controlled analgesia (PCA) 4. Opioid dosage based on valid numerical scale

1. Multimodal strategies Ans: 1 Multimodal therapies for postoperative patients include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies. This approach is thought to be the most important strategy for pain management for most postoperative patients. Standing orders are less optimal because there is no consideration of individual needs or characteristics. PCA is one important element, but not all patients can manage PCA devices. Assessment tools are an important part of overall management, but basing opioid dose on a numerical scale does not consider individual patient circumstance

34. Which nursing action is the best example of the principle of nonmaleficence as an ethical consideration in pain management? 1. Patient seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication. 2. Patient has no known disease disorders and no objective signs of poor health or injury, but reports severe pain, so nurse advocates for pain medicine. 3. Patient is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages the patient to verbalize personal goals for pain management. 4. Patient repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication.

1. Patient seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication. Ans: 1 Nonmaleficence is to prevent harm. If the patient is excessively sedated, the nurse knows that giving additional opioid medication could do more harm than good, so the nurse would conduct further assessments and seek alternative options for pain relief. The patient's report of pain should be believed, so based on the principle of justice, the nurse advocates for pain medication even though an organic cause of disease is not identified. By encouraging the patient to have a voice in his or her own pain management goals, the nurse is applying the principle of autonomy. By explaining the benefits of pain medication, the nurse is applying the principle of beneficence to help the patient recognize the balance between pain control and safety

15. Which patients must be assigned to an experienced RN? Select all that apply. 1. Patient who was in an automobile crash and sustained multiple injuries 2. Patient with chronic back pain related to a workplace injury 3. Patient who has returned from surgery and has a chest tube in place 4. Patient with abdominal cramps related to food poisoning 5. Patient with a severe headache of unknown origin 6. Patient with chest pain who has a history of arteriosclerosis

1. Patient who was in an automobile crash and sustained multiple injuries 3. Patient who has returned from surgery and has a chest tube in place 5. Patient with a severe headache of unknown origin 6. Patient with chest pain who has a history of arteriosclerosis Ans: 1, 3, 5, 6 Patients with acute conditions that require close monitoring for complications should be assigned to an experienced RN. Abdominal cramps secondary to food poisoning is an acute condition; however, cramping, vomiting, and diarrhea are usually self-limiting. The patient with chronic back pain would be considered physically stable. Although all patients will benefit from care provided by an experienced RN, the patient with abdominal cramps and the patient with back pain could be assigned to a new RN, an LPN/LVN, or a float nurse

2. According to Centers for Disease Control and Prevention (CDC) guidelines for opioid use for patients with chronic pain, which actions are part of the nurse's responsibility related to the current opioid crisis? Select all that apply. 1. Recognize that negative attitudes toward substance abusers is a barrier to patient compliance. 2. Access electronic prescription drug monitoring program whenever patients receive an opioid prescription. 3. Learn to recognize the signs and symptoms of opioid overdose and the proper use of naloxone. 4. Use a tone of voice and facial expression that convey acceptance and understanding of patients who are addicted. 5. Report health care providers who fail to safely prescribe opioids according to the guidelines

1. Recognize that negative attitudes toward substance abusers is a barrier to patient compliance. 3. Learn to recognize the signs and symptoms of opioid overdose and the proper use of naloxone. 4. Use a tone of voice and facial expression that convey acceptance and understanding of patients who are addicted. Ans: 1, 3, 4 The widespread use of opioids and the increase in mortality and morbidity make it essential for nurses to recognize any personal negative bias and work toward conveying acceptance and understanding. This increases the likelihood of patient engagement and success in treatment programs. Learning about the signs and symptoms of an opioid overdose and the proper use of naloxone is also a nursing responsibility. Electronic prescription drug monitoring programs show promise but are not currently available nationwide and checking the database for all opioid prescriptions may be time-consuming and unnecessary (short-term opioid prescriptions for acute pain are less problematic). The nurse would question a health care provider if an opioid prescription did not seem safe; however, the CDC recommendations are not legally binding and deviations are not reportable.

9. When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the patient is pain free or an acceptable level is reached. 3. Titrate downward to prevent toxicity, overdose, and adverse effects. 4. Titrate to a dosage that is adequate to meet the patient's subjective needs.

1. Titrate to the smallest dose that provides relief with the fewest side effects. Ans: 1 The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside

30. A patient with pain disorder and depression has chronic low back pain. He states, "None of these doctors has done anything to help." Which patient statement is cause for greatest concern? 1. "I twisted my back last night, and now the pain is a lot worse." 2. "I'm so sick of this pain. I think I'm going to find a way to end it." 3. "Occasionally, I buy pain killers from a guy in my neighborhood." 4. "I'm going to sue you and the doctor; you aren't doing anything for me."

2. "I'm so sick of this pain. I think I'm going to find a way to end it." Ans: 2 This statement could be a veiled suicide threat, and patients with pain disorder and depression have a high risk for suicide. New injuries must be evaluated, but this type of pain report is not uncommon for patients with pain disorder. Risk for substance abuse is very high and should eventually be addressed. The patient can always threaten to sue, but the nurse must remain calm and continue to provide care with professional courtesy

19. A patient received as-needed morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel (AP) reports that the patient has a respiratory rate of 10 breaths/min. Which action is the priority? 1. Call the health care provider to obtain a prescription for naloxone. 2. Assess the patient's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20 breaths/min. 4. Double-check the prescription to see which drugs were prescribed.

2. Assess the patient's responsiveness and respiratory status. Ans: 2 The AP has correctly reported findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on assessment findings, the other options may also be appropriate.

16. Which postoperative patient is manifesting the most serious negative effect of inadequate pain management? 1. Demonstrates continuous use of call bell related to unsatisfied needs and discomfort 2. Develops venous thromboembolism because of immobility caused by pain and discomfort 3. Refuses to participate in physical therapy because of fear of pain caused by exercises 4. Feels depressed about loss of function and hopeless about getting relief from pain

2. Develops venous thromboembolism because of immobility caused by pain and discomfort Ans: 2 Inadequate pain management for postsurgical patients can affect quality of life, function, recovery, and postsurgical complication; thus all the manifestations are examples of negative results. Nevertheless, venous thromboembolism is the most serious because it can lead to pulmonary embolism, which is an immediate life-threatening concern. The nurse also needs to implement interventions to resolve unsatisfied needs, fear of pain, and hopelessness term-16related to pain and function

25. For a cognitively impaired patient who cannot accurately report pain, which action would the nurse take first? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Note the time of and patient's response to the last dose of analgesic. 4. Give the maximum as-needed dose within the minimum time frame for relief.

2. Obtain baseline behavioral indicators from family members. Ans: 2 Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff must rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.

35. The nurse is assessing a patient who has been receiving opioid medication via patient-controlled analgesia. Which early sign alerts the nurse to a possible adverse opioid reaction? 1. Patient reports shortness of breath. 2. Patient is more difficult to arouse. 3. Patient is more anxious and nervous. 4. Patient reports pain is worsening.

2. Patient is more difficult to arouse. Ans: 2 Most adverse opioid events are preceded by an increased level of sedation.

28. Which patients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply. 1. Anxious patient with chronic pain who frequently uses the call button 2. Patient on the second postoperative day who needs pain medication before dressing changes 3. Patient with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Patient with chronic pain who is to be discharged with a new surgically implanted catheter 5. Patient who is reporting pain at the site of a peripheral IV line 6. Patient with a kidney stone who needs frequent as-needed pain medication

2. Patient on the second postoperative day who needs pain medication before dressing changes 5. Patient who is reporting pain at the site of a peripheral IV line 6. Patient with a kidney stone who needs frequent as-needed pain medication Ans: 2, 5, 6 The patient who is on the second postoperative day, the patient who has pain at the IV site, and the patient with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious patient with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The patient with acquired immune deficiency syndrome has complex issues that require expert assessment skills. The patient pending discharge will need special and detailed instructions for the implanted catheter Test-Taking Tip: "Select all that apply" questions are particularly challenging. At least two options must be correct; it is likely that three or more are correct. Read each option carefully and try to exclude incorrect options

20. The patient is diagnosed with an acute migraine by the health care provider (HCP). For which situation is it most important to have a discussion with the HCP before medication is prescribed? 1. The HCP is considering dexamethasone, and the patient has type 2 diabetes. 2. The HCP is considering subcutaneous sumatriptan, and the patient took ergotamine 3 hours ago. 3. The HCP is considering valproate sodium, and the patient recently started birth control pills. 4. The HCP is considering prochlorperazine, and the patient drove himself to the hospital.

2. The HCP is considering subcutaneous sumatriptan, and the patient took ergotamine 3 hours ago. Ans: 2 The American Headache Society has guidelines for the treatment of acute migraines. Migraines may be treated with nonsteroidal anti-inflammatory drugs (including aspirin), nonopioid analgesics, acetaminophen, caffeinated analgesic combinations or migraine-specific agents (triptans, dihydroergotamine), corticosteroids, antiemetics, or anticonvulsants (e.g., valproate sodium and topiramate, except in women of childbearing age who are not using reliable birth control). Sumatriptan should not be used if ergotamine, dihydroergotamine, or another triptan medication has been used in the past 24 hours because of the additive effect of narrowing of the blood vessels that could result in damage to major organs (e.g., stroke or myocardial infarction). Thus it is most important for the nurse to have a conversation with the HCP about the sumatriptan. The other options are concerning but not to the same degree. Dexamethasone may cause increased glucose levels. If the patient recently started birth control pills, pregnancy should be ruled out before prescribing valproate sodium. Prochlorperazine can cause drowsiness

29. A patient's spouse comes to the nurse's station and says, "He needs more pain medicine. He is still having a lot of pain." Which response is best? 1. "The medication is prescribed to be given every 4 hours." 2. "If medication is given too frequently, there are ill effects." 3. "Please tell him that I will be right there to check on him." 4. "Let's wait 40 minutes. If he still hurts, I'll call the health care provider."

3. "Please tell him that I will be right there to check on him." Ans: 3 Responding to the patient and family in a timely fashion is important. Next, directly ask the patient about the pain and perform a complete pain assessment. This information will determine which action to take next.

32. The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a prescription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication. The patient begs, "Please don't stop the morphine. My pain is really a lot worse today than it was yesterday." Which response is best? 1. "Let me stop the pump; we can try oral pain medication to see if it gives relief." 2. "I realize that you are scared of the pain, but we must try to wean you off the pump." 3. "Show me where your pain is and describe how it feels compared with yesterday." 4. "Let's take your vital signs; then I will call the health care provider."

3. "Show me where your pain is and describe how it feels compared with yesterday." Ans: 3 Assessing the pain is the priority in this acute care setting because there is a risk of infection or hemorrhage. The other options might be appropriate based on the assessment findings

11. When a patient stoically abides with his parent's encouragement to "tough out the pain" rather than risk an addiction to opioids, the nurse recognizes that the sociocultural dimension of pain is the current priority for the patient. Which question will the nurse ask? 1. "Where is the pain located, and does it radiate to other parts of your body?" 2. "How would you describe the pain, and how is it affecting you?" 3. "What do you believe about pain medication and drug addiction?" 4. "How is the pain affecting your activity level and your ability to function?"

3. "What do you believe about pain medication and drug addiction?" Ans: 3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension.

37. For which of these patients is IV morphine the first-line choice for pain management? 1. A 33-year-old intrapartum patient needs pain relief for labor contractions. 2. A 24-year-old patient reports severe headache related to being hit in the head. 3. A 56-year-old patient reports breakthrough bone pain related to multiple myeloma. 4. A 73-year-old patient reports chronic pain associated with hip replacement surgery.

3. A 56-year-old patient reports breakthrough bone pain related to multiple myeloma. Ans: 3 The patient with cancer needs morphine for symptom relief. For obstetric patients, morphine can suppress fetal respiration and uterine contractions, so regional or epidural methods are preferred. For head injuries, morphine could make evaluation of mental status more difficult. In addition, if respirations are depressed, intracranial pressure could increase. Opioids are usually not the firstline choice for chronic pain, and opioids must be used with caution in older adult patients because of changes related to aging, such as renal clearance. In addition, use of opioids increases the risk for falls and contributes to constipation.

12. Which patient is most likely to receive opioids for extended periods of time? 1. A patient with fibromyalgia 2. A patient with phantom limb pain in the leg 3. A patient with progressive pancreatic cancer 4. A patient with trigeminal neuralgia

3. A patient with progressive pancreatic cancer Ans: 3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with non-opioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine. Phantom limb pain usually subsides after ambulation begins

22. A patient's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps

3. Diaphoresis Ans: 3 Diaphoresis is one of the early signs that occurs between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours after withdrawal Test-Taking Tip: In studying for the NCLEX®, pay attention to early signs of disease processes. Early detection is considered a safety measure; therefore NCLEX® tests to determine if you can perform early identification of potential problems.

40. For a postoperative patient, the health care provider (HCP) prescribed multimodal therapy, which includes acetaminophen, nonsteroidal antiinflammatory drugs, asneeded (PRN) opioids, and nonpharmaceutical interventions. The patient continuously asks for the PRN opioid, and the nurse suspects that the patient may have a drug abuse problem. Which action by the nurse is best? 1. Administer acetaminophen and spend extra time with the patient. 2. Explain that opioid medication is reserved for moderate to severe pain. 3. Give the opioid because the patient deserves relief and drug abuse is unconfirmed. 4. Ask the HCP to validate suspicions of drug abuse and alter the opioid prescription.

3. Give the opioid because the patient deserves relief and drug abuse is unconfirmed. Ans: 3 The nurse is weighing benefit against harm. If the patient is a drug abuser, the medication given in the hospital is not harming him. If the patient is not a drug abuser, then withholding the medication causes him to suffer pain because of unconfirmed suspicions. Administration of correctly prescribed opioids does not cause addiction, and for patients who are addicted, withholding medication in the hospital setting does not resolve the addictive behavior

36. The charge nurse of a long-term care facility is reviewing the methods and assessment tools that are being used to assess the residents' pain. Which nurse is using the best method to assess pain? 1. Nurse A uses a behavioral assessment tool when the resident is engaged in activities. 2. Nurse B asks a resident who doesn't speak English to point to the location of pain. 3. Nurse C uses the same numerical rating scale every day for the same resident. 4. Nurse D asks the daughter of a confused patient to describe the resident's pain.

3. Nurse C uses the same numerical rating scale every day for the same resident. . Ans: 3 Pain assessment is very complex, but the consistent use of the same assessment tool is the best method. All tools are used in conjunction with observation, self-report, and other assessment skills. When a person is engaged in an activity, behavior may not accurately reflect pain. Asking someone to point to the pain is only one part of the total pain assessment. Relatives of confused residents can assist the nurse to recognize the meaning of behaviors, but they are not able to describe pain sensations for the resident

18. Which patient has the most immediate need for IV access to deliver analgesia with rapid titration? 1. Patient who has sharp chest pain that increases with cough and shortness of breath 2. Patient who reports excruciating lower back pain with hematuria 3. Patient who is having an acute myocardial infarction with severe chest pain 4. Patient who is having a severe migraine with an elevated blood pressure

3. Patient who is having an acute myocardial infarction with severe chest pain Ans: 3 The patient with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain and increase venous capacitance. The other patients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent.

1. Based on the principles of pain treatment, which consideration comes first? 1. Treatment is based on patient goals. 2. A multidisciplinary approach is needed. 3. Patient's perception of pain must be accepted. 4. Drug side effects must be prevented and managed.

3. Patient's perception of pain must be accepted. Ans: 3 The patient must be believed, and his or her experience of pain must be acknowledged as valid. The data gathered via patient reports can then be applied to the other options in developing the treatment plan. Focus: Prioritization; QSEN: PCC; Concept: Pain; Cognitive Level: Applying.

39. The home health nurse discovers that an older adult patient has been sharing his pain medication with his daughter. He acknowledges the dangers of sharing, but states, "My daughter can't afford to see a doctor or buy medicine, so I must give her a few of my pain pills." Which member of the health care team would the nurse consult first? 1. Health care provider to renew the prescription so that the patient has enough medicine 2. Pharmacist to monitor the frequency of the prescription refills 3. Social worker to help the family locate resources for health care 4. Home health aide to watch for inappropriate medication usage by family

3. Social worker to help the family locate resources for health care Ans: 3 If the social worker can help the family to find affordable alternatives, then the father is more likely to stop giving his medication to the daughter

4. The team is providing emergency care to a patient who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

4. Applying oxygen per nasal cannula as ordered Ans: 4 The LPN/LVN is well trained to administer oxygen per nasal cannula. This patient is considered unstable; therefore the RN should take responsibility for administering drugs and monitoring the response to therapy, which includes the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy.

5. What is the best way to schedule medication for a patient with constant pain? 1. As needed at the patient's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around-the-clock

4. Around-the-clock Ans: 4 If the pain is constant, the best schedule is around-the-clock to provide steady analgesia and pain control. The other options may require higher dosages to achieve control.

41. An inexperienced new nurse compares the medication administration record (MAR) and the health care provider's (HCP's) prescription for a patient who has a patient controlled analgesia (PCA) pump for pain management. Both the MAR and prescription indicate that larger doses are prescribed at night compared with doses throughout the day. Who would the new nurse consult first? 1. Ask the patient if he typically needs extra medication in the evening. 2. Ask the HCP to verify that the larger amount is the correct dose. 3. Ask the pharmacist to confirm the dosage on the original prescription. 4. Ask the charge nurse if this is a typical dosage for nighttime PCA.

4. Ask the charge nurse if this is a typical dosage for nighttime PCA. Ans: 4 The nurse has taken the first correct step and compared the MAR to the HCP's original prescription. Because the nurse is new, the charge nurse would be the best resource. In fact, larger PCA doses are given at night to increase the interval between doses. This helps the patient to rest and sleep. The nurse can contact the other members of the health care team at any time if the charge nurse is unable to help

3. On the first day after surgery, a patient who is on a patient-controlled analgesia pump reports that the pain control is inadequate. Which action would the nurse take first? 1. Deliver the bolus dose per standing order. 2. Contact the health care provider (HCP) to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity.

4. Assess the pain for location, quality, and intensity. Ans: 4 Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps. Taking Tip: During clinical rotations, you may observe nurses giving pain medication without performing an adequate pain assessment. This is an error in clinical performance. In postoperative patients, pain could signal complications, such as hemorrhage, infection, or decreased perfusion related to tissue swelling. Always assess pain first, then make a decision about giving medication, using nonpharmacologic methods, or contacting the HCP.

24. The health care provider (HCP) prescribed a placebo for a patient with chronic pain. The newly hired nurse feels very uncomfortable administering a placebo. Which action would the new nurse take first? 1. Prepare the prescribed placebo and hand it to the HCP. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice and suggestions.

4. Contact the charge nurse for advice and suggestions. Ans: 4 Administering placebos is generally considered unethical. (There are circumstances, such as clinical drug research, where placebos are used, but patients are aware of that possibility.) The charge nurse is a resource person who can help clarify the situation and locate and review the hospital policy. If the HCP is insistent, suggest that he or she could give the placebo. Although following a personal ethical code is correct, the nurse must ensure that the patient is not abandoned and that care continues.

14. A newly graduated RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for documenting dose and time and discuss documentation deficits.

4. Give praise for documenting dose and time and discuss documentation deficits. Ans: 4 When supervising a new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching does not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists

26. A patient with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action? 1. Check the medication administration records for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the patient and take a pain history. 4. Have a conference with the staff nurses to assess their care of this patient.

4. Have a conference with the staff nurses to assess their care of this patient. Ans: 4 The charge nurse must assess the performance and attitude of the staff in relation to this patient. After data are gathered from the nurses, additional information can be obtained from the records and the patient as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem Test-Taking Tip: The first step of the nursing process is assessment. In this case, the charge nurse applies the nursing process to assess the nursing staff's performance and attitudes.

7. The home health nurse is interviewing an older patient with a history of rheumatoid arthritis who reports "feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed." Which member of the health care team would be notified to aid in the patient's pain? 1. Health care provider to review the dosage and frequency of pain medication 2. Physical therapist for evaluation of function and possible exercise therapy 3. Social worker to locate community resources for complementary therapy 4. Home health aide to help patient with a warm shower in the morning

4. Home health aide to help patient with a warm shower in the morning Ans: 4 One of the common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A nonpharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions.

31. A patient has severe pain and bladder distention related to urinary retention and possible obstruction; insertion of an indwelling catheter is prescribed. An experienced unlicensed assistive personnel (AP) states that she is trained to do this procedure. Which task can be delegated to this AP? 1. Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a specimen

4. Measuring the urine output after the catheter is inserted and obtaining a specimen Ans: 4 Measuring output and obtaining a specimen are within the scope of practice of the AP. Insertion of the indwelling catheter in this patient should be done by an experienced RN because patients with obstruction and retention are usually very difficult to catheterize, and the nurse must evaluate the pain response during the procedure. The AP's knowledge of sterile technique or catheter insertion is not the issue

6. Which patient is at greatest risk for respiratory depression when receiving opioids for analgesia? 1. Older adult patient with chronic pain related to joint immobility 2. Patient with a heroin addiction and back pain 3. Young female patient with advanced multiple myeloma 4. Opioid-naïve adolescent with an arm fracture and cystic fibrosis

4. Opioid-naïve adolescent with an arm fracture and cystic fibrosis Ans: 4 At greatest risk are older adult patients, opioid-naïve patients, and those with underlying pulmonary disease. The adolescent has two of the three risk factors.