Chapter 9 Pain

An important nursing responsibility related to pain is to a. leave the patient alone to rest b. help the patient appear to not be in a pain c. believe what the patient says about the pain d. assume responsibility for eliminating the patient's pain

.Correct answer: c Rationale: Pain is a subjective experience, and patients need to feel confident that the nurse will believe their reports of pain.

Which assessment is of highest priority for the nurse to complete before administration of morphine? A. Pain rating B. Blood pressure C. Respiratory rate D. Level of consciousness

C A decreased respiratory rate below 12/min is a sign of opioid toxicity. Using the ABC approach in prioritization of care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine.

An example of distraction to provide pain relief is a. TENS b. music c. exercise d. biofeedback

Correct answer: b Rationale: Distraction involves redirection of attention away from the pain and to something else. Distraction can be achieved by engaging the patient in any activity that can hold his or her attention (e.g., watching TV or a movie, conversing, listening to music, playing a game).

Appropriate nonopijoid analgesic for mild pain include (SATA) a. oxycodone b. ibuprofen(advil) c. lorazepam (ativan) d. acetaminophen (Tylenol) e. codeine w/ acetaminophen(Tylenol #3)

Correct answers: b, d Rationale: Nonopioid analgesics include acetaminophen, aspirin and other salicylates, and nonsteroidal antiinflammatory drugs (NSAIDs).

A patient who has been treated with morphine by patient-controlled analgesia (PCA) is discharged from the hospital with instructions that all of the following medications may be used for pain. Which medication will the nurse instruct the patient to use first? 1. Aspirin 2. Ibuprofen (Motrin, Advil) 3. Acetaminophen (Tylenol) 4. Oxycodone/acetaminophen (Percocet)

4. Oxycodone/acetaminophen (Percocet)

Which nursing intervention is most appropriate when preparing to administer an opioid analgesic agent? a. Give the medication on an empty stomach. b. Count the number of doses on hand before administration. c. Give the medication with a glass of juice or other cold beverage. d. Assess the patient for allergies to aspirin before administration.

B Because opioid analgesics are controlled substances, the nurse needs to count the number of doses and check that it matches the number recorded before removing and administering the medication.

The nurse is caring for a patient who is receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication? a. Pain rating 3/10, awake and alert, respirations 24 b. Pain rating 2/10, awake and alert, respirations 18 c. Pain rating 2/10, drowsy but arousable, respirations 18 d. Pain rating 1/10, drowsy but arousable, respirations 16

B Effective pain management is achieved when there is adequate pain control (rating of 3 or less on a scale of 0 to 10) with normal respirations and an absence of sedation. These data exhibit the best effectiveness of the pain medication in all of these areas.

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient (select all that apply)? a. Ataxia b. Itching c. Nausea d. Urinary retention e. Gastrointestinal bleeding

B, C, D Common side effects of intraspinal opioids include nausea, itching, and urinary retention. Ataxia is a common side effect of intraspinal clonidine.

Put these in order of use: aspirin (Bayer), naproxen (Aleve), oxycodone (Roxicodone), acetaminophen (Tylenol).

Tylenol Aspirin Aleve Oxycodone

A patient with osteoarthritis has been taking ibuprofen (Advil) 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge? a. Another NSAID may be indicated because of individual variations in response to drug therapy. b. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. c. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. d. The patient is probably not compliant with the drug therapy, and therefore the nurse must initially assess the patient's knowledge base and initiate appropriate teaching.

A Patients vary in their response to medications so when one NSAID does not provide relief, another should be tried. There is no evidence to ascertain any noncompliance to drug therapy.

When planning care for a 76-year-old patient with chronic low back pain and severe cervical arthritis, the nurse recognizes that chronic pain in the older adult: 1. Is better tolerated than in younger patients. 2.Is often seen as an inevitable part of aging. 3. Does not require the use of opioids for pain control. 4. Is poorly tolerated because of past experiences with pain.

2.Is often seen as an inevitable part of aging.

The nurse should question an order written for Percocet for a patient exhibiting which clinical manifestation? a. Severe jaundice b. Oral candidiasis c. Increased urine output d. Elevated blood glucose

A Acetaminophen and oxycodone are the ingredients in Percocet. Because acetaminophen is metabolized in the liver, the patient could develop acetaminophen toxicity in the presence of severe liver disease (evidenced by jaundice). The prudent nurse would question the order before administration.

A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication? a. Diarrhea b. Agitation c. Constipation d. Urinary incontinence

C Morphine sulfate is an opioid analgesic that can lead to constipation as a side effect, and tolerance to opioid-induced constipation does not develop. It is very important to use measures, such as increased fiber and fluids in the diet, and exercise when possible, to prevent this side effect. A gentle stimulant laxative plus a stool softener are also frequently needed to prevent constipation in a patient who is likely to develop this side effect.

A cancer patient who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes is a. probably exaggerating his pain b. best treated by referral for surgical treatment of his pain c. best treated by receiving both long-acting and short-acting opioid d.best treated by regular scheduled short-acting opioids plus acetaminophen

Correct answer: c Rationale: Moderate to severe pain usually necessitates an opioid analgesic. Constant, moderate pain is treated with a long-acting opioid; procedural severe pain is treated with a short-acting opioid.

Pain is best described as A. a creation of a person's imagination B. an unpleasant, subjective experience C. a maladaptive response to stimulus D. a neurologic event resulting from activation of nociceptors

1. Correct answer: b Rationale: The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."

The nurse's role in analgesic titration for a postoperative patient is: 1. Monitoring the effects of continuous infusion of opioid analgesics. 2. Determining with the patient the dosage of analgesic required for pain relief. 3. Teaching the patient to try to increase the time between doses of pain medication. 4. Assisting the patient to plan the distribution of a specific total dose of analgesic over a 24-hour period.

2.Titration is a dose adjustment based on assessment based on the adequacy of analgesic effect vs the S/E produced. E.g post op pts the dose pf analgesic generally decreases over time as the acute pain resolves vs Opioids for chronic, severe cancer pain may be titrated upward. GOAL of titration: is to use smallest dose of analgesic that provides effective pain control w/the fewest S/E.

The registered nurse (RN) is caring for patients on a surgical unit. Which tasks may the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Administer oral pain medications to a patient after abdominal surgery. B. Teach the patient how to use patient-controlled analgesia after surgery. C. Determine strategies for pain management as part of a patient's discharge plan. D. Evaluate whether the pain management plan is providing adequate pain control.

A An LPN/LVN may administer ordered pain medications, but depending on the state nurse practice act and agency policy, the LPN/LVN may not be able to administer medication by all routes. The tasks of teaching, evaluation, and discharge planning are within the scope of practice of an RN.

Before administering celecoxib (Celebrex), the nurse will assess the patient's medical record for which medication that would increase the risk of adverse effects? A. Aspirin B. Scopolamine C. Theophylline D. Acetaminophen

A Celecoxib is a nonsteroidal antiinflammatory drug (NSAID) of the cyclooxygenase-2 (COX-2) inhibitor type. Although celecoxib does not inhibit COX-1 and thus has a decreased risk of bleeding, bleeding is still of concern as an adverse effect. For this reason, the drug should not be taken with other drugs that increase risk of bleeding, such as aspirin.

A postoperative patient has an order to receive morphine sulfate 4 mg IM every 3 to 4 hours prn for pain. On hand are prefilled syringes labeled morphine sulfate 10 mg/mL. How many milliliters should the nurse administer? a. 0.4 mL b. 0.55 mL c. 0.6 mL d. 0.75 mL

A Dose (mg) ÷ availability (mg/mL) = mL to administer. Therefore, 4 mg ÷ 10 mg/mL = 0.4 mL.

Which patient is most at risk for respiratory depression related to opioid administration for pain relief? A. 82-year-old patient who had abdominal surgery 4 hours ago B. 24-year-old patient who had a vaginal delivery 12 hours ago C. 32-year-old patient with chronic neuropathic pain for 6 months D. 20-year-old patient with a closed reduction of a fractured right arm

A Patients most at risk for respiratory depression include those who are older, have underlying lung disease, have a history of sleep apnea, or are receiving other central nervous system depressants. For postoperative patients the greatest risk is in the first 24 hours after surgery. Respiratory depression related to opioid administration is higher in hospitalized patients who are opioid naïve.

The nurse should teach a patient to avoid which medication while taking ibuprofen? a. Aspirin b. Furosemide (Lasix) c. Nitroglycerin (Nitro-Bid) d. Morphine sulfate (generic)

A The patient should not take aspirin while taking ibuprofen because the combination could increase the risk of GI bleeding.

The nurse is developing a treatment regimen for an active 78-year-old woman who has osteoarthritis with chronic joint pain. Which modality would be the safest for this patient? A. Regular exercise program and acetaminophen as needed B. High-dose opioids titrated to reach an acceptable pain level C. Placebo to reduce the risk of adverse medication side effects D. Regularly scheduled doses of nonsteroidal antiinflammatory drugs

A Treatment regimens for older adults should include nondrug modalities such as exercise. Acetaminophen should be used whenever possible instead of nonsteroidal antiinflammatory drugs that have a high incidence of serious GI bleeding when used in older adults. In older adults, opioids should be initiated at low doses and titrated upward while monitoring carefully for side effects. The use of placebos in clinical practice to assess or treat pain outside of the situation of informed consent in research studies is unethical.

To reduce the risk of adverse effects, what should the nurse do when caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA)? a. Instruct the patient not to push the button too frequently. b. Teach the caregiver not to push the button for the patient. c. Ask the patient to do deep breathing exercises every hour. d. Administer medications to prevent the occurrence of diarrhea.

B It is important to teach the caregiver not to push the button for the patient because it is only the patient who can determine the need for the medication. If the caregiver pushes the button, the patient could receive more of a dose than is actually needed, and this increases the risk of adverse effects.

After administering acetaminophen and oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room? A. Leave the overbed light on at low setting. B. Ensure that the upper two side rails are raised. C. Offer to turn on the television to provide distraction. D. Ensure that documentation of intake and output is accurate.

B Percocet has acetaminophen and oxycodone as ingredients. Since the medication contains an opioid analgesic with sedative properties, the nurse must ensure patient safety before leaving the room, such as leaving the top two bedrails raised. This will help prevent the patient from falling from bed, while not restraining the patient (as four side rails would do). Leaving the light or television on will not provide a positive environment for healing sleep.

A nurse is reviewing the assessment data from the admission assessment of a 62-year-old male patient admitted from the emergency department. What specific element of a pain assessment is missing from the documentation? Tab 1 Tab 2 Tab 3 General Survey Subjective information Abdominal assessment Trembling Doubled over Right upper-quadrant "belly pain." Pain radiates to back. More comfortable bent forward than in bed. Similar pain in the past, but only for 2 hours. "This is the worst pain ever!" Pain started after eating fish and chips at a fast food restaurant 4 hours ago. Abdomen bloated and tender on examination. Skin warm and moist. a. Pattern b. Quality c. Intensity d. Location

B The quality or characteristics of the pain is missing (e.g., cramping, stabbing, throbbing). The pattern includes the onset and duration (after eating fish and chips 4 hours ago). The intensity is "the worst pain ever!" The location is the right upper-quadrant of the abdomen with radiation to the back.

When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate drops down to or below which parameter? a. 16 breaths/min b. 14 breaths/min c. 12 breaths/min d. 10 breaths/min

C To protect the patient from adverse effects of respiratory depression from this medication, the nurse should alert the physician as soon as the respiratory rate drops down to or below 12 breaths/min.

A 68-year-old man has chronic pain because of lung cancer that has metastasized to the bone in his back and hip. The nurse is teaching the patient and his family about tolerance and physical dependence to opioid medications. Which statement, if made by the patient, indicates a need for further teaching? A. "High doses of the medication may cause more side effects than lower doses." B. "If I need higher doses of the drug to relieve pain, I have developed an addiction." C. "Physical dependence is expected when this drug is used for long periods of time." D. "I may eventually need a higher dose of the medication to get the same pain relief."

B Tolerance and physical dependence are not indicators of addiction. Tolerance and physical dependence are normal physiologic responses to chronic exposure to opioids. Tolerance is the need for an increased opioid dose to maintain the same degree of analgesia. Physical dependence is manifested by a withdrawal syndrome that occurs when blood levels of the drug are abruptly decreased. Tolerance is a condition characterized by aberrant behaviors arising from a drive to obtain and take substances for reasons other than the prescribed therapeutic value.

A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate? a. "PCA will never be effective unless a loading dose is given first." b. "The IV push dose will enhance the effects of the PCA for the next 8 hours." c. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." d. "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim."

C An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off.

Which clinical manifestation should the nurse attribute to adverse effects of morphine sulfate administered via PCA? a. Diarrhea b. Urinary incontinence c. Nausea and vomiting d. Increased blood pressure

C Morphine sulfate promotes nausea and vomiting by directly stimulating the chemoreceptor trigger zone in the medulla. Other common side effects include constipation, sedation, respiratory depression, decreased blood pressure, and pruritus.

The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8/minute. Which medication would the nurse prepare to administer to treat these symptoms? a. Atropine sulfate b. Protamine sulfate c. Naloxone (Narcan) d. Neostigmine bromide (Prostigmin)

C Naloxone is the antidote or reversal agent for opioid analgesics, such as morphine. Excessive sedation and respiratory depression are symptoms of overdose and/or severe adverse effects that must be reversed for patient safety.

The patient's neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient's pain (select all that apply)? a. NSAIDs b. Fentanyl c. Antiseizure drugs d. β-adrenergic agonists e. Tricyclic antidepressants

C, E Antiseizure drugs, tricyclic antidepressants, SNRIs, transdermal lidocaine, and α2-adrenergic agonists will be used for multimodal treatment when opioid analgesics alone do not control neuropathic pain.

he nurse is performing nonpharmacologic comfort measures. In addition to the comfort measures seen in the video, what other nonpharmacologic measures could the nurse use? (Select all that apply.) a. Play music. b. Give melatonin. c. Perform massage. d. Darken the room. e. Provide distractions. f. Administer heat or cold therapy.

C, E, F The video shows playing music and darkening the room. Massage, distractions, and hot or cold therapy are not shown. Giving melatonin is considered a drug measure.

A 45-year-old woman who had abdominal surgery yesterday received IV pain medication 30 minutes ago. Which assessment by the nurse would most accurately determine the effectiveness of the medication? A. The patient is resting quietly with eyes closed and is not grimacing. B. The patient is talking with visitors and intermittently watching the television. C. The patient states the pain has decreased from an 8 to a 3 on a 0 to 10 pain scale. D. The patient's heart rate is 78 beats/minute with a blood pressure of 122/76 mm Hg.

C. Pain is a subjective experience. The patient is the best judge of his or her own pain and is the expert on the effectiveness of treatment of the pain.

A patient is receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awaken when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths/min. The most appropriate nursing action in the situation is to A. stop the PCA infusion B. obtain oxygen saturation level C. continue to closely monitor the patient D. administer naloxone and contact the physician

Correct answer: c Rationale: Close monitoring is indicated for this patient with a sedation score of 3 and a respiratory rate of 8 breaths/minute. If the respiration rate falls below 8 breaths/minute and the sedation level is 5 or greater, the nurse should vigorously stimulate the patient and try to keep the patient awake.

Providing opioids to a dying patient who is experiencing moderate to severe pain a. may cause addiction b. will probably be ineffective c. is an appropriate nursing action d. will likely hasten the person's death

Correct answer: c Rationale: Opioid therapy is an appropriate intervention for moderate to severe pain experienced by a dying patient, and the drugs may be titrated upward many times over the course of therapy to maintain adequate pain control.

A nurse believes that patients with the same type of tissue injury should have the same amount pain. The statement reflects a. a belief that will contribute to appropriate pain management b. an accurate statement about pain mechanism and an expected goal of pain therapy c. a belief that will have no effect on the type of care provided to people in pain d. a lack of knowledge about pain mechanism, which is likely to contribute to poor pain management

Correct answer: d Rationale: Genetic makeup and variability among individuals affects the plasticity of the central nervous system; this phenomenon helps explain individual differences in responses to pain. Poor knowledge of pain mechanisms often leads to poor pain management.

Which effect should the nurse instruct a patient receiving NSAIDs to report? a. Blurred vision b. Nasal stuffiness c. Urinary retention d. Black or tarry stools

D Black, tarry stools could indicate GI bleeding, which is a risk associated with NSAIDs. For this reason, the patient should be taught to report this sign and other signs of bleeding immediately.

The patient is a known abuser of narcotics and just had surgery. The nurse is frustrated by drug addiction and worried about the high dose of narcotic analgesic prescribed for this patient. What is the best action for the nurse to take? a. Remember that pain can be observed in patients. b. Relieve this patient's pain to avoid adverse consequences. c. Be sure the patient is really in pain before giving the analgesic. d. This patient has the right to appropriate assessment and management of pain.

D Patients with addictive disease and pain have the right to be treated with dignity, respect, and the same quality of pain assessment and management as all other patients. For an addict, severe pain should be treated with a single opioid at much higher doses than those used with drug-naïve patients. Observation of pain is not always evident. The stress of unrelieved pain may contribute to increased drug use in the patient actively abusing drugs.

The patient is receiving fentanyl (Duragesic) patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential adverse effect of this medication? a. Hypertension b. Pupillary dilation c. Urinary incontinence d. Decreased respiratory rate

D Respiratory depression is a potentially life-threatening adverse effect of fentanyl (Duragesic), which is an opioid analgesic, via any route.

unrelieved pain is a. expected after major surgery b. expected in a person with cancer c. dangerous and can lead to many physical and psychologic complications d. an annoying sensation, but it is not as important as other physical care needs

c Rationale: Consequences of untreated pain include unnecessary suffering, physical and psychosocial dysfunction, impaired recovery from acute illness and surgery, immunosuppression, and sleep disturbances. In the acutely ill patient, unrelieved pain can result in increased morbidity as a result of respiratory dysfunction, increased heart rate and cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal motility and transit, and increased breakdown of body energy stores (i.e., catabolism).

Which words are most likely to be used describe neuropathic pain.(SATA) a. dull b. mild c. burning d. shooting e. shock-like

c, d, e Rationale: Neuropathic pain is caused by damage to peripheral nerves or structures in the central nervous system (CNS). Typically described as numbing, hot or burning, shooting, stabbing, sharp, or electric shock-like in nature, neuropathic pain can be sudden, intense, shortlived, or lingering.