Comfort and Pain Management Chapter 35 PrepU N400

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse? Hold the pain medication. Administer the pain medication. Reassess the client's pain in 30 minutes. Contact the client's health care provider.

Administer the pain medication. Explanation: Pain is considered to be present whenever the client states it is. Therefore, the nurse should administer the client's pain medication. It is important that the nurse understand that clients have different ways to manage their pain. It would be inappropriate to delay administration or to hold the medication. There is no indication that the client's health care provider needs to be notified at this time.

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? Wong-Baker CRIES Pain Scale FLACC Scale PAINAD Scale

CRIES Pain Scale Explanation: The CRIES scale is appropriate for neonates (0 to 6 months). The Wong-Baker Faces Pain Rating scale requires children to be at least 3 years old. The FLACC scale is used for infants and children (2 months to 7 years) unable to validate the presence of or quantify pain severity; and the PAINAD scale is specific to the needs of clients with dementia.

What type of pain will the client experience as a result of the intervention being preformed? (Needle being injected on the patients forearm skin) Cutaneous Somatic Visceral Referred

Cutaneous Explanation: Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. This is the type of pain that results from introduction of an intravenous access line. Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Visceral pain is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Pain can originate in one part of the body but be perceived in an area distant from its point of origin. This is known as referred pain.

The demonstration provided by the nurse is directed at helping the postsurgical client manage what type of pain? Splanchnic Deep somatic Neuropathic Superficial

Deep somatic Explanation: Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, muscles and nerves. The nurse is demonstrating splinting, which will help minimize muscular pain caused by coughing and deep breathing after abdominal surgery. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Neuropathic pain caused by a lesion or disease of the peripheral or central nerves. Cutaneous or superficial pain usually involves the skin or subcutaneous tissue.

Which of the following is considered to be the most potent neuromodulators? Endorphins Enkephalins Efferent Afferent

Endorphins Explanation: Endorphins and enkephalins are opioid neuromodulators. Endorphins are powerful pain blocking chemicals with prolonged analgesic effects. Enkephalins are considered less potent. There are no neuromodulators called efferent or afferent.

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 Increased protein Enema

Increased fluids Increased fiber Stool softener Explanation: 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? Acute Chronic Diffuse Intractable

Intractable Explanation: Malignant pain is acute pain episodes, persistent chronic pain, or both associated with a progressive malignant-type process. The etiology for malignant pain is resistant to cure, and the pain may be described as intractable.

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client? NSAIDs Corticosteroids Opioid analgesics Nonopioid analgesics

Opioid analgesics Explanation: The nurse would expect to administer opioid analgesics to a client with severe pain following a mastectomy. Nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are usually the drugs of choice for both acute and persistent moderate chronic pain. Corticosteroids would be used to address inflammation and swelling.

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? Administer a dose of naloxone and report this finding to the primary care provider. Discontinue the client's pain medication until his or her level of consciousness improves. Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. Increase the frequency of the client's vital signs assessment to every 2 hours for the next 6 hours.

Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. Explanation: The sedation score for this client is 3. This requires collaboration with the primary care provider to decrease the analgesic dose. Naloxone is not likely necessary, nor is it appropriate to completely discontinue the client's pain control.

The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use? word scale numeric scale visual analog scale Wong-Baker FACES® scale

Wong-Baker FACES® scale Explanation: Children as young as 3 years of age can use the Wong-Baker FACES® scale. A word, numeric, or visual analog scale is more appropriate for adults.

The nurse is caring for a client who reports throbbing pain at the site of a recent laceration from a pocketknife. How will the nurse document this type of pain? Select all that apply. acute somatic neuropathic chronic cutaneous

acute cutaneous Explanation: Cutaneous pain originates at the skin level and is commonly experienced as a sensation resulting from some form of trauma. Acute pain (discomfort that lasts a short duration) lasts for a few seconds to less than 6 months.

The nurse is caring for a client who has had back pain for 2 years, following a fall from a ladder. How does the nurse going off-shift report this kind of pain to the oncoming nurse? Select all that apply. acute chronic cutaneous somatic visceral

chronic somatic Explanation: Somatic pain develops from injury to structures such as muscles, tendons, and joints. Chronic pain is discomfort that lasts longer than 6 months.

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

gabapentin Explanation: Gabapentin is used to treat nerve pain.

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain? pupil constriction decreased pulse rate increased blood pressure decreased respiratory rate

increased blood pressure Explanation: The increase in blood pressure that may accompany acute pain is believed to be due to overactivity of the sympathetic nervous system.

Which of the following nonpharmacologic pain relief measures has been found to be effective for soothing agitated newborns and comatose clients? distraction music humor imagery

music Explanation: Listening to music can relax, soothe, decrease pain, and provide distraction. It has proven effective for soothing agitated newborns and comatose clients. Distraction, something that prevents someone from giving full attention to something else, can be used for school aged children and older. Imagery means to use figurative language to represent objects, actions, and ideas in such a way that it appeals to our physical senses. Imagery is used for adolescents and older clients.

Besides controlling pain of the postabdominal surgery client with opioids, the nurse suggests to the client that he: focus on pain relief. use distraction. describe the pain. think about the next dose.

use distraction. Explanation: Distraction is useful when clients are undergoing brief periods of sharp, intense pain, such as dressing changes, wound debridement, biopsy, or incident pain from shifting positions.

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as "Your present pain is worse because you had your packing removed." "Acute pain tends to increase during the day and is called a routine pain response" "I will call your doctor because you may have loosened sutures when walking." "You will need more pain medication as the days progress."

"Acute pain tends to increase during the day and is called a routine pain response" Explanation: Acute pain occurs abruptly after an injury or disease and persists until healing occurs. Acute pain also may be associated with anxiety and fear. Acute pain consistently increases at night and during wound care, ambulation, coughing, and deep breathing.

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? S 1 2 3

1 Explanation: Using a sedation scale, 1 indicates that the client is alert and awake. S is used to document that the client is sleeping but easy to arouse. 2 is used to denote that the client is slightly drowsy but easy to arouse. 3 is used to denote that the client is frequently drowsy, arousable but drifts off to sleep during a conversation.

A client who has a leg cast tells the nurse that he has pain inside his cast. Which type of stimulus is most likely causing this pain? Thermal Chemical Electrical Mechanical

Mechanical Explanation: Receptors in the skin may be stimulated by mechanical, thermal, chemical, and electrical agents. Pressure from a cast is a mechanical agent causing pain. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. The jolt of a static charge is an electrical stimulant.

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 Diphenhydramine Atropine Epinephrine

Naloxone Explanation: Naloxone is an opioid antagonist that reverses the respiratory-depressant effect of an opioid. Diphenhydramine is an antihistamine mainly used to treat allergies. Atropine is a medication to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate and to decrease saliva production during surgery. It is typically given intravenously or by injection into a muscle. Epinephrine injection is used for emergency treatment of severe allergic reactions (including anaphylaxis) to insect bites or stings, medicines, foods, and other options but not for opioids.

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? Administer pain medications in smaller doses but more frequently. Decrease external stimuli in the room during painful episodes. Reposition the client and gently massage the client's back. Advise the client to try to sleep following administration of pain medication.

Reposition the client and gently massage the client's back. Explanation: The nurse would reposition the client and gently massage the client's back using the gate-control theory of pain. The gate-control theory provides the most practical model regarding the concept of pain. It describes the transmission of painful stimuli and recognizes a relationship between pain and emotions. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Decreasing the dosage of the pain medication—but giving the doses more frequently—does not follow this theory. Decreasing external stimuli in the room during painful episodes would not address the gate-control theory. Advise the client to sleep following administration of pain medication does not address the gate-control theory.

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? Respiratory Cardiovascular Peripheral Vascular Neuromuscular

Respiratory Explanation: The priority assessment for the nurse caring for a client with a PCA pump is respiratory, with particular attention to the respiratory rate and pattern. Too much opioid or a displaced catheter may allow the medication to have a depressant effect on the brainstem center, causing life-threatening respiratory depression. The cardiac system can be affect by a opioid PCA by decreasing the blood pressure and heart rate as the pain decreases. It is expected but not the priority. The neuromuscular and peripheral vascular system are not affected by the PCA.

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 is unable to sleep without medication the following night. The client experiences respiratory depression after the drug takes effect. The client exhibits restless, uncharacteristic behavior after receiving the drug. In the morning, the client is unable to identify his location or the day of the week.

The client exhibits restless, uncharacteristic behavior after receiving the drug. Explanation: Paradoxical effects of hypnotics involve a stimulating effect or mental changes. Tolerance, somnolence, and respiratory depression are not indicative of paradoxical effects.

Which circumstance may preclude the use of cutaneous stimulation to relieve a client's pain? The client has difficulty localizing his pain. The client's pain is chronic rather than acute. The client has a history of heart disease. The client is receiving both scheduled and breakthrough analgesia.

The client has difficulty localizing his pain. Explanation: Cutaneous stimulation requires that the client be able to localize his pain. It may be used on both chronic and acute pain, and neither analgesics nor heart problems contraindicate the use of cutaneous stimulation.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? The dose that is delivered when the client activates the machine is preset. Thorough client education is necessary to prevent overdoses. Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. An antidote is automatically delivered if the client exceeds the recommended dose.

The dose that is delivered when the client activates the machine is preset. Explanation: PCAs are designed to make it impossible for the client to exceed the client-specific dosing parameters programmed into the machine. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics. The client does not need to be educated about overdoses.

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? Physical therapy referral A walking aid Acupuncture A chronic opioid therapy plan

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

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? A client suspected to have a perforated peptic ulcer A client who has a sprained ankle A client with chest pain who is having a myocardial infarction A client who has appendicitis

A client who has a sprained ankle Explanation: Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Visceral pain is one of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed such as with a ruptured peptic ulcer or appendicitis. A client having a myocardial infarction with chest pain is experiencing referred pain.

Which medical client is most likely to be experiencing diffuse pain? A client who is undergoing diagnostic testing for appendicitis A client with shingles affecting her entire torso A client who has presented to the emergency department with a stab wound A client who has been prescribed antibiotics for the treatment of strep throat

A client with shingles affecting her entire torso Explanation: Diffuse pain is pain that covers a large area and, usually, the client is unable to point to a specific area without moving the hand over a large surface, such as the client's entire torso. Pain related to appendicitis, a stab wound, or strep throat is more likely to be localized and sharp.

What will the nurse place at the bedside of a client receiving epidural analgesia? Ampule of 0.4 mg naloxone Ampule of 0.4 mg epinephrine An extra chest drainage system Bottle of sterile saline

Ampule of 0.4 mg naloxone Explanation: 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.

Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain? This approach can only be used with oral analgesics. A PCA pump must be used and monitored in a health care facility. The PCA pump is not effective for chronic pain. The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval.

The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. Explanation: The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. This approach can be used with oral analgesic agents as well as with infusions of opioid analgesic agents by intravenous, subcutaneous, epidural, and perineural routes. This drug delivery system may be used to manage acute and chronic pain in a health care facility or the home.

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. They react with acetylcholine and serotonin. They occupy cell receptors for neurotransmitters. They block glutamate receptors and peptides.

They bind to opioid receptor sites throughout the CNS. Explanation: When endogenous opioids are released, they are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the central nervous system (CNS), blocking the release or production of pain-transmitting substances.

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: document the client's lack of medication. assume the client does not need medication. ask the client's family if he ever uses pain medicines. actively solicit information about the client's pain level.

actively solicit information about the client's pain level. Explanation: Some cultures see pain tolerance as a virtue; often men are expected to tolerate pain more stoically than women do. Health care providers need to recognize the client's cultural beliefs and not impose their own judgments.

The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? B/P 178/92 and pulse 118 confused to time and place right shoulder immobilizer in place rates pain an 8 on a 0 to 10 scale

confused to time and place Explanation: Clients must be cognitively and physically capable of using the PCA equipment safely. Confusion in a client would lead the nurse to question the client's ability to correctly use the PCA.

A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? Select all that apply. cutaneous somatic neuropathic acute chronic

cutaneous acute Explanation: Cutaneous pain originates at the skin level and is commonly experienced as a sensation resulting from some form of trauma. Acute pain lasts for a few seconds to less than 6 months. Therefore, the nurse documents that the client has acute, cutaneous pain. Somatic, visceral, referred, chronic, and neuropathic pain are not demonstrated in this scenario.

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? biofeedback cutaneous stimulation patient controlled analgesia percutaneous electrical nerve stimulation

cutaneous stimulation Explanation: Acupressure, a modern-day Western descendant of acupuncture, involves the use of the fingertips to create gentle but firm pressure to usual acupuncture sites. This technique of holding and releasing various pressure points has a calming effect, most likely related to the body's release of endorphins and enkephalins. Acupressure is easily taught to patients and families. Because patients can perform acupressure on themselves, it gives them a feeling of control in their care.

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? acute pain chronic pain referred pain limited pain

referred pain Explanation: Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage. Acute pain is distinct from chronic pain and is relatively more sharp and severe and lasts from 3 to 6 months. Chronic pain is often defined as any pain lasting more than 12 weeks. Limited pain is not usually a term used.

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. cutaneous visceral referred acute chronic

visceral referred acute Explanation: Visceral pain (discomfort arising from internal organs) is associated with disease or injury. It is sometimes referred or poorly localized. Referred pain (discomfort perceived in a general area of the body, usually away from the site of stimulation) is not experienced in the exact site where an organ is located. Acute pain (discomfort that has a short duration) lasts for a few seconds to less than 6 months.

A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain? referred pain phantom pain visceral pain cutaneous pain

phantom pain Explanation: The nurse should document the pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client perceives that the amputated limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed. The client is not experiencing referred pain, visceral pain, or cutaneous pain. Visceral pain is associated with disease or injury. Referred pain is not experienced in the exact site where an organ is located. Cutaneous pain originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma.

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. cutaneous pain. somatic pain. neuropathic pain.

visceral pain. Explanation: The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

When implementing the gate-control theory of pain, which intervention will enhance the closing of the gate to the client's pain? Position the client on several pillows. Teach the client relaxation techniques. Give the client a back rub. Darken the room.

Give the client a back rub. Explanation: The gate-control theory of pain involves cutaneous nerve fibers, which are large diameter fibers carrying impulses to the CNS. When the skin is stimulated, pain is believed to be controlled by closing the gating mechanism in the spinal cord. This decreases the number of pain impulses that reach the brain for perception. A back rub will stimulate this mechanism. Pillows do not provide enough pressure for stimulation. Darkening the room and relaxation techniques do not involve touching the skin.

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? "This will allow me to control my own pain medication." "I should only take medication when my pain is intense." "I give myself the pain medication by pushing the button." "The pump is programmed to limit the chance of overmedicating."

"I should only take medication when my pain is intense." Explanation: 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.

Which client statements would indicate to the nurse that the client needs additional teaching regarding prn pain medication and management? Select all that apply. "I should wait until my pain gets worse before asking for pain medications." "It's better to put up with the pain than deal with side effects of medication." "If I ask for pain medication, I may become addicted." "I should ask for my pain medication when I am feeling pain." "The nurse will know when my medication is due and will give it to me automatically."

"I should wait until my pain gets worse before asking for pain medications." "It's better to put up with the pain than deal with side effects of medication." "If I ask for pain medication, I may become addicted." "The nurse will know when my medication is due and will give it to me automatically." Explanation: The nurse should determine that additional teaching is needed relating to prn pain medication and management if the client states, "I should wait until my pain gets worse before asking for pain medications"; "It's better to put up with the pain than deal with the side effects of medication"; or "If I ask for pain medication, I may become addicted."

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? 1 2 3 4

3 Explanation: The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows:1 = awake and alert; no action necessary2 = occasionally drowsy but easy to arouse; requires no action3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.

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. Administer the medication when the client's blood pressure is > 140/90. Administer the medication when the client's heart rate is < 90. Administer the medication when the client's heart rate is > 80.

Administer the medication if respiratory rate is > 9. Explanation: The nurse can safely administer the new pain medication when the client's respiratory rate is greater than 9. Opioids can cause respiratory depression. Therefore, this is important to monitor before administering the opioid. Blood pressure and heart rate are slightly elevated due to the client experiencing pain. These vital signs are stable to administer the opioid.

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety? Feeding the client food and fluids while in a semi-Fowler's (partially upright) position Administering an oral dose of morphine to treat the client's breakthrough pain Administering a glycerin suppository to treat the client's constipation Palpating the client's abdomen during a head-to-toe assessment

Administering an oral dose of morphine to treat the client's breakthrough pain Explanation: 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.

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse? Administer a lower dose of the analgesic for the next dose Begin CPR Place the client in the supine position Administration of 0.4 mg of naloxone

Administration of 0.4 mg of naloxone Explanation: The client is experiencing impending respiratory arrest due to the effect of the medication and this should be reversed immediately prior to arrest. This is the priority action and will correct the respiratory depression immediately. CPR is not indicated at this time, because the client is not in full arrest. Placing the client in the supine position may decrease respirations further.

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply. Delegate pain assessment to the UAP. Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Infer that the client who does not complain has no pain. Provide pain medication before activity that may increase pain.

Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain. Explanation: Pain assessment should never be delegated to a UAP. Pain medication should be given in advance of an activity that may increase pain. The nurse should consider cultural implications associated with pain and assess for pain control after medication is given. Assumptions should not be made about 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 Physiologic Affective Psychosomatic

Behavioral Explanation: Behavioral (voluntary) responses would include moving away from painful stimuli, grimacing, moaning, crying, restlessness, protecting the painful area, and refusing to move the limb. Physiologic (involuntary) responses would include increased blood pressure, increased pulse and respiratory rates, pupil dilation, muscle tension and rigidity, pallor (due to peripheral vasoconstriction), increased adrenaline output, and increased blood glucose. Psychological responses would include exaggerated weeping and restlessness, withdrawal, stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, and powerlessness.

A client who suffered multiple trauma in a motor vehicle accident is receiving care in an orthopedic trauma unit. The client has a documented history or opioid addiction and the hospital's advanced pain control team has become involved in his pain control plan. Which of the following are aspects of addiction? Select all that apply. Compulsive use of a particular drug Presence of an unusually low pain threshold The need to use opioids for purposes other than pain relief The need for increasing size or frequency of opioid doses to achieve pain relief The use of more than 30 mg of morphine or 15 mg of hydromorphone in a 24 hour period

Compulsive use of a particular drug The need to use opioids for purposes other than pain relief Explanation: The American Pain Society (2008) defines addiction as "a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief." Drug tolerance is not synonymous with addiction and increased tolerance does not lead to addiction. Addiction is not defined in absolute terms of opioid doses and it is not related to a low pain threshold.

The nurse is preparing to initiate PCA therapy for a client with sleep apnea. What is the correct action by the nurse? Contact the physician. Initiate the therapy. Increase the lock out time. Decrease the loading dose.

Contact the physician. Explanation: The nurse should contact the physician, as PCA therapy for pain management is contraindicated for clients with sleep apnea. This is due to the fact that oversedation in clients with sleep apnea poses a significant health risk. PCA therapy is also contraindicated in confused clients, infants and very young children, cognitively impaired clients, and clients with asthma.

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. Client is allowed to have one drink of alcohol each day. You may smoke cigarettes during the day but not at night. You must check with your primary care provider before breast-feeding your infant. For better absorption, take your pain medication on an empty stomach. Keep a diary to record level of pain and time medication is taken.

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. Explanation: The nurse will provide instructions about the medication prescribed for pain relief. This medication is an opioid, and extra precautions are required. The client is not to drive a vehicle while taking an opioid due to slowed reflexes and decreased cognitive thinking. The client is not to breast-feed her infant without checking with her primary care provider. The opioid may be absorbed into the breast milk and fed to the infant, which may adversely affect the infant. The client is to keep a diary about her pain experiences, which includes level of pain and time the medication was taken. This provides a more accurate documentation of the pain experience and prevents overdosage from taking the medication too frequently. The client is not to drink alcohol. Alcohol will depress the central nervous system when taken with an opioid and may lead to respiratory failure. The client may smoke, but someone will need to be present (for safety reasons) since the client may fall asleep due to the opioid. It does not matter whether it is day or night. The medication is not better absorbed when taken on an empty stomach. The client takes the pain medication with food, since nausea is a frequent side effect when the opioid is taken on an empty stomach.

How should the nurse position the head of the bed for a client receiving epidural opioids? Elevated 30 degrees Flat Reverse Trendelenburg Trendelenburg

Elevated 30 degrees Explanation: 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.

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client? Treat the pain only as it occurs to prevent drug addiction. Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. Increase and decrease the serum level of the analgesic as needed. Do not provide analgesia if there is any doubt about the likelihood of pain occurring.

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. Explanation: The client would benefit from the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. The phantom pain is real pain and should be treated as such. The nurse would not increase and decrease the serum level of the analgesic as needed. The nurse would not doubt the client's report of pain and would not withhold analgesia if she doubted the likelihood of the pain occurring.

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 Serotonin Melatonin Dopamine

Endorphins Explanation: Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that certain measures, such as skin stimulation and relaxation techniques, release endorphins. Serotonin is an important chemical and neurotransmitter in the human body. It is believed that serotonin helps regulate mood and social behavior, appetite and digestion, sleep, memory, and sexual desire and function. Melatonin is a hormone that is produced by the pineal gland in humans and animals and regulates sleep and wakefulness. Dopamine is a neurotransmitter that helps control the brain's reward and pleasure centers.

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? Compare the client's current assessment with previous admission assessment Educate the client/caregiver about signs of impending death Assess the client's serum albumin level Examine the effectiveness of the current pain regimen

Examine the effectiveness of the current pain regimen Explanation: When a client has a painful diagnosis and is nearing the end of life, pain management is the priority. Education is important along with assessment and comparison, however, these are not the priority.

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? FACES scale FLACC scale Braden scale Apgar score

FLACC scale Explanation: The FLACC scale (face, legs, activity, cry, and consolability) is used to measure pain for children between the ages of 2 months and 7 years. The Braden scale is used to predict pressure sore risk. The FACES scale is used to assess pain in older children using a series of faces, ranging from a happy face to a crying face. Apgar score is done at birth to assess how well the baby tolerated the birthing process.

The nurse is performing an assessment of a client that is experiencing pain after a surgical procedure. What symptoms does the nurse assess based on the pain response? Pulse rate is decreased. Blood pressure is normal. Pupils are dilated. Respirations are shallow.

Pupils are dilated. Explanation: Acute pain stimulates the sympathetic nervous system and produces the following objective symptoms: increased blood pressure, increased pulse, increased respiratory rate, dilated pupils, and diaphoresis.

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 Heart rate, capillary refill, bowel sounds and pedal pulses Temperature, pedal pulses, and assessment of cranial nerves Gastrointestinal status, bowel movements, and urine output

Respiratory status, oxygen saturation, pain, and sedation level Explanation: Respiratory status, oxygen saturation, pain, and sedation level are the best description of the priority of the hourly assessments for this client. The priority concern for this client is the risk of respiratory depression because of the use of analgesia; therefore, the priority assessments during the first 12 hours of epidural therapy include assessing the client's vital signs, respiratory status, pain status, sedation level, oxygen saturation at least once per hour during the first 12 hours of therapy. If there are no complications after 12 hours, the assessments should continue every 2 hours and then decrease per facility policy. Airway, breathing, and circulation are the top priorities in the care of any client, and in this client, breathing is a concern because of the risk of respiratory depression from the epidural analgesia. Although important, the other options do not best describe the priority assessments because the main concern, the risk of respiratory depression, is not the focus of the other options.

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 Visceral Neuropathic Persistent

Somatic Explanation: Somatic pain originates in bone, skin, and soft tissue and is often well localized. Clients will describe somatic pain as aching or throbbing; when asked if they can point to the location of their pain, they are often able to specifically pinpoint where it hurts. Examples of somatic pain include soft tissue injury such as a contusion from a sprained ankle. Visceral pain originates internally and is the result of stretching, distention, inflammation, or damage to the hollow and solid organs. Clients tend to describe visceral pain as aching, throbbing, cramping, pressure, deep, or radiating. This type of pain is often diffuse and difficult for clients to pinpoint. Neuropathic pain arises from damage to the peripheral nerves or the CNS and, unlike nociceptive pain, is the result of abnormal sensory input. Clients describe neuropathic pain as tingling, itching, burning, cold, prickly, or "shock-like." Unlike acute pain, which follows the normal nociceptive pain process, persistent (chronic) pain serves no useful purpose. Health care providers are using the term persistent pain in place of chronic pain to help avoid the negative and often inaccurate assumptions associated with chronic pain clients. Persistent pain is an abnormal pain-signaling process with origins that can occur both peripherally and centrally. Persistent pain is cyclical and irreversible and generally persists longer than 3 to 6 months.

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? Notify the physician. Stop the PCA pump. Administer naloxone. Increase the primary IV rate.

Stop the PCA pump. Explanation: A side effect of morphine is respiratory depression. In this situation, the nurse should first stop the PCA pump and then notify the physician. Naloxone is used to reverse the sedative effects of opioids, but this is not the first step.

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. Stop the PCA infusion, check the medication level, and restart the infusion at a lower dose. Stop the PCA infusion, increase the frequency of sedation and respiratory rate monitoring to every 15 minutes, rouse the client, and encourage deep breathing. Stop the infusion and report the incident to the nurse manager in charge; follow the protocol of oxygen and naloxone administration.

Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and naloxone. Explanation: If a client receiving a PCA infusion becomes somnolent, with a sedation score of 4, the nurse should stop the medication infusion immediately and notify the primary care provider. The nurse should prepare to administer oxygen and an opioid antagonist, such as naloxone.

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. Apply sequential compression stockings. Arrange for a high-protein, low-residue diet. Encourage the client to drink an 8-oz glass of water every 2 hours.

Teach the client to perform deep-breathing and coughing exercises. Explanation: 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 client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory? asking client how sensory stimuli produces pain administering backrub when client's head hurts removing items from the room that remind client of former spouse requesting health care provider to order the client's opioid medication

administering backrub when client's head hurts Explanation: Administering a backrub reflects the Gate Control Theory. Asking the client how sensory stimuli produces pain reflects the Pattern Theory. Removing items that remind the client of a former spouse reflects the Neuromatrix Theory. Having the health care provide order the client's opioid medication reflects the endogenous opioid theory.

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. transcutaneous electrical nerve stimulation (TENS). hypnosis. Therapeutic Touch (TT).

biofeedback. Explanation: Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin. 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. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers. Hypnosis is an alteration in a person's state of consciousness so that pain is not perceived as it normally would be. Therapeutic Touch involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief.

The nurse is caring for a client who had a below-the-knee amputation of the left leg 8 months ago. The client is reporting left foot pain of 7 on a 1-to-10 scale. The pain began earlier today. How will the nurse document this type of pain? Select all that apply. somatic visceral referred neuropathic acute

neuropathic acute Explanation: Neuropathic pain often is experienced days, weeks, or even months after the source of the pain has been treated and resolved. Phantom pain, such as when a limb has been amputated, is a form of neuropathic pain. Acute pain lasts for a few seconds to less than 6 months. Therefore, the nurse documents that the client has acute, neuropathic pain. Cutaneous, somatic, visceral, referred, and chronic pain are not supported by the scenario.

The most important pathway for pain sensation is the: corticospinal tract dorsal horn neural tract afferent tract spinothalamic tract

spinothalamic tract Explanation: The spinothalamic tract appears to be the most important pathway for pain sensation.

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 recent responses to pain and to pain medication nonverbal cues of the client the nurse's impression of the client's pain the client's pain based on a pain rating

the client's pain based on a pain rating Explanation: The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, but which are not more important than the pain rating. Pain relief after nursing intervention is appropriate, but is a part of evaluation.