EAQ Ch 5 Pain Assessment & Mgmnt in Children

A child is prescribed a buccal analgesic for pain relief. How should the nurse administer the drug to the child? 1 Place the drug between cheeks and gums. 2 Place the drug above the tongue. 3 Instruct the child to swallow the drug. 4 Instruct the child to chew the drug.

1 A transmucosal route of administration helps in rapid absorption of drug due to the rich blood supply to the oral mucosa. The drug should be placed between cheeks and gums for proper absorption through the oral mucosa. The drugs are placed under the tongue during buccal administration of drug. A drug meant to be administered through the transmucosal route should not be swallowed or chewed, as this can affect the therapeutic levels of the drug.

The nurse observes that the usual dose of analgesic is unable to relieve pain in a 12-year-old child with sickle cell anemia after 3 weeks. What does the nurse conclude from this finding? 1 The child has developed tolerance to the analgesic. 2 The child has developed another complication. 3 The doses were not spaced efficiently. 4 The child has become addicted to the analgesic.

1 If the body gets adapted to the drug, the usual doses of the drug are unable to have the desired effect. This is called tolerance to the drug. Development of other complications is evident from fever, nausea, or other physical symptoms. Tolerance is caused by the neuroadaptation to the effects of the drug, not by ineffective spacing of the drug. Addiction is indicated by preoccupation with obtaining the drug and using it continually, even if there is adequate analgesia.

A nurse is caring for a 5-year-old child who has a new order for the insertion of an intravenous line. What intervention will be the most effective way of providing analgesia before this procedure? 1 Applying LMX (4% liposomal lidocaine cream) 30 minutes before the procedure 2 Applying a transdermal fentanyl patch at the site of venipuncture 3 Applying EMLA (eutectic mixture of local anesthetics) immediately before the procedure 4 Administering TAC (tetracaine, epinephrine], cocaine) 15 minutes before the procedure

1 LMX is an effective analgesic agent when applied to the skin 30 minutes before a procedure. It eliminates or reduces the pain of most procedures involving skin puncture. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control. EMLA needs to be applied 60 minutes before the procedure to be effective. TAC provides skin anesthesia about 15 minutes after application to nonintact skin.

While caring for a child receiving morphine, the nurse observes that the child is apneic and cannot be aroused. Which medication does the nurse administer as prescribed to the child? 1 Naloxone 2 Diazepam 3 Midazolam 4 Flumazenil

1 Opioid analgesics such as morphine can cause apnea. Naloxone acts as an antagonist and restores respiration in the patient. Diazepam and midazolam do not reverse the action of morphine; instead, they increase the risk of respiratory depression. Flumazenil acts as an antagonist for benzodiazepines, but not opioid analgesics.

In which way is chronic pain in children differentiated from recurrent pain? 1 Chronic pain persists for 3 months or more. 2 Chronic pain is episodic and reoccurs. 3 Depression is elevated in children with recurrent pain. 4 Anxiety is elevated in children with chronic pain.

1 Pain that persists for 3 months or more is known as chronic pain. Recurrent pain is pain that is episodic and recurs in 3 months. Chronic pain is not episodic. It persists for a long time. Anxiety and depression are elevated in children with chronic as well as recurrent pain, because they interfere with normal functioning.

The nurses caring for a child are concerned about the child's frequent requests for pain medication. During a team conference a nurse suggests that they consider administering a placebo instead of the usual pain medication. The decision should be based on which knowledge? 1 It is unjustified and unethical to administer placebos instead of pain medication. 2 The absence of a response to a placebo indicates an organic basis for the pain. 3 A positive response to a placebo will not occur if the child's pain has an organic basis. 4 Administering a placebo instead of the usual pain medication is effective in determining whether a child's pain is real.

1 Placebos should never be given, by any route, in the assessment or management of pain. The response to a placebo is not a measure of the origin of pain and should never be used as a means of assessing pain. Placebos should never be given as a means of determining whether pain is real. Individuals respond differently to placebos; therefore the patient's response may not be an accurate measure of pain.

What is the most effective strategy for obtaining postoperative pain control in children? 1 Providing preemptive analgesia 2 Administering pain medications around the clock 3 Teaching the child nonpharmacologic pain-control measures 4 Increasing the dose of analgesic until the child is adequately sedated

1 Preemptive analgesia is the administration of medications (local and regional anesthetics and analgesics) before the child experiences pain or before surgery is performed so the sensory activation and changes in the pain pathways of the peripheral and central nervous system can be controlled. Giving medications around the clock, teaching the child nonpharmacologic pain control measures, and providing an increased dosage of analgesic until the child is adequately sedated are not the most effective strategies for obtaining postoperative pain control in children.

*Which self-report pain rating scale can be used with children ages 3 to 13 years? 1 Oucher scale 2 Numeric scale 3 Visual analog scale 4 Word-graphic rating scale

1 The Oucher scale is recommended for children ages 3 to 13 years. The numeric scale is recommended for children 5 years (if they can count). The visual analog scale is recommended for children as young as 4.5 years but preferably 7 years and older. The word-graphic rating scale is recommended for children 4 to 17 years of age.

The nurse is assessing a 4-year-old child for intensity of pain after administering an injection. What does the nurse use for this purpose? 1 Faces pain scales 2 Numerical rating scale 3 Pain Assessment Tool (PAT) 4 Postoperative Pain Score

1 The nurse uses a faces pain scale, which shows a series of facial expressions depicting the degrees of pain. The child can easily point at the face that represents how the child is feeling. The numerical rating scale is used for children more than 8 years old, whereby the child can rate the intensity of pain on a scale of 0 to 10. The PAT is used to examine pain in infants. The Postoperative Pain Score is used for testing postoperative pain in infants less than 7 months old.

The nurse observes increased irritability, nausea, diarrhea, sweating, and fever in a child on the second day after discontinuing the opioid dose. What does the nurse conclude from the child's condition? 1 The child is having withdrawal symptoms. 2 The child is addicted to opioids. 3 The child is having a painful episode due to sickle cell disease. 4 The child is displaying side effects of opioids.

1 Withdrawal symptoms such as increased irritability, nausea, diarrhea, sweating, and fever are seen when an opioid is abruptly discontinued. This happens because the use of opioids causes physical dependence. Patients need to be gradually weaned to avoid withdrawal symptoms. The child is not addicted to opioids, but there is physical dependence on the drug. Painful episodes, indicated by chest pain, enlarged spleen, and fever, are observed in children with sickle cell disease. Increased irritability, nausea, diarrhea, sweating, and fever are not side effects of opioids but are withdrawal symptoms.

A nurse is caring for an 8-year-old child who has undergone surgery for multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. What is an important consideration in the management of the child's pain? 1 Giving only an opioid analgesic at this time 2 Planning a preventive schedule of pain medication around the clock 3 Increasing the dosage of analgesic until the child is adequately sedated 4 Giving the child a clock and explaining when he may have pain medications

2 An around-the-clock administration strategy should be used for a child recovering from trauma and surgery. This schedule will help prevent a low plasma level of the drug, which could result in breakthrough pain. It is appropriate for the immediate concern of the child's pain to give an opioid analgesic, but this will not facilitate the more long-term plan of pain management. The dosage of analgesic is increased until the pain is controlled, not until sedation is adequate. The child should be frequently assessed for pain and doses titrated accordingly. It is inappropriate to give a child a clock with instructions for when pain medication may be given, especially a child who has experienced a traumatic event.

The nurse is preparing an 8-year-old child for a subcutaneous injection. Which statement by the nurse is most effective? 1 "I promise that it is going to hurt just a little bit." 2 "It may feel like pinching. You tell me how it feels." 3 "It feels like burning pain, but it goes away soon." 4 "This is terrible, but I know you are very strong."

2 The nurse prepares the child by saying that the injection may feel like pinching so that the child is not anxious or scared. Telling the child that it is going to hurt just a little may make the child scared. If the nurse says that it feels like burning pain, the child perceives it as threatening. Instead the nurse can say that it feels like heat. Using evaluative statements such as "this is terrible" increases the child's anxiety.

Which is an important consideration when the FACES Pain Rating Scale is used with children? 1 The scale is not appropriate for use with adolescents. 2 The scale may be used with most children as young as 3 years of age. 3 Children color the face with the color they choose to best describe their pain. 4 The scale is useful in pain assessment but is not as accurate when physiologic responses are being assessed.

2 (guessed 4) The FACES scale has been validated for children as young as 3 years of age as a means of rating pain. The child points at the face that best describes the pain being experienced. The scale is useful for people of all ages above 3 years, including adults. The scale does not have a means of assessing physiologic data. Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

The nurse is caring for a comatose child with multiple injuries. Which statement should the nurse recognize? 1 Cannot occur if a child is comatose 2 May occur if the child regains consciousness 3 Requires astute nursing assessment and management 4 Is best assessed by family members who are familiar with the child

3 Because the child cannot communicate pain through one of the standard pain-rating scales, the nurse must focus on physiologic and behavioral manifestations to accurately assess his pain. Pain can occur in the comatose child. The family can provide insight into the child's responses, but the nurse should be monitoring physiologic and behavioral manifestations.

What method of analgesia delivers a constant amount of analgesic and prevents pain from returning? 1 Regional nerve blocks 2 Nurse-administered boluses 3 Continuous basal rate infusion 4 Patient-administered boluses

3 Continuous basal rate infusions deliver a constant amount of analgesic and prevent pain from returning. Patient-administered boluses are infused according to the preset amount and lockout interval. Nurse-administered boluses are typically used to give an initial loading dose to increase blood levels rapidly and to relieve breakthrough pain.

The nurse is teaching a group of children about strategies of pain management. Which teaching strategy does the nurse use to educate the children? 1 Get assistance from their parents. 2 Provide the children with medical journals. 3 Educate using interactive audio visual aids. 4 Get assistance from primary health care provider.

3 Prior education of children about pain management strategies is important for effective pain management. Children can be educated with the help of an interactive session in which the instructions are recorded and played. Assistance from parents may not promote learning in children. Children may not be interested in reading medical journals. Assistance from a healthcare provider may not be helpful in promoting learning in children.

The nurse is teaching pain management strategies to the parents of a 6-year-old child with recurrent abdominal pain. The nurse instructs the parents to not give excessive attention to the child's abdominal pain. What is the purpose of this advice? 1 To teach the child not to complain about pain 2 To make the child feel comfortable with the pain 3 To prevent positive reinforcement of the sick behavior 4 To help the child learn to deal with the pain

3 The nurse tells the parents to employ cognitive-behavioral strategy in which the parents avoid paying excessive attention to the pain. Instead the parents reward the healthy behavior of the child. This helps the child to modify the sick behavior and demand less attention. The strategy is not to prevent the child from complaining but to avoid paying special attention to it. The child is taught self-control skills to feel comfortable about the pain and to deal with it effectively.

What is the appropriate action when the route of morphine administration is changed from intravenous to oral? 1 The oral morphine dosage must be equal to the intravenous dosage to be effective. 2 The oral morphine dosage must be one half of the intravenous dosage to be effective. 3 The oral morphine dosage must be larger than the intravenous dosage to be effective. 4 The oral morphine dosage must be one quarter of the intravenous dosage to be effective.

3 The oral morphine dosage needs to be larger than the intravenous dosage to be effective when the route of morphine administration is changed from intravenous to oral. Oral morphine is not as effective at the same dosage or one half or one quarter of the dosage of intravenous morphine.

A child who has been receiving morphine by way of the intravenous (IV) route will now start receiving it orally. For equianalgesia (equal analgesic effect) to be achieved, what must the oral dose be? 1 Same as the IV dose 2 One half of the IV dose 3 Greater than the IV dose 4 One fourth of the IV dose

3 When the route of morphine administration is changed from IV to PO (by mouth), it is essential that the dose be increased to produce an equianalgesic effect. Oral morphine is not as effective at the same dose as IV morphine. The dosage of morphine is increased, not decreased, when the administration route changes from IV to PO.

*The nurse is caring for a child who needs continuous pain control medications. Which medication route for analgesic administration proves to be most effective for the child? 1 Oral 2 Sublingual 3 Intravenous (IV) 4 Transmucosal

3 (guessed 1) IV route is the best route for administering pain medications because it enables the rapid control of severe pain. The child may need rest and may not be able to take oral medications, and oral medications do not provide rapid control of severe pain. Sublingual and transmucosal medications have an increased risk of swallowing in small children.

*The nurse is assessing pain in a 7-year-old child with cognitive impairment and communication difficulties. Which sign does the nurse observe for pain in the child? 1 Rapid talking 2 Sleeping often 3 Moaning 4 Fist clenching

3 (guessed 4) Moaning is an indication of pain experienced by a child with cognitive impairment. Children with pain interact and speak less instead of talking rapidly. Children with pain sleep less, as they are uncomfortable. Fist clenching is observed in infants who experience pain.

What is the most consistent indicator of pain in infants? 1 Increased heart rate 2 Squirming and jerking 3 Quickened respiration 4 Facial expression of pain

4 A facial expression of pain is the most consistent indicator of pain in infants. Increased heart rate may or may not be a symptom of pain in infants. Squirming and jerking are common in infants with and without pain. An increased rate of respiration may or may not be a symptom of pain in infants.

The nurse should recognize that children with unrelieved severe pain may engage in certain behaviors. What behaviors should the nurse expect to encounter in a child experiencing severe unrelieved pain? 1 Addiction 2 Increase in appetite 3 Mental clarity and alertness 4 Frequent checking of the clock

4 Frequently checking the clock is common in a patient suffering from severe unrelieved pain. They may appear to others to be preoccupied with getting more opioids, but the preoccupation is actually focused on finding relief of the pain. Pseudoaddiction, rather than addiction, is a behavior that the nurse can expect to encounter in a child experiencing severe unrelieved pain. A decrease in appetite, rather than an increase in appetite, is more likely to occur. Mental clouding, rather than mental clarity, is to be expected.

A child who is terminally ill with bone cancer is in severe pain. Nursing interventions should be based on which knowledge? 1 Children tend to be overmedicated for pain. 2 Giving large doses of opioids results in death. 3 Narcotic addiction is common in terminally ill children. 4 Large doses of opioids are justified when there are no other treatment options.

4 Large doses of opioids may be needed because the child has become physiologically tolerant of the drug, requiring higher doses to achieve the same degree of pain control. Pain is considered the fifth vital sign, and management of pain is critical to treatment of a child with bone cancer. Continuing studies report that children are consistently undermedicated for pain. The dosage of opioids is titrated to relieve pain, not to prevent death. Addiction is a psychologic dependence on the narcotic medication, which does not occur in terminal care.

What is the current understanding for how nonpharmacologic strategies for pain management work in children? 1 They make the pharmacologic strategies less effective. 2 They work faster than most pharmacologic strategies do. 3 The convince children that they are not experiencing pain. 4 They provide coping strategies that help reduce pain perception.

4 Nonpharmacologic techniques provide children with coping strategies that may help reduce pain perception. Nonpharmacologic techniques may enhance the effectiveness of pharmacologic strategies rather than making them less effective. Nonpharmacologic strategies may take longer to reduce pain perception than pharmacologic strategies do. Nonpharmacologic strategies do not trick children into believing that they are not experiencing pain.

A child is being seen in the emergency department with multiple facial abrasions and lacerations. A combination agent containing lidocaine, adrenaline, and tetracaine (LAT gel/tetraphen) is applied topically to the wounds. What is the purpose of this combination therapy? (p. 133) 1 Cleanse the wound 2 Promote scab formation 3 Prevent infection of the wound 4 Provide anesthesia to the wound

4 The combination of lidocaine, adrenaline, and tetracaine (LAT) provides anesthesia within 10 to 15 minutes of application. LAT has no cleansing effect, no effect on scab formation, and no antibacterial effect.

The nurse is asked to administer the prescribed dose of an analgesic via the oral route to a 7-year-old child. The nurse observes that the child is unwilling to take the medication orally. The nurse considers obtaining a prescription to change the route to intravenous (IV) administration. What is the nurse's first action? 1 The nurse uses a conversion table to calculate the dose. 2 The nurse administers the dose as prescribed in the original order. 3 The nurse documents the change of route in the records. 4 The nurse asks whether the child can take the medication intravenously.

4 The nurse assesses whether the child can take the medication intravenously and only then gets the prescription to change the medication route. The conversion table is used to calculate the dose when the change is made from oral to the IV route, because the measurement may be different for oral and IV doses. The nurse does not administer the dose as prescribed, because the dose needs to be calculated and administered according to the body weight of the child. The dose is documented after it is administered safely to the child.

Transdermal fentanyl is being used for an adolescent with cancer who is in hospice care. The adolescent has been comfortable for several hours but now complains of severe pain. What is the most appropriate nursing action? 1 Using a nonpharmacologic strategy 2 Administering meperidine intramuscularly 3 Placing another fentanyl patch on the adolescent 4 Administering morphine sulfate immediate release (MSIR) intravenously

4 The nurse should administer an immediate-release opioid, such as MSIR, intravenously for the breakthrough pain. Intramuscular (IM) injections should be avoided in cancer patients because of the increased risk of bleeding and the fact that IM injections do not take effect immediately. Nonpharmacologic strategies will not be effective in easing severe pain. Transdermal fentanyl will take as long as 24 hours to reach its peak effect and therefore is not effective against severe breakthrough pain.

A child indicates "worst possible pain" on the Word-Graphic Rating Scale. What medication is most appropriate to be ordered for the child as a substitute for morphine? 1 Ibuprofen 2 Acetaminophen 3 Meperidine 4 Hydromorphone

4 (guessed 3) The Word-Graphic Rating Scale is a pain assessment technique used in children of age group 4 years to 17 years. "Worst possible pain" has a score of 10 on the scale and can be treated by hydromorphone, an effective substitute for morphine. Ibuprofen and acetaminophen are used to treat mild pain in children. Meperidine is not the drug of choice, because it is associated with many side effects.