Prep U's - Chapter 9 - Pain Management

The client is scheduled for surgery. The nurse is reviewing with the client about postoperative pain management. The client states her goal after receiving treatment is "0." The first action of the nurse is to: A. Ensure the client is prescribed large doses of opioids postoperatively. B. Plan to use medication and nonpharmacologic interventions. C. Notify the surgeon of the client's goal of "0." D. Educate the client that this goal may not be achievable.

Answer: D Rationale: The client's goal of complete elimination of pain may be unrealistic. The nurse needs to first teach the client about setting an achievable goal. The nurse will plan to use a combination of pharmacologic and nonpharmacologic interventions for pain relief. The nurse may need to notify the surgeon of the client's goal of "0" for pain relief. The nurse does not ensure large doses of opioids are prescribed for the client. Many factors go into the prescription of medication for pain relief, including the client's response to the medication.

The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting: A. Medical interventions for pain management. B. Anticipated harmful effects of the pain experience. C. Anticipated duration of the pain. D. Severity of the pain as judged by the patient.

Answer: D Rationale: The patient's perception of pain severity should always be the primary consideration. It forms the baseline for all management.

The nurse plans nonpharmacologic interventions for a client who is approaching discharge after a left knee arthroplasty to address the client's pain. For each intervention, click to specify if the therapy indicates a physical modality (A), cognitive and behavioral method (B), or movement therapy (C) for the treatment of pain. Intervention: - Aquatic therapy - Relaxation breathing - Yoga - Imagery - Proper body alignment - Distraction - Application of heat or cold - Thai Chi

Answer: - A - B - C - A - B - C - A - B Rationale: Nonpharmacologic pain management strategies should be included in the plan of care for clients who experience acute pain during hospitalization. The application of heat or cold is a physical therapy the nurse includes in the client's plan of care to address postoperative pain. Treating pain with hot and cold can be extremely effective for a number of different conditions and injuries, with cold therapy being effective for acute injuries and hot therapy being effective for chronic pain. Relaxation is an example of a cognitive and behavioral method that the nurse includes in the client's plan of care to address postoperative pain. This nonpharmacologic pain management strategy releases endorphins, the body's natural pain killer. Yoga is a movement therapy that the nurse includes in the client's plan of care to address postoperative pain. By building strength, releasing muscle tension, improving flexibility, and bolstering joints and bones, yoga can bring the body into balance, thereby alleviating pain. Aquatic therapy is a physical therapy the nurse includes in the client's plan of care to address postoperative pain. Aquatic therapy uses the physical properties of water to assist in client healing and exercise performance as is supported by evidence-based practice (EBP) guidelines for the treatment of pain associated with knee arthroplasty. Distraction is an example of a cognitive and behavioral method that the nurse includes in the client's plan of care to address postoperative pain. Mental distractions block pain signals from the body before they ever reach the brain, thus distraction is an appropriate nonpharmacologic pain management strategy to include in this client's plan of care. Thai Chi is a movement therapy that the nurse includes in the client's plan of care to address postoperative pain. Thai Chi is a low-impact, slow-motion, mind-body exercise that combines breath control, meditation, and movements to stretch and strengthen muscles and can be an effective nonpharmacologic pain management strategy for a client who is postoperative for knee arthroplasty. Proper body alignment is a physical therapy the nurse includes in the client's plan of care to address postoperative pain. Making sure the client's hips, back, and head are in proper alignment can be a great way to prevent muscle strains, joint pain, or back pain after knee arthroplasty. Imagery is an example of a cognitive and behavioral method that the nurse includes in the client's plan of care to address postoperative pain. Guided imagery places the client's mind into a state of deep relaxation, reducing the presence of stress hormones, decreasing muscle tension, and ultimately shifting attention away from pain.

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing? A. Neuropathic pain. B. Visceral pain. C. Breakthrough pain. D. Referred pain.

Answer: A Rationale: An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Chronic pain sufferers may have periods of acute pain, which is referred to as breakthrough pain. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located.

A patient is complaining of a headache during epidural administration of an anesthetic agent. Which of the following nursing interventions should be completed? A. Keep the head of the bed flat. B. Place patient in semi-Fowler's position. C. No intervention is necessary. D. Maintain a dehydrated state.

Answer: A Rationale: If a headache develops, the patient should remain flat in bed, should be given large amounts of fluids (provided the medication condition allows), and the physician should be notified.

A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client: A. That medication will be prescribed for pain relief. B. That the nurse will notify the surgeon of his fear. C. How anxiety could increase his pain perception. D. About activities that would distract him from pain.

Answer: A Rationale: Pain is expected postoperatively, and the client should be reassured that medication will be prescribed to relieve pain. The client may have less pain knowing that measures will be taken to reduce it. Diversional activities may be used in addition to analgesics. Anxiety about pain could increase the client's perception of pain. Another nursing activity is being an advocate for the client and notifying his surgeon of the client's fear.

Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy? A. Risk for impaired gas exchange. B. Risk for injury. C. Diarrhea. D. Altered mobility.

Answer: A Rationale: Problems that may develop with opioid and opiate therapy include risk for impaired gas exchange related to respiratory depression, constipation related to slowed peristalsis, and risk for injury related to drowsiness and unsteady gait.

Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain? A. Do not administer if respirations are less than 12 breaths per minute. B. Monitor weight, vital signs, and serum glucose concentration. C. Avoid caffeine or other stimulants, such as decongestants. D. Monitor blood counts and liver function tests.

Answer: A Rationale: The nurse should not administer the prescribed opiate therapy if respirations are less than 12 breaths per minute. The nurse should instruct a client who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose concentration when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests.

A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the client: A. "Only you are to push the button for medication." B. "Whenever you hurt, push the button." C. "This will completely relieve your pain." D. "Wait until your pain is severe before pushing the button."

Answer: A Rationale: With a PCA machine, clients control the administration of their pain medication within prescribed parameters. Family members or other visitors should not push the button on the PCA machine for the client; doing so overrides the safety features of the machine. Clients may become frustrated if pushing the button frequently does not result in pain relief. The nurse needs to instruct the client about time limits. Other instructions include not waiting until the pain is severe before pushing the button and that the PCA machine is used to control pain.

When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress? A. Chance of sedation is rare when using a PCA pump. B. The pump will deliver a preset amount of medication. C. The client should wait until the pain is severe to push the button to prevent overdose. D. Teach the client to avoid pushing the button multiple times because additional doses will be given.

Answer: B Rationale: A client experiencing pain can administer small amounts of medication directly into the IV, subcutaneous, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The client should not wait until the pain is severe to push the button. Even if the client pushes the button multiple times in rapid succession, no additional doses are released because of the preset lock-out time. Sedation can occur with the use of the PCA pump. Assessment of respiratory status remains a major nursing role.

A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect? A. Dependence B. Addiction C. Tolerance D. Placebo

Answer: B Rationale: Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a client who has been taking opioids becomes less sensitive to their analgesic properties.

The nurse is obtaining data regarding medications the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving? A. Withdrawal therapy. B. Adjuvant drug therapy. C. Replacement drug therapy. D. Alternate drug therapy.

Answer: B Rationale: Adjuvant drugs are medications that are ordinarily administered for reasons other than treating pain. Duloxetine is used to treat depression but is being used for neuropathic pain for this client.

When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose? A. Hyper alertness B. Confusion C. Hyperventilation D. Insomnia

Answer: B Rationale: Patients should be informed about signs and symptoms of fentanyl overdose such as shallow or difficulty breathing, extreme sleepiness, confusion, sedation. Hyper alertness, hyperventilation, and insomnia would not occur.

A new surgical patient has been prescribed an opioid analgesic intravenously for pain control. The nurse should be aware of which most serious adverse effect of this medication? A. Nausea and vomiting. B. Respiratory depression. C. Pruritus. D. Constipation.

Answer: B Rationale: Respiratory depression is the most serious adverse effect of opioid analgesic agents administered by IV, subcutaneous, or epidural routes. The other side effects can occur with administration of opioids but are not the most serious.

Which condition is a heightened response that occurs after exposure to a noxious stimulus? A. Pain tolerance B. Sensitization C. Pain threshold D. Dependence

Answer: B Rationale: Sensitization is a heightened response that occurs after exposure to a noxious stimulus. Pain tolerance is the maximum intensity or duration of pain that a person is willing to endure. Pain threshold is the point at which a stimulus is perceived as painful. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued.

Which of the following is a true statement with regards to the preventative approach to the use of analgesics? A. It promotes tolerance to analgesic agents. B. Smaller doses of medication are needed. C. The use increases peaks and troughs in the serum level. D. Larger doses of medication are needed.

Answer: B Rationale: Smaller doses of medication are needed with the preventative approach, because the pain does not escalate to a level of severe intensity. A preventative approach may result in the administration of less medication over a 24-hour period, helping prevent tolerance to analgesic agents and decreasing the severity of side effects. The preventative approach reduces the peaks and troughs in the serum level and provides more pain relief with fewer side effects.

Which route of administration of medication is preferred in the most acute care situations? A. Epidural B. Intravenous C. Intramuscular D. Subcutaneous

Answer: B Rationale: The intravenous route is the preferred parenteral route in most acute care situations because it is much more comfortable for the client and peak serum concentrations and pain relief occur more rapidly and reliably. Epidural administration is used to control postoperative and chronic pain. Subcutaneous administration results in slow absorption of medication. Medication administered intramuscularly is absorbed more slowly than intravenously administered medication.

Which of the following is true regarding the use of narcotic analgesics in older adults? A. A short duration of pain relief is achieved. B. There is an increased potential for falls related to sedation. C. An increased dosage is necessary for desired effect. D. There is a decreased susceptibility to drug reactions.

Answer: B Rationale: The risk of increased accumulation of narcotics, benzodiazepines, or antidepressants also increases potential for falls from sedation and changes in cognitive functioning. A longer duration of pain relief is achieved. A lower dosage is necessary in older adults for a desired effect. There is an increased susceptibility to drug reactions.

Which of the following is the appropriate intervention to avoid physical withdrawal on drugs in a client? A. Increase dosage of the drug. B. Discontinue drugs gradually. C. Administer subtherapeutic doses. D. Administer adjuvant drugs along with the prescribed drug.

Answer: B Rationale: To avoid withdrawal symptoms, drugs that are known to cause physical dependence are discontinued gradually. The most appropriate nursing action to avoid tolerance is to consult with the physician for an increased dosage of the drug. Subtherapeutic dosages and adjuvant drugs are not needed to avoid physical dependence of drugs in a client.

The nurse informs the patient that a preventive approach for pain relief will be used, involving nonsteroidal anti-inflammatory drugs. What will this mean for the patient? A. The pain medication will be administered when the pain is at its peak. B. The pain medication will be administered before the pain is experienced. C. The pain medication will be administered when the level of pain tolerance has been exceeded. D. The pain medication will be administered before the pain becomes severe.

Answer: B Rationale: Two basic principles of providing effective pain management are preventing pain and maintaining a pain intensity that allows the patient to accomplish functional or quality-of-life goals with relative ease (Pasero, Quinn et al., 2011). Accomplishment of these goals may require the mainstay analgesic agent to be administered on a scheduled around-the-clock (ATC) basis, rather than PRN (as needed) to maintain stable analgesic blood levels.

A client is being taught to self-administer a narcotic analgesic by means of an intravenous PCA pump system. Which of the following would help prevent accidental overdosage? A. Reducing the frequency of administration of the narcotic analgesic. B. Programming the dosage and time interval into the device. C. Reducing the dosage of the narcotic analgesic. D. Drawing up a schedule chart for the client.

Answer: B Rationale: When the client is being taught to self-administer a narcotic analgesic, the dosage and time interval between doses are programmed into the PCA intravenous pump system to prevent accidental overdosage. The frequency or dosage of the narcotic analgesic need not be reduced. Although a schedule chart is useful to the client, it does not effectively prevent accidental overdosage.

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply. A. "You've never had this pain before, have you?" B. "What aggravates your chest pain?" C. "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." D. "Please point to where you are experiencing pain." E. "How long have you experienced this pain?"

Answer: B, C, D, E Rationale: The nurse needs to assess pain as to intensity, timing, location, and aggravating factors. Assessing frequency is important, but the statement "You've never had this pain before, have you" is leading and nontherapeutic.

The nurse administered an analgesic to a client who was reporting pain. The medication is ordered as needed every 3 hours. Forty minutes later the client states he has had little relief. The nurse does the following: (Select all that apply.) A. states, "I can administer the medication to you in about 2 hours". B. consults with the healthcare provider about the client's report. C. assesses respirations, pulse, and blood pressure. D. plans to place the client in a position of comfort when pain is relieved. E. evaluates the pain level using the established pain scale.

Answer: B, C, E Rationale: The dose of the pain medication is ineffective in relieving the client's pain. The nurse evaluates client response using the same pain scale and vital signs. The nurse may need to consult with the healthcare provider and inform of the ineffectiveness of the medication. The nurse places the client in a position of comfort to enhance effectiveness of the medication now, not later. The nurse's statement delays appropriate treatment for the client.

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse? A. "You are so brave to not take your pain medication when the dressing change will hurt." B. "If you need pain relief, I can give you some medication when I have completed the dressing change." C. "I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication." D. "You are so right to not take your pain medication. You can become dependent on the medication."

Answer: C Rationale: The nurse needs to explore the reason a client denies pain when pain is expected during a treatment, as with a dressing change to burns, and when the client grimaces during the dressing change. The nurse needs to educate clients about effects of pain on recovery. The nurse also cannot ignore that pain relief will hasten recovery. The nurse should not allow the client to associate pain with his dressing changes.

An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client? A. Exercise regularly. B. Reduce fiber intake. C. Follow a bowel regimen. D. Avoid harsh sunlight.

Answer: C Rationale: The nurse should ensure that a bowel regimen to prevent constipation is started when any older adult is treated with opioids. A high-fiber diet along with increased fluids should be encouraged. The client should not reduce fiber intake because this increases the risk for constipation. The client need not exercise regularly or avoid harsh sunlight because these have no effects on the drug therapy.

The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective? A. Consult with the health care prescriber to include hydroxyzine with the opioid. B. Provide the client with a fresh gown. C. Position the client for comfort. D. Encourage the client to eat crackers.

Answer: C Rationale: The nurse should provide a comfort level with positioning first. Hydroxyzine may be given with opioid analgesics. However, elderly clients are more susceptible to adverse reactions of this medication, and alternative measures should be tried first. Providing a fresh gown will not make the medication more effective. Ingesting food with an opioid medication does not make the medication more effective.

A nurse is caring for a client with pain. What should the nurse monitor for when administering intravenous acetaminophen? A. renal toxicity B. bleeding C. hepatotoxicity D. gastrointestinal effects

Answer: C Rationale: The nurse will need to monitor the client receiving acetaminophen for hepatotoxicity. Intravenous acetaminophen should not cause renal toxicity, bleeding, and gastrointestinal effects.

A client reports having joint pain that has gotten worse over the last year despite gradually increasing doses of an OTC pain reliever. Which type of pain will the nurse document as the chief complaint? A. referred pain. B. breakthrough pain. C. chronic pain. D. acute pain.

Answer: C Rationale: This client is experiencing chronic pain, which is pain or discomfort that lasts for a period longer than 6 months. Pain or discomfort with a short duration is acute pain. It is associated with trauma, injury, or surgery. Referred pain is pain felt in the body in a location that is different from the actual source of the pain. Breakthrough pain is a period of acute pain experienced by those suffering from chronic pain.

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission? A. A patient taking tramadol to enhance pain management. B. A surgeon making an incision to perform surgery. C. A child quickly removing a hand when touching a hot object. D. A mother in labor utilizing imagery to reduce pain.

Answer: C Rationale: Transduction, the first process involved in nociception, refers to the processes by which a noxious stimulus, such as a burn, releases of a number of excitatory compounds, which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual-mechanism analgesic agent, such as tramadol, involves many different neurochemicals as in the process of modulation.

When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use? A. Intermittent B. Severe C. Burning D. Chronic

Answer: C Rationale: When asking the patient to describe how the pain feels, the nurse should suggest to the patient descriptors such as "sharp," "shooting," or "burning," which may help identify the presence of neuropathic pain.

Which of the following is a disadvantage of using the transdermal route of opioid administration? A. Slightly less constipation noted than with oral opioids. B. A constant opioid serum level. C. Less costly than parenteral route. D. A delay in effect until the dermal layer is saturated.

Answer: D Rationale: A disadvantage of using the transdermal route of administration is that there is a delay in effect when the dermal layer is saturated. Advantages include a consistent opioid serum level, slightly less constipation than with oral opioids, and less cost as compared to the parenteral route.

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be: A. Rapidly occurring and subsiding with treatment. B. Attributed to a specific cause. C. Separate from any central or peripheral pathology. D. Prolonged in duration.

Answer: D Rationale: A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged.

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain. A. Appendicitis B. A migraine headache C. Angina D. Intervertebral disk herniation

Answer: D Rationale: Chronic pain is found with degeneration or traumatic conditions and can sometimes be the cause of the patient's primary disorder. The other three choices refer to acute pain. Migraines could be chronic pain but are not the best example here.

The client experienced abdominal surgery the previous day and has just received an opioid medication for report of pain. The client is sitting in a chair next to the bed. An additional activity that the nurse uses to relieve pain is: A. have the client deep breathe and hold. B. assist the client to ambulate on the nursing unit. C. apply ice to the incision site for 30 minutes. D. encourage the client to watch television.

Answer: D Rationale: Distraction, such as watching television, helps relieve pain. Ice may be applied for 15 to 20 minutes at a time but may be uncomfortable when applied to the abdomen. Ambulating has other benefits for the client but may not relieve pain. The client should concentrate on breathing slowly in and out, not hold the breath.

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain? A. Hypotension B. Bradycardia C. Decreased respiratory rate. D. Diaphoresis

Answer: D Rationale: Observe behavioral signs, e.g., facial expressions, crying, restlessness, diaphoresis (sweating), and changes in activity. A pain behavior in one patient may not be in another. Try to identify pain behaviors that are unique to the patient ("pain signature"). Increased heart rate, blood pressure, and respiratory rate would be more likely to be associated with pain rather than decreased levels of these measures.

The nurse is administering an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully? A. Older people have increased hepatic, renal, and gastrointestinal function. B. Older people metabolize drugs more rapidly. C. Older people have lower ratios of body fat and muscle mass. D. Older people are more sensitive to drugs.

Answer: D Rationale: Older adults are often sensitive to the effects of the adjuvant analgesic agents that produce sedation and other CNS effects, such as antidepressants and anticonvulsants. Therapy should be initiated with low doses, and titration should proceed slowly with systematic assessment of patient response.

A client is recovering from abdominal surgery and sleeping. The client had received an opioid medication 3 hours ago. The client's son requests pain medication for the client, stating "I do not want her to wake up in pain." The first nursing action is: A. Administer the prescribed medication. B. Wake the client and ask about her pain rating. C. Refuse to administer the pain medication. D. Instruct the son about lack of client consent.

Answer: D Rationale: One of the client's rights is to participate in management of his or her own care. The nurse follows the nursing process by assessing the client's perception of pain but does not awaken the client to do this. The nurse can administer the pain medication only after assessment. The nurse does not administer the pain medication but does take the opportunity to educate the son.

The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering? A. Nubain B. Buprenex C. Stadol D. Fentanyl

Answer: D Rationale: Opioid analgesic agents are divided into two major groups: (1) mu agonist opioids (also called morphine-like drugs) and (2) agonist-antagonist opioids. The mu agonist opioids comprise the larger of the two groups and include morphine, hydromorphone, hydrocodone, fentanyl, oxycodone, and methadone, among others. The agonist-antagonist opioids include buprenorphine (Buprenex, Butrans), nalbuphine (Nubain), and butorphanol (Stadol).

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client? A. Administering the analgesics on an as needed per client request. B. Administering analgesics with increased dosage. C. Administering the analgesics intravenously. D. Administering the analgesics on a regular basis.

Answer: D Rationale: Routine scheduling of the administration of analgesics, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client? A. Administering the analgesics on an as needed basis. B. Administering the analgesics intravenously. C. Administering analgesics with increased dosage. D. Administering the analgesics every three hours.

Answer: D Rationale: Scheduling the administration of analgesics every three hours, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician.