Chapter 11: Pain Management

A nurse on an oncology unit has arranged for an individual to lead meditation exercises for clients who are interested in this nonpharmacologic method of pain control. The nurse should recognize the use of what category of nonpharmacologic intervention? a. A body-based modality b. A mind-body method c. A biologically based therapy d. An energy therapy

b Meditation is one of the recognized mind-body methods of nonpharmacologic pain control. The other answers are incorrect.

Which condition, approved by the U.S. Food and Drug Administration, is the only use for the lidocaine 5% patch? a. Postherpetic neuralgia b. Epidural anesthesia c. General anesthesia d. Diabetic neuropathy

a A lidocaine 5% patch has been approved for use in postherpetic neuralgia, though research suggests that is effective and safe for a wide variety of acute and chronic pain conditions. A lidocaine 5% patch has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.

A preventative approach to pain relief with non-steroidal anti-inflammatory drugs (NSAIDs) means that the medication is given: a. Before pain becomes severe. b. Before pain is experienced. c. When pain is at its peak. d. When the level of pain tolerance has been exceeded.

b NSAIDs are most effective for preventive pain management when administered on a fixed-schedule (i.e., every 3-4 hours) to prevent the pain experience. When combined with an opioid, the medication regimen is highly effective in managing moderate to severe pain.

The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for? a. Asystole b. Hypertension c. Bradypnea d. Tachycardia

c Most patients experience sedation at the beginning of opioid therapy and whenever the opioid dose is increased significantly. If left untreated, excessive sedation can progress to clinically significant respiratory depression (bradypnea, or reduced breathing rate).

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 metabolize drugs more rapidly. b. Older people have increased hepatic, renal, and gastrointestinal function. c. Older people are more sensitive to drugs. d. Older people have lower ratios of body fat and muscle mass.

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 patient who is postoperative day 1 following a discectomy has lit his call light and requested a dose of hydromorphone, which he receives on a p.r.n. basis for breakthrough pain. What should the nurse first do in response to the patient's request? a. Assess the characteristics of the patient's pain. b. Draw up the prescribed dose of hydromorphone. c. Propose the use of nonpharmacologic interventions. d. Discuss the use of NSAIDs as an alternative to opioids.

The most appropriate immediate response to a patient's complaint of pain is an assessment of characteristics such as intensity, quality, onset, location, timing, associated or aggravating factors, and radiation. This assessment should normally precede the nurse's chosen interventions.

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. Burning b. Chronic c. Intermittent d. Severe

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.

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

a 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 10-year-old client twisted an ankle playing soccer. The ankle can't support weight and has already begun to swell despite application of an ice pack. As part of the pain assessment, the nurse must determine the intensity of the client's pain. Which question will the nurse ask to obtain this information? a."Which one of the faces on this card shows how much your ankle hurts?" b. "How long ago did you hurt your ankle?" c. "Do you feel the pain only in your ankle or does it hurt anywhere else?" d. "Tell me if it hurts when I touch your ankle here."

a Adult patients are asked to report the intensity of their pain using a word scale, linear scale, or a numeric scale of 1 to 10. The Wong-Baker FACES Pain Rating Scale is an assessment tool used with children, the mentally challenged, and patients who would have difficulty understanding other assessment tools. Patients are asked to describe their pain by choosing a face that depicts how much they hurt. Intensity is not related to the timing of the injury, the general location of the pain, or the specific location of pain in the ankle.

The nurse is caring for a client with metastatic bone cancer. The client asks the nurse why he has had to keep getting larger doses of his pain medication, although they do not seem to affect him. What is the nurse's best response? a. "Over time you become more tolerant of the drug." b. "You may have become immune to the effects of the drug." c. "You may be developing a mild addiction to the drug." d. "Your body absorbs less of the drug due to the cancer."

a Over time, the client is likely to become more tolerant of the dosage. Little evidence indicates that clients with cancer become addicted to the opioid medications. Clients do not become immune to the effects of the drug, and the body does not absorb less of the drug because of the cancer.

The nurse understands that which statement is true about tolerance and addiction? a. Although clients may need increasing levels of opioids, they are not addicted. b. Tolerance to opioids is uncommon. c. Addiction to opioids commonly develops. d. The nurse must be primarily concerned about development of addiction by a client in pain.

a Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.

Which is a gastrointestinal route for administration of analgesics? a. Rectal b. Epidural space c. Oral mucosa d. Subcutaneous

a A gastrointestinal route of administration of analgesics is the rectal route. The epidural space, oral mucosa, and subcutaneous sites are not related to the gastrointestinal route.

Opioid analgesics are effective pain management tools for many clients. A significant portion of a nurse's practice is older adults who suffer from chronic pain. What impact does a client's age have on initial dosing? a. Older clients should receive a reduced dose. b. Older clients should receive an increased dose. c. Opioid analgesics should not be used to treat older adults. d. Age has no impact on dosing.

a A reduced dose of analgesics, especially opioid analgesics, may be prescribed for the older adult initially because older adults experience a higher peak effect and longer duration of pain relief from an opioid. An increased dose is not generally recommended for older adults. Opioid analgesics can be used to treat older adults, but there are special dosing considerations.

A home health nursing practice has 7 out of 10 clients who are over the age of 65. Understanding the prevalence of noncancerous chronic pain among those over 65, how many of the clients would the nurse expect to experience chronic pain? a. 5 b. 3 c. 2 d. 0

a At least 70% of all persons over 65 years of age experience noncancerous chronic pain, primarily due to osteoarthritis and neuralgia (Davis et al., 2002).

The nurse who is a member of the palliative care team is assessing a client. The client indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this client? a. Medication should be taken when pain levels are low so the pain is easier to reduce. b. Pain medication can be increased when the pain becomes intense. c. It is difficult to control chronic pain, so this is an inevitable part of the disease process. d. The client will likely benefit more from distraction than pharmacologic interventions.

a Better pain control can be achieved with a preventive approach, reducing the amount of time clients are in pain. Low levels of pain are easier to reduce or control than intense levels of pain. Pain medication is used to prevent pain so pain medication is not increased when pain becomes intense. Chronic pain is treatable. Giving the client alternative methods to control pain is good, but it will not work if the client is in so much pain that he cannot institute reliable alternative methods.

Which substance reduces the transmission of pain? a. Endorphins b. Acetylcholine c. Serotonin d. Substance P

a Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses a. That the client's past experiences with pain may influence her perception of current pain b. That based on her past experiences the client's perception of pain should be less c. That the client has become dependent on drugs from her previous experience of burns d. That the client is experiencing pain relating to the burn injuries from several years ago

a Clients who have had previous experiences with pain are usually more frightened about subsequent painful events, as in the client who experienced partial-thickness burns to more than 60% of her body. The clients in these situations are less able to tolerate pain. Insufficient data in the stem support that the client is dependent on drugs or that this current pain is related to the client's previous burn injuries.

The decision to order an opioid dosage for an elderly patient that is slightly smaller than the dose of medication prescribed for younger patients is based on the following physiologic reason: a. Increased metabolism results in higher blood levels. b. Decreased renal excretion of drugs increases toxic levels. c. Some opioids have increased binding by plasma proteins. d. Susceptibility to respiratory system depression is lowered.

b In the elderly, metabolism tends to decrease, respiratory system depression is increased, and metabolism is decreased. The kidneys tend to decrease renal excretion.

A patient with a spirally fractured femur had surgical repair of the bone. After surgery, the client reports a pain rating of 7 (on a 0 to 10 scale). How would the nurse expect the client to describe the characteristics of the pain? a. local, sharp, intense b. generalized, dull, aching c. burning, sharp discomfort d. dull intermittent ache

a Deeper somatic pain such as that caused by trauma (e.g., a fracture) produces localized sensations that are sharp, throbbing, and intense. A generalized, dull, or aching pain is associated with visceral pain, which is not what this client is experiencing. A sharp, burning discomfort is associated with superficial somatic pain (cutaneous pain), such as that from an insect bite, not with a more significant injury such as a fracture requiring surgery. An intermittent dull ache is not intense and would not be rated as a 7 on a 0 to 10 pain scale.

Two clients have recently returned to the postsurgical unit after knee arthroplasty. One client is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other client is reporting a pain level of 3 to 4 on the same pain scale. What is the nurse's most plausible rationale for understanding the clients' different perceptions of pain? a. Endorphin levels may vary between clients, affecting the perception of pain. b. One of the clients is exaggerating the sense of pain. c. The clients are likely experiencing a variance in vasoconstriction. d. One of the clients may be experiencing opioid tolerance.

a Different people feel different degrees of pain from similar stimuli. Opioid tolerance is associated with chronic pain treatment and would not likely apply to these clients. The nurse should not assume the client is exaggerating the pain because the client is the best authority of their existence of pain, and definitions for pain state that pain is "whatever the person says it is, existing whenever the experiencing person says it does."

A 64-year-old client is experiencing joint pain on a regular basis and asks the nurse what the options are beyond heat and the yoga exercises the client has been doing. What does the nurse describe as the cornerstone treatment modality for pain? a. drug therapy b. physical therapy c. acupuncture d. psychological counseling

a Drug therapy is the primary method used for pain management. Physical therapy is often used as a co therapy, along with prescription or nonprescription drugs. It can help to strengthen muscles weakened by disuse. Acupuncture is a pain management technique that involves the insertion of very thin needles at strategic points on the body. It is not a primary therapy in conventional Western medicine. Psychological counseling may be recommended in some cases to help clients deal with depression and anxiety associated with pain. It is not a primary therapy.

The nurse applies a transdermal patch of fentanyl for a client with pain due to cancer of the pancreas. The client puts the call light on 1 hour later and tells the nurse that it has not helped. What is the best response by the nurse? a. "It will take approximately 12 to 18 hours for the medication to begin to work, so I will give you something else now to relieve the pain." b. "It should have begun working 30 minutes ago. I will call the doctor and let the doctor know you need something stronger." c. "You have probably developed a tolerance to the medication." d. "It will take about 24 hours for the medication to work. I can't give you anything else or you will overdose."

a Its lipophilicity makes fentanyl ideal for drug delivery by transdermal patch (Duragesic) for long-term opioid administration and by the oral transmucosal (Actiq) and buccal (Fentora) routes for BTP treatment in patients who are opioid tolerant. Following application of the transdermal patch, a subcutaneous depot of fentanyl is established in the skin near the patch. After absorption from the depot into the systemic circulation, the drug distributes to fat and muscle. When the first patch is applied, 12 to 18 hours are required for clinically significant analgesia to be obtained; attention must be paid to providing adequate supplemental analgesia during that time.

According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment? a. location, onset, alleviating factors, and aggravating factors b. quality, location, intensity, and family history c. nutritional deficiencies, onset, duration, and effects of pain d. intensity, variations, range of motion, and the client's goal for pain control

a Location, onset, alleviating factors, and aggravating factors are all essential components of a comprehensive pain assessment according to The Joint Commission's standards. Family history is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Nutritional deficiencies are not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Range of motion is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards.

A client is on a second round of radiation therapy for an inoperable tumor, and asks the nurse for medication to help with pain. The nurse suspects that the client's pain is the result of nerve damage from the radiation. Which type of pain is the client likely experiencing? a. neuropathic pain b. somatic pain c. visceral pain d. referred pain

a Neuropathic pain can affect cancer patients due to nerve damage from chemotherapy or radiation therapy. Somatic pain is caused by damage or disorders that affect bones, joints, muscles, skin, or other structures. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is pain felt in the body in a location that is different from the actual source of the pain.

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain? a. Diaphoresis b. Bradycardia c. Hypotension d. Decreased respiratory rate

a 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 has been frequently assessing an older adult's pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a client of this age, what principle should the nurse best apply? a. Monitor for signs of drug toxicity due to a decrease in metabolism. b. Monitor for an increase in absorption of the drug due to age-related changes. c. Monitor for a paradoxical increase in pain with opioid administration. d. Administer analgesics every 4 to 6 hours as prescribed to control pain.

a Older adults may respond differently to pain than younger adults. Because elderly people have a slower metabolism and a greater ratio of body fat to muscle mass compared with younger people, small doses of analgesic agents may be sufficient to relieve pain, and these doses may be effective longer. This fact also corresponds to an increased risk of adverse effects. Paradoxical effects are not a common phenomenon. Frequency of administration will vary widely according to numerous variables.

A client suffers from osteoarthritis and is prescribed a scheduled dose of analgesics to manage chronic pain. Because of limited income, the client sometimes skips doses or takes half doses to "make the medicine last longer." To ensure uniform pain management, the nurse should advise the client to: a. take medication doses when ordered. b. reduce all doses to the amount of the lowest dose. c. take pain medication on an "as needed" basis. d. None of the responses is correct.

a Pain management cannot be effective if medication is not consistently used. Especially for chronic pain, medication doses should never be skipped or reduced without physician input. Because chronic pain is pain that continues for an extended period of time (6 months or more), pain management cannot be effective if medication is not consistently used.

A client who is recovering from knee replacement surgery asks for the lowest possible dose of pain medication, and reports having been able to handle pain ever since childhood. Which of the following aspects of pain is the client describing to the nurse? a. tolerance b. threshold c. perception d. transmission

a Pain tolerance is the amount of pain a person can endure once the pain threshold has been reached. The pain threshold is the point at which pain-transmitting chemicals reach the brain, resulting in conscious awareness of the pain. Pain perception is the phase of impulse transmission during which the brain experiences pain at a conscious level. Pain transmission is the phase of impulse transmission during which peripheral nerve fibers form synapses with neurons in the spinal cord. The pain impulses move from the spinal cord to sequentially higher levels in the brain.

A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about? a. the limits on dose and frequency that are programmed into the PCA b. the fact that naloxone will be kept readily available at all times c. the use of non-pharmacologic pain interventions to minimize use of the PCA d. the importance of limiting the use of the PCA to no more than twice per hour

a Patient-controlled analgesia (PCA) devices allow clients to self-administer their own narcotic analgesic using an intravenous pump system and pressing a handheld button. The dose and time intervals between doses are programmed into the device to prevent accidental overdose. Dosing may or may not be more than twice per hour. Naloxone treats overdoses, but this will not likely alleviate the client's concerns about overdosing in the first place. The client may benefit from non-pharmacologic pain measures, but should not be encouraged to minimize the use of the PCA or to endure pain.

A patient is being seen in the health clinic for chronic headaches. He has been using pain medications on a regular basis. Which of the following would be part of the teaching plan for a patient? a. Inform the primary health care provider about the use of salicylates before any procedure. b. Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. c. Minimize the intake of fiber during the therapy. d. Consume the medications just before or along with meals.

a Patients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the patient to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Patients need not avoid harsh sunlight after administering analgesic agents; these drugs do not cause photosensitivity.

Regarding tolerance and addiction, the nurse understands that a. although clients may need increasing levels of opioids, they are not addicted. b. tolerance to opioids is uncommon. c. addiction to opioids often develops. d. the nurse must be primarily concerned about the development of addiction by a client in pain.

a Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.

In which situation is it most likely that pain management may not be readily forthcoming to an adult client in pain? a. The client's expressions of pain do not match the nurse's expectations. b. Analgesics are contraindicated for the client's condition. c. A numeric scale is used to assess pain intensity. d. The pain is chronic.

a Responses to pain and coping techniques are learned, and clients may express them in a variety of ways. If a client's expressions of pain are inconsistent with the nurse's expectations, pain management may not be readily forthcoming, and the client's pain may be undertreated. Analgesics may be contraindicated in certain situations, but efforts should still be made to alleviate a client's pain. The use of a numeric scale for pain assessment is not related to the lack of pain management. The risk for improper management of pain does not increase specifically in the case of chronic pain.

The home health nurse is developing a plan of care for a client who will be managing his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the client teaching? a. Self-care and safety b. Autonomy and need c. Health promotion and exercise d. Dependence and health

a The client will be at home monitoring his own pain management, administering his own medication, and monitoring and reporting side effects. This requires the ability to perform self-care activities in a safe manner. Creating autonomy is important, but need is a poorly defined concept. Health promotion is an important global concept for maintaining health, and exercise is an appropriate activity; however, self-care and safety are the priorities. Dependence is not a concept used to develop a nursing plan of care, and health is too broad a concept to use as a basis for a nursing plan of care.

The nurse is receiving an older adult client from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that the client has been agitated in the past following opioid administration. What principle should guide the nurse's management of the client's pain? a. The elderly may require lower doses of medication and are easily confused with new medications. b. The elderly may have altered absorption and metabolism, which prohibits the use of opioids. c. The elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication. d. The elderly may require a higher initial dose of pain medication followed by a tapered dose.

a The elderly often require lower doses of medication and are easily confused with new medications. The elderly have slowed metabolism and excretion, and, therefore, the elderly should receive a lower dose of pain medication given over a longer period of time, which may help to limit the potential for confusion. Unfortunately, the elderly are often given the same dose as younger adults, and the resulting confusion is attributed to other factors like environment. Opioids are not absolutely contraindicated and confusion following surgery is never normal. Medication should begin at a low dose and slowly increase until the pain is managed.

When the nurse is performing an assessment and finds no physical cause for a patient's pain, what should the nurse do when the patient continues to complain of pain? a. Believe a patient when he or she states that pain is present. b. Doubt that pain exists when no physical origin can be identified. c. Realize that patients frequently imagine and state that they have pain without actually feeling painful sensations. d. Assume that the patient may be a drug seeker and should be given other methods for pain control.

a The highly subjective nature of pain causes challenges in assessment and management; however, the patient's self-report is the undisputed standard for assessing the existence and intensity of pain (APS, 2008; McCaffery et al., 2011). Accepting and acting on the patient's report of pain are sometimes difficult. Because pain cannot be proved, the health care team is vulnerable to inaccurate or untruthful reports of pain. Clinicians are entitled to their personal doubts and opinions, but those doubts and opinions cannot be allowed to interfere with appropriate patient care.

A client is admitted to the trauma unit after being injured in an industrial accident. The nurse needs to carefully monitor traumatic injuries. How often should the nurse assess and document the client's pain? a. every time the client's vital signs are assessed b. upon the client's admission and discharge c. an hour after analgesics are administered d. an hour after every meal the client consumes

a The nurse should check and document the client's pain every time the client's temperature, pulse, respirations, and blood pressure are assessed. The American Pain Society (APS) has proposed that pain assessment should be considered the fifth vital sign. Pain assessment should be done on a different schedule that is not related to drug administration or food consumption. An hour after administration may be too long to wait for assessment of the effects of the intervention.

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. Severity of the pain as judged by the patient b. Anticipated harmful effects of the pain experience c. Anticipated duration of the pain d. Medical interventions for pain management

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

A client has been taking opioid analgesics for more than 2 weeks to control post-surgical pain. Although pleased with the client's progress, the surgeon decides to change the analgesic to a non-opioid drug. The surgeon prescribes a gradually lower opioid dose and increasingly larger non-opioid doses. The surgeon is changing medications in this manner to avoid: a. withdrawal symptoms. b. addiction. c. tolerance. d. respiratory depression.

a To avoid withdrawal symptoms, drugs that are known to cause physical dependence are discontinued gradually. The dosage or the frequency of their administration is lowered over 1 week or longer. The process described is not used in cases of drug addiction. Tolerance is a condition in which a client needs larger doses of a drug to achieve the same effect as when first administered. The process described is not used to address drug tolerance. Although respiratory depression is a risk associated with opioid therapy, this client has not shown any sign of respiratory problems.

A client who has undergone extensive fracture repair continues to request opioid pain medication with increasing frequency. The initial surgeries occurred more than 2 months ago, and the nurse is concerned about the repeated requests. What does the nurse suspect to be the cause of the client's frequent appeals for pain medication? a. tolerance b. addiction c. drug allergy d. poor quality control by the drug manufacturer

a Tolerance is a condition in which a client needs larger doses of a drug to achieve the same effect as when first administered; it may not develop until an opioid drug is used regularly for 4 weeks or more. Activation of NMDA receptors is believed to decrease the effect of opioids, resulting in the need for higher doses to achieve a therapeutic effect. The development of tolerance is not an indication of addiction; rather, the client's request for pain-relieving drugs more often is a consequence of poor pain control. Addiction is a repetitive pattern of drug seeking and drug use to satisfy a craving for a drug's mind-altering or mood-altering effects. Although opioid drugs can result in addiction, there is very little evidence that those who require narcotics for legitimate pain actually become addicted. An allergic reaction to a drug could present many symptoms, such as a rash, hives, or difficulty breathing, but it would not result in a client requesting increased medication. Most prescription drugs are manufactured using strict quality control standards, so poor quality control is not likely to be a reason for the client's request for increased medication.

The nurse is caring for a client with sickle cell disease who lives in the community. Over the years, there has been joint damage, and the client is in chronic pain. The client has developed a tolerance to her usual pain medication. When does the tolerance to pain medication become the most significant problem? a. When it results in inadequate relief from pain b. When dealing with withdrawal symptoms resulting from the tolerance c. When having to report the client's addiction to her physician d. When the family becomes concerned about increasing dosage

a Tolerance to opioids is common and becomes a problem primarily in terms of maintaining adequate pain control. Symptoms of physical dependence may occur when opiates are discontinued, but there is no indication that the client's medication will be discontinued. This client does not have an addiction and the family's concerns are secondary to those of the client.

A client is experiencing severe pain after suffering an electrical burn in a workplace accident. The nurse is applying knowledge of the pathophysiology of pain when planning this client's nursing care. What is the physiologic process by which noxious stimuli, such as burns, activate nociceptors? a. Transduction b. Transmission c. Perception d. Modulation

a Transduction refers to the processes by which noxious stimuli, such as a surgical incision or burn, activate primary afferent neurons called nociceptors. Transmission, perception, and modulation are subsequent to this process.

A client is reporting her pain as "8" on a 0-to-10 pain intensity scale. Then, the client states the pain is "3." Before the nurse leaves the room, the client states her pain is "6." The best action of the nurse is to a. Obtain a pain scale with faces for the client to measure her pain. b. Average the numbers and report that number as the client's level of pain. c. Medicate the client for pain based on the highest number of "8." d. Record each of the numbers the client stated for her pain.

a Various scales are helpful to clients trying to describe pain intensity. If the client cannot use one scale, such as the numeric pain intensity scale, the nurse uses another pain intensity scale that the client finds easy to understand and use. The nurse does not average the numbers, medicate based on the highest number, nor record each of the numbers the client stated.

A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing? a. visceral b. neuropathic c. deeper somatic d. chronic

a Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Visceral pain usually is diffuse, poorly localized, and accompanied by autonomic nervous system symptoms such as nausea, vomiting, pallor, hypotension, and sweating. Neuropathic pain is pain that is processed abnormally by the nervous system. Deeper somatic pain such as that caused by trauma produces localized sensations that are sharp, throbbing, and intense. Chronic pain has a duration longer than 6 months.

Prostaglandins are chemical substances with what property? a. Increase the sensitivity of pain receptors b. Reduce the perception of pain c. Inhibit the transmission of pain d. Inhibit the transmission of noxious stimuli

a Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

The nurse understands the definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Which of the following comments by a client confirm the client's understanding of the fundamental concepts of pain? Select all that apply. a. "I am tired of living with this nagging pain; I'm not sure how much longer I can go on." b. "I would love to go to church, but my back pain is too uncomfortable to make it through the service." c. "I used to walk every day for exercise; pain in my knee made me stop walking." d. "I feel good in knowing that my doctor will determine when and how I get pain medication." e. "I will depend on you and your experience to treat my pain, as you feel appropriate."

a, b, c A fundamental concept of pain is that pain is a complex phenomenon that can affect a person's psychosocial, emotional, and physical functioning. Helplessness is an emotional response to pain. Inability to continue normal activities, such as going to church, is a psychosocial consequence of pain. Inability to perform normal exercise because of pain is a physical restriction related to pain. Pain is highly personal and subjective. The client's report is the most reliable indicator of pain. The client works with the nurse and doctor to establish a pain management regimen.

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

a, b, d, e 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.

Choose the most likely reason why a nurse should question the use of Demerol for pain management in an elderly patient? There is (are): a. Increased susceptibility to nervous system depression. b. Decreased binding of meperidine by plasma protein. c. Changes in renal metabolism. d. Decreased metabolism of medications.

b Meperidine (Demerol) may not be administered because its active neurotoxic metabolite, normeperidine, is more likely to accumulate and cause CNS excitation and seizures. Refer to Table 7-1 in the text.

A client is receiving postoperative morphine through a patient-controlled analgesia (PCA) pump and the client's prescriptions specify an initial bolus dose. What is the nurse's priority assessment? a. Assessment for decreased level of consciousness (LOC) b. Assessment for respiratory depression c. Assessment for fluid overload d. Assessment for paradoxical increase in pain

b A client who receives opioids by any route must be assessed frequently for changes in respiratory status. Sedation is an expected effect of a narcotic analgesic, though severely decreased LOC is problematic. Fluid overload and paradoxical increase in pain are unlikely, though opioid-induced hyperalgesia (OIH) occurs in rare instances.

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. Attributed to a specific cause. b. Prolonged in duration. c. Rapidly occurring and subsiding with treatment. d. Separate from any central or peripheral pathology.

b A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged.

The nurse is caring for a patient who has been hospitalized on several occasions for lower abdominal pain related to Crohn's disease. How may this chronic pain be described? a. Attributable to a specific cause b. Prolonged in duration c. Rapidly occurring and subsiding with treatment d. Separate from any central or peripheral pathology

b Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life.

The emergency department (ED) nurse is caring for an adult client who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain is the nurse addressing with this client? a. Chronic b. Acute c. Intermittent d. Osteopenic

b Acute pain is usually of recent onset and commonly associated with a specific injury. Acute pain indicates that damage or injury has occurred. Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Phantom pain occurs when the body experiences a loss, such as an amputation, and still feels pain in the missing part. "Osteopenic" pain is not a recognized category of pain.

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. A migraine headache b. Intervertebral disk herniation c. Angina d. Appendicitis

b 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.

About which issue should the nurse inform clients who use pain medications on a regular basis? a. Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. b. Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. c. Minimize fiber intake during the therapy. d. Consume the medications just before or along with meals.

b Clients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the client to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Clients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends a. ingesting up to 6 glasses of fluids per day b. increasing the amount of bran and fresh fruits and vegetables c. using milk of magnesia 30 mL every day d. inserting a bisacodyl (Dulcolax) rectal suppository every morning

b Constipation is a common problem with the use of opioid medications, such as methadone. Activities to prevent constipation include increasing bran and fresh fruits and vegetables in the diet. The client should ingest 8 to 10 glasses of fluids per day. Milk of magnesia may be used if no bowel movement is produced in 3 days. Milk of magnesia is not to be used daily. A glycerin suppository, not bisacodyl, may be used to make the bowel movement less painful.

A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to a. Administer the prescribed alprazolam (Xanax). b. Assess the reason for the client's anxiety. c. Administer the prescribed dose of morphine. d. Assist the client out of bed and into a chair.

b Following the steps of the nursing process, the nurse needs to assess the reason for the client's anxiety. The client could be anxious about impending surgery, an unattended pet, a sick family member, etc. Then, the nurse intervenes appropriately by obtaining the assistance the client may need or administering anti-anxiety medication. The question is asking about treatment for anxiety. Pain medication should not be administered for anxiety. The nurse will not assist the client to a chair, because the client is on bedrest and in Buck's traction.

A medical nurse is appraising the effectiveness of a client's current pain control regimen. The nurse is aware that if an intervention is deemed ineffective, goals need to be reassessed and other measures need to be considered. What is the role of the nurse in obtaining additional pain relief for the client? a. Primary caregiver b. Client advocate c. Team leader d. Case manager

b If the intervention was ineffective, the nurse should consider other measures. If these are ineffective, pain-relief goals need to be reassessed in collaboration with the physician. The nurse serves as the client's advocate in obtaining additional pain relief.

The nurse in a pain clinic is caring for a client who is suffering from long-term, intractable pain. The pain team feels that first-line pharmacologic and nonpharmacologic methods of pain relief have been ineffective. What recommendation should guide this client's subsequent care? a. The client may want to investigate new alternative pain management options that are available in other countries. b. The client may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options. c. The client may want to increase his exercise and activities significantly to create distractions. d. The client may want to relocate to long-term care in order to have his ADL needs met.

b In some situations, especially with long-term severe intractable pain, usual pharmacologic and nonpharmacologic methods of pain relief are ineffective. In those situations, neurologic and neurosurgical approaches to pain management may be considered. Investigating new alternative pain-management options that are available abroad is unrealistic and may even be dangerous advice. Increasing his exercise and activities to create distractions is unrealistic when a client is in intractable pain and this recommendation conveys the attitude that the pain is not real. Moving into a nursing home so others may care for him is an intervention that does not address the issue of pain.

Which is a true statement regarding placebos? a. A placebo effect is an indication that the client does not have pain. b. Placebos should never be used to test a client's truthfulness about pain. c. A placebo should be used as the first line of treatment for a client. d. A positive response to a placebo indicates that the client's pain is not real.

b Many pain guidelines, position papers, nurse practice acts, and hospital policies nationwide agree that placebos should not be used to assess or manage pain in any client, regardless of age or diagnosis. Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. Reduction in pain as a response to placebo should never be interpreted as an indication that the person's pain is not real.

A client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies a. "I will notify your physician." b. "What do you mean by the word sick?" c. "A lot of people have a similar problem with this medication." d. "A nausea medication has been prescribed that I will give you."

b Nausea may occur with opioid use; however, before taking any other action, the nurse needs to clarify that this is what the client means by the word "sick."

How can the nurse determine that a client's pain is characteristic of acute pain? a. It does not respond well to treatment. b. It is associated with a specific injury. c. It serves no useful purpose. d. It responds well to placebos.

b Pain often is described as being acute or chronic (persistent) (Pasero & Portenoy, 2011). Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life.

Which condition is a heightened response that occurs after exposure to a noxious stimulus? a. Pain tolerance b. Sensitization c. Pain threshold d. Dependence

b 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.

A client's intractable neuropathic pain is being treated using a multimodal approach to analgesia. After administering a recently increased dose of IV morphine to the client, the nurse has returned to assess the client and finds the client unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug? a. Acetylcysteine b. Naloxone c. Celecoxib d. Acetylsalicylic acid

b Severe opioid-induced sedation necessitates the administration of naloxone, an opioid antagonist. Celecoxib, acetylcysteine, and acetylsalicylic acid are ineffective.

What pain assessment scale would be best to use with a 5-year-old child? a. A pain assessment scale is inappropriate for a 5-year-old child. b. The FACES Scale c. A visual analog scale d. The Numeric Rating Scale

b The FACES scale was developed for use in children. It consists of six pictures depicting faces ranging from np pain to worst pain. The child points to the face that best shows how much he or she hurts. The FACES scale may also be useful for adults who have difficulty with numerical or visual analog scales. Specific pain assessment scales have been tested for use in many patient populations, from neonates to clients who have dementia. The Visual Analog Scale and Numeric Rating Scale are not the best choices for a 5-year-old because they depend on the client being able to read and use numbers.

The nurse is assessing a client's pain while the client awaits a cholecystectomy. The client is tearful, hesitant to move, and grimacing, but rates his pain as a 2 at this time on a 0-to-10 pain scale. How should the nurse best respond to this assessment finding? a. Remind the client that he is indeed experiencing pain. b. Reinforce teaching about the pain scale number system. c. Reassess the client's pain in 30 minutes. d. Administer an analgesic and then reassess.

b The client is physically exhibiting signs and symptoms of pain. Further teaching may need to be done so the client can correctly rate the pain. The nurse may also verify that the same scale is being used by the client and caregiver to promote continuity. Although all answers are correct, the best initial approach would be to reinforce teaching about the pain scale.

The client is prescribed 2 mg of intravenous morphine every 2 hours as needed for pain. The nurse administers the medication. Thirty minutes later, the client reports the pain level remains at a "6" on a pain intensity scale of 0 to 10. The nurse first a. States that "You received the full dose. I can give you no more." b. Assesses the client's mental status and vital signs c. Contacts the physician to report the ineffectiveness of the medication d. Teaches the client about guided imagery and distraction

b The nurse is to reassess the client after administration of a medication for pain. Reassessment includes a pain rating scale, mental status, and vital signs. If the reassessment of the client demonstrates the client is alert, has satisfactory vital signs, and reports unrelieved pain, the nurse then consults with the physician. The listed statement of the nurse is nontherapeutic. It is not appropriate to teach the client about guided imagery or distraction when the client has pain. It should be done prior to pain onset.

An older adult client has been admitted to the rehabilitation facility after falling and fracturing her left hip. The client has not regained functional ability and may have to be readmitted to an acute-care facility. When planning this client's care, what should the nurse know about the negative effects of the stress associated with pain? a. Stress is less pronounced in older adults because they generally have more sophisticated coping skills than younger adults b. Stress is particularly harmful in the elderly who have been injured or who are ill. c. It affects only those clients who are already debilitated prior to experiencing pain. d. It has no inherent negative effects; it just alerts the person/health care team of an underlying disease process.

b The widespread endocrine, immunologic, and inflammatory changes that occur with the stress of pain can have significant negative effects. This is particularly harmful in clients whose health is already compromised by age, illness, or injury. Older adults are not immune to the negative effects of stress. Prior debilitation does not have to be present in order for stress to cause potential harm.

An older adult client has been admitted to the rehabilitation facility after falling and fracturing her left hip. The client has not regained functional ability and may have to be readmitted to an acute-care facility. When planning this client's care, what should the nurse know about the negative effects of the stress associated with pain? a. Stress is less pronounced in older adults because they generally have more sophisticated coping skills than younger adults b. Stress is particularly harmful in the elderly who have been injured or who are ill. d. It affects only those clients who are already debilitated prior to experiencing pain. e. It has no inherent negative effects; it just alerts the person/health care team of an underlying disease process.

b The widespread endocrine, immunologic, and inflammatory changes that occur with the stress of pain can have significant negative effects. This is particularly harmful in clients whose health is already compromised by age, illness, or injury. Older adults are not immune to the negative effects of stress. Prior debilitation does not have to be present in order for stress to cause potential harm.

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

c 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.

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 all of the following: a. states, "I can administer the medication to you in about 2 hours" b. evaluates the pain level using the established pain scale c. assesses respirations, pulse, and blood pressure d. consults with the healthcare provider about the client's report e. plans to place the client in a position of comfort when pain is relieved

b, c, d 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 nurse has cited a research study that highlights the clinical effectiveness of using placebos in the management of postsurgical clients' pain. What principle should guide the nurse's use of placebos in pain management? a. Placebos require a higher level of informed consent than conventional care. b. Placebos are an acceptable, but unconventional, form of nonpharmacologic pain management. c. Placebos are never recommended in the treatment of pain. d. Placebos require the active participation of the client's family.

c Broad agreement is that there are no individuals for whom and no condition for which placebos are the recommended treatment. This principle supersedes the other listed statements.

The nurse is caring for a client whose medical history includes chronic fatigue and poorly controlled back pain. These medical diagnoses should alert the nurse to the possibility of what consequent health problem? a. Anxiety b. Skin breakdown c. Depression d. Hallucinations

c Depression is associated with chronic pain and can be exacerbated by the effects of chronic fatigue. Anxiety is also plausible, but depression is a paramount risk. Skin breakdown and hallucinations are much less likely.

An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical client rates her pain as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the client is exaggerating and does not need pain medication. What is the nurse's best response? a. "Pain often comes and goes with postsurgical clients. Please ask her about pain again in about 30 minutes." b. "We need to provide pain medications because it is the law, and we must always follow the law." c. "Unless there is strong evidence to the contrary, we should take the client's report at face value.'" d. "It's not unusual for clients to misreport pain to get our attention when we are busy."

c A broad definition of pain is "whatever the person says it is, existing whenever the experiencing person says it does." Action should be taken unless there are demonstrable extenuating circumstances. Rechecking without offering an intervention would be insufficient and the law is not the sole reason for providing care.

A client is asking for a breakthrough dose of analgesia. The pain-medication prescriptions are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? a. To prevent respiratory depression from the opioid b. To eliminate the need for additional medication during the night c. To achieve better pain control than with one medication alone d. To eliminate the potentially adverse effects of the opioid

c A multimodal regimen combines drugs with different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects. This method also reduces, but does not eliminate, adverse effects of the opioid. This regimen is not motivated by the need to prevent respiratory depression or to eliminate nighttime dosing.

A patient comes into the clinic frequently with complaints of pain. What would the nurse recognize as chronic benign pain in a patient? a. A migraine headache b. An exacerbation of rheumatoid arthritis c. Low back pain d. Sickle cell crisis

c Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life. Examples of noncancer pain include peripheral neuropathy from diabetes, back or neck pain after injury, and osteoarthritis pain from joint degeneration.

The nurse is assessing an 86-year-old postoperative client who has an unexpressive, stoic demeanor. The client is curled into the fetal position, vital signs are elevated and he is diaphoretic. On a 10-point scale, the client indicates a pain level of "3 or so." How should the nurse treat this client's pain? a. Treat the client on the basis of objective signs of pain and reassess him frequently. b. Call the physician for new prescriptions because it is apparent that the pain medicine is not working. c. Believe what the client says, reinforce education, and reassess often. d. Ask the family what they think and treat the client accordingly.

c As always, the best guide to pain management and administration of analgesic agents in all clients, regardless of age, is what the individual client says. However, further education and assessment are appropriate. The scenario does not indicate the present pain-management prescriptions are not working for this client. The family's insights do not override the client's self-report.

The nurse needs to carefully monitor a client with traumatic injuries. Which action by the nurse demonstrates understanding of the most essential component of the client's pain assessment? a. The nurse administers ketorolac upon admission to the unit. b. The nurse validates the client's report of pain by assessing the client's blood pressure. c. The nurse administers pain medication based on the client's reported pain level. d. The nurse assesses the response to medication after every meal consumed by the client.

c Clients quickly adapt physiologically despite pain and may have normal or below normal vital signs in the presence of severe pain. The overriding principle is that the absence of an elevated blood pressure or heart rate does not mean the absence of pain. The ability of an individual to give a report of pain, especially its intensity, is the most essential component of pain assessment. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the client. Pain medication should not routinely be administered to a client upon admission to the unit.

The home health nurse is caring for a homebound client who is terminally ill and is delivering a patient-controlled analgesia (PCA) pump at today's visit. The family members will be taking care of the client. What would the nurse's priority interventions be for this visit? a. Teach the family the theory of pain management and the use of alternative therapies. b. Provide psychosocial family support during this emotional experience. c. Provide client and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication. d. Provide family teaching regarding use of morphine, recognizing morphine overdose, and offering spiritual guidance.

c If PCA is to be used in the client's home, the client and family are taught about the operation of the pump as well as the side effects of the medication and strategies to manage them. The family would also need to monitor the IV site and notify the nurse of any changes, such as infiltration, that could endanger the client. Teaching the family the theory of pain management or the use of alternative therapies and the nurse providing emotional support are important, but the family must be able to operate the pump as well as know the side effects of the medication and strategies to manage them. Offering spiritual guidance would not be a priority at this point and morphine is not the only medication given by PCA.

The nurse has just received report on a client who is coming to the unit from the emergency department with a torn meniscus. The nurse reviews the PRN medications and sees that an NSAID (ibuprofen) is prescribed every 6 hours. How should the nurse best implement preventive pain measures? a. Use a pain scale to assess the client's pain, and let the client know ibuprofen is available every 6 hours if she needs it. b. Do a complete assessment, and give pain medication based on the client's report of pain. c. Check for allergies, use a pain scale to assess the client's pain, and offer the ibuprofen every 6 hours until the client is discharged. d. Provide medication as per client request and offer relaxation techniques to promote comfort.

c One way preventive pain measures can be implemented is by using PRN medications on a more regular or scheduled basis to allow for more uniform pain control. Smaller drug doses of medication are needed with the preventive pain method when PRN medications are given around the clock. Offering the medication is more beneficial than letting the client know ibuprofen is available.

A client is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the client's pain in the plan of nursing care, the nurse should consider what characteristic of cancer pain? a. Cancer pain is often related to the stress of the client knowing she has cancer and requires relatively low doses of pain medications along with a high dose of anti-anxiety medications. b. Cancer pain is always chronic and challenging to treat, so distraction is often the best intervention. c. Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications. d. Cancer pain is often misreported by clients because of confusion related to their disease process.

c Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that when cancer clients are asked about possible outcomes, pain is reported to be the most feared outcome. Higher doses of pain medication are usually needed with cancer clients, especially with metastasis. Cancer pain is not treated with anti-anxiety medications. Cancer pain can be chronic and difficult to treat so distraction may help, but higher doses of pain medications are usually the best intervention. No research indicates cancer clients misreport pain because of confusion related to their disease process.

Which of the following is a physiologic response to pain? a. Bradycardia b. Dry skin c. Pallor d. Hypotension

c Physiologic responses to pain include pallor, tachycardia, diaphoresis, and hypertension.

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe? a. Tramadol b. Ketamine c. Gabapentin d. Hydromorphone

c The anticonvulsant gabapentin is a first-line analgesic agent for neuropathic pain. Tramadol is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine is used as a third-line analgesic agent for refractory acute pain. Hydromorphone is a first-line opioid not used as an analgesic agent for neuropathic pain.

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."

c 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.

The nurse needs to carefully monitor a client with traumatic injuries. How often should the nurse check and document the client's pain? a. Upon admission and discharge b. An hour after analgesics are administered c. Every time the client's vital signs are assessed d. After every meal consumed by the client

c The nurse should check and document the client's pain every time the client's temperature, pulse, respirations, and blood pressure are assessed. The American Pain Society (APS) has proposed that pain assessment should be considered the fifth vital sign. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the client. Pain should not be assessed only on admission and discharge of the client.

Prior to starting a peripheral intravenous line on a patient, what intervention can the nurse provide to decrease the pain from the needle puncture? a. Give an oral opioid analgesic 30 minutes before the procedure. b. Apply diclofenac gel over the site 1 hour before the procedure. c. Apply eutectic mixture of local anesthetic cream 30 minutes prior to the procedure. d. Inject lidocaine 2% with epinephrine locally around the potential procedure site.

c The topical route of administration is used for both acute and chronic pain. For example, the nonopioid diclofenac is available in patch and gel formulations for application directly over painful areas. Local anesthetic creams, such as EMLA (eutectic mixture or emulsion of local anesthetics) and L.M.X.4 (lidocaine cream 4%), can be applied directly over the injection site prior to painful needle stick procedures, and the lidocaine patch 5% is often used for well-localized types of neuropathic pain, such as postherpetic neuralgia.

A 20-year-old man has presented to the emergency department with a 24-hour history of abdominal pain. The nurse who is admitting the patient notes that he is diaphoretic, wincing, and guarding the lower right quadrant of his abdomen. The nurse asks the patient to rate his pain on a scale of 1 to 10, to which the patient responds, "One or two." How should the nurse best respond to this patient's statement? a. Administer ibuprofen or acetaminophen rather than an opioid. b. Reassess the patient's pain in 30 to 45 minutes. c. Explain the 0-to-10 pain scale in greater detail. d. Document the fact that the patient has slight pain.

c While it is important to accept a patient's self-report of pain, this does not mean that further education about pain scales is not sometimes necessary. This is especially the case when there is a clear inconsistency between patient's subjective pain report and the nurse's assessment findings. Thus, further teaching should take place prior to choosing an intervention or documenting the patient's pain as "slight."

A 60-year-old client who has diabetes had a below-knee amputation 1 week ago. The client asks, "Why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the client. The nurse should describe what pathophysiologic process? a. The proliferation of nociceptors during times of stress b. Age-related deterioration of the central nervous system c. Psychosocial dependence on pain medications d. The abnormal reorganization of the nervous system

d At any point from the periphery to the CNS, the potential exists for the development of neuropathic pain. Hyperexcitable nerve endings in the periphery can become damaged, leading to abnormal reorganization of the nervous system called neuroplasticity, an underlying mechanism of some neuropathic pain states. Neuropathic pain is not a result of age-related changes, nociceptor proliferation, or dependence on medications.

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. Placebo b. Dependence c. Tolerance d. Addiction

d 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.

A 60-year-old client who has diabetes had a below-knee amputation 1 week ago. The client asks, "Why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the client. The nurse should describe what pathophysiologic process? a. The proliferation of nociceptors during times of stress b. Age-related deterioration of the central nervous system c. Psychosocial dependence on pain medications d. The abnormal reorganization of the nervous system

d At any point from the periphery to the CNS, the potential exists for the development of neuropathic pain. Hyperexcitable nerve endings in the periphery can become damaged, leading to abnormal reorganization of the nervous system called neuroplasticity, an underlying mechanism of some neuropathic pain states. Neuropathic pain is not a result of age-related changes, nociceptor proliferation, or dependence on medications.

The mother of a client with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her daughter's pain management? a. The dose range is higher with cancer clients, and the medical team will be very careful to prevent addiction. b. Frequently, female clients and younger clients need higher doses of opioids to be comfortable. c. The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment. d. There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

d Clients requiring opioids for chronic pain, especially cancer clients, need increasing doses to relieve pain. The requirement for higher drug doses results in a greater drug tolerance, which is a physical dependency as opposed to addiction, which is a psychological dependency. The dose range is usually higher with cancer clients. Although tolerance to the drug will increase, addiction is not dose related, but is a separate psychological dependency issue. No research indicates that women and/or younger people need higher doses of morphine to be comfortable. Overdose is not an "inevitable" risk.

The nurse caring for an older adult client with osteoarthritis is reviewing the client's chart. This client is on a variety of medications prescribed by different care providers in the community. In light of the QSEN competency of safety, what is the nurse most concerned about with this client? a. Depression b. Chronic illness c. Inadequate pain control d. Drug interactions

d Drug interactions are more likely to occur in older adults because of the higher incidence of chronic illness and the increased use of prescription and OTC medications. The other options are all good answers for this client because of the client's age and disease process. However, they are not what the nurse would be most concerned about in terms of ensuring safety.

The nurse's major area of assessment for a patient receiving patient-controlled analgesia is assessment of what system? a. Cardiovascular b. Integumentary c. Neurologic d. Respiratory

d Essential to the safe use of a basal rate with PCA is close monitoring by nurses of sedation and respiratory status and prompt decreases in opioid dose (e.g., discontinue basal rate) if increased sedation is detected (Pasero, Quinn et al., 2011).

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced how often? a. Every 12-24 hours b. Every 24-36 hours c. Every 36-60 hours d. Every 48-72 hours

d Fentanyl patches should be replaced every 48-72 hours, depending on client response. The other time frames are incorrect.

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced every a. 12-24 hours. b. 24-36 hours. c. 36-60 hours. d. 48-72 hours.

d Fentanyl patches should be replaced every 48-72 hours, depending on patient response. The other time frames are incorrect.

A 19-year-old woman had a mandibular osteotomy (jaw surgery) performed early this morning and is being assessed by the nurse after being transferred from the PACU. The nurse has asked the patient about her pain, to which the patient has responded, "I'm not really having any pain, but I've got a dull ache all around my jaw that's really bad." How should the nurse best interpret this patient's statement? a. The patient is not experiencing pain but likely requires interventions for her discomfort. b. The patient is misinterpreting her body's pain response. c. The patient is currently free of pain but is likely to experience pain in the near future. d. The patient is experiencing pain but is describing it in different terms.

d It is reasonable to conclude that this patient is experiencing pain but is using different terms to describe the sensation. It would be erroneous for the nurse to conclude that this patient is pain free and to reject interventions. This patient is not "misinterpreting" her sensation but is rather characterizing it in a different way from the nurse.

The nurse is caring for a victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurse's aide (NA) tells the nurse that she is concerned because the client's resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 37.3°C (99.1°F) axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as the nurse assesses this client's physiologic status? a. The client's understanding of pain physiology b. The client's serum glucose level c. The client's white blood cell count d. The client's rating of her pain

d The nurse's assessment of the client's pain is a priority. There is no suggestion of diabetes and leukocytosis would not occur at this early stage of recovery. The client does not need to fully understand pain physiology in order to communicate the presence, absence, or severity of pain.

The nurse is creating a nursing care plan for a client with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of clients who live with chronic pain should be integrated into care planning? a. They are typically more comfortable with underlying pain than clients without chronic pain. b. They often have a lower pain threshold than clients without chronic pain. c. They often have an increased tolerance of pain. d. They can experience acute pain in addition to chronic pain.

d It is tempting to expect that people who have had multiple or prolonged experiences with pain will be less anxious and more tolerant of pain than those who have had little experience with pain. However, this is not true for many people. The more experience a person has had with pain, the more frightened he or she may be about subsequent painful events. Chronic pain and acute pain are not mutually exclusive. These clients may not have a different pain threshold or tolerance to pain.

A client was diagnosed with rheumatoid arthritis 1 year ago, but has achieved adequate symptom control with celecoxib, a COX-2 selective NSAID. The nurse should recognize that this drug, like other NSAIDs, influences what aspect of the pathophysiology of nociceptive pain? a. Distorting the action potential that is transmitted along the A-delta (δ) and C fibers b. Diverting noxious information from passing through the dorsal root ganglia and synapses in the dorsal horn of the spinal cord c. Blocking modulation by limiting the reuptake of serotonin and norepinephrine d. Inhibiting transduction by blocking the formation of prostaglandins in the periphery

d NSAIDs produce pain relief primarily by blocking the formation of prostaglandins in the periphery; this is a central component of the pathophysiology of transduction. NSAIDs do not act directly on the aspects of transmission, perception, or modulation of pain that are listed.

The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering? a. Nubain b. Stadol c. Buprenex d. Fentanyl

d 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).

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. About activities that would distract him from pain b. That the nurse will notify the surgeon of his fear c. How anxiety could increase his pain perception d. That medication will be prescribed for pain relief

d 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.

A high school football player hurts his foot while playing a game. The client complains of intense pain with muscle spasms and swelling of the toe. Which pain assessment tool will the nurse most likely use to assess the client's pain level? a. Wong-Baker FACES Pain Rating Scale b. Verbal Descriptor Scales (VDS) c. Visual Analog Scale (VAS) d. Numeric Rating Scale (NRS)

d The NRS is most appropriate for this client. The VDS requires the patient to use words or phrases; in this situation, intense pain may affect the client's ability to use this scale appropriately. The FACES scale is most often used in adults and children as young as 3 years of age. The VAS is impractical for use in daily clinical practice.