Chapter 15: Pain Management

29. _____ and _____ are natural opioid-like substances that block pain perception.

ANS: Endorphins; enkephalins Enkephalins; endorphins Endorphins and enkephalins are natural opioid substances that help block the perception of pain. DIF: Cognitive Level: Knowledge REF: p. 213 OBJ: 2 TOP: Endorphins KEY: Nursing Process Step: N/A

28. A nurse explains that afferent pathways are activated by pain receptors called _____.

ANS: nociceptors Pain receptors that are called nociceptors activate the afferent pathways. DIF: Cognitive Level: Knowledge REF: p. 213 OBJ: 2 TOP: Nociceptors KEY: Nursing Process Step: Implementation

12. A patient admitted with the diagnosis of possible myocardial infarction complains of pain and tingling in the left arm and says, "How in the world could I be having a heart attack when it's just my arm that is giving me trouble?" What type of pain should the nurse explain that the patient is experiencing? a. Referred pain b. Psychogenic pain c. Neuromuscular pain d. Muscle spasms of shoulder

ANS: A Pain is what the patient says it is and should be communicated as such. However, pain in specific areas may be referred pain, and left arm discomfort is typically referred from the heart. The nurse administers the analgesic as ordered and frequently checks to determine whether the pain is relieved. DIF: Cognitive Level: Comprehension REF: p. 218 OBJ: 4 TOP: Referred Pain KEY: Nursing Process Step: Implementation

9. What should greatly reduce postoperative pain for a patient about to undergo a hip replacement? a. Femoral nerve blocks b. Extremely deep general anesthesia c. Practicing leg lifting exercises before surgery d. Placing an analgesic patch directly over the incision

ANS: A Preoperative femoral nerve blocks will significantly reduce the pain for 24 hours postoperatively. DIF: Cognitive Level: Comprehension REF: p. 215 OBJ: 8 TOP: Femoral Blocks KEY: Nursing Process Step: Implementation

20. How does the International Association for the Study of Pain define the sensation of pain? a. Unpleasant sensory and emotional experience b. Whatever the person experiencing it says it is c. Psychogenic response to tissue injury d. Physical and psychogenic response to the need for drugs

ANS: A The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience. DIF: Cognitive Level: Knowledge REF: p. 212 OBJ: 1 TOP: Definition of Pain KEY: Nursing Process Step: N/A

3. What sympathetic responses to pain might be assessed by the nurse? a. Increased blood pressure, increased pulse, and increased respiratory rate b. Decreased blood pressure, decreased pulse, and increased respiratory rate c. Increased blood pressure, decreased pulse, and increased respiratory rate d. Decreased blood pressure, decreased pulse, and decreased respiratory rate

ANS: A The sympathetic nervous system controls blood pressure, pulse, and respiration; it is stimulated during pain. DIF: Cognitive Level: Comprehension REF: p. 215 OBJ: 2 | 7 TOP: Sympathetic Response to Pain KEY: Nursing Process Step: Assessment

15. A patient who is obviously in pain refuses the morphine that has been prescribed for pain control because of a fear of addiction. What should the nurse explain is the estimated percentage of patients taking prescribed pain protocols who become addicted? a. Less than 1% b. 10% to 25% c. 30% to 50% d. 80% to 90%

ANS: A When used for severe pain management relief, opioids rarely result in addiction. DIF: Cognitive Level: Knowledge REF: p. 227 OBJ: 9 TOP: Addiction Potential KEY: Nursing Process Step: Implementation

26. What are the standards for pain management published by The Joint Commission (TJC)? (Select all that apply.) a. Perform organized pain assessment. b. Record results of analgesia. c. Give adequate discharge instruction about pain relief. d. Recognize the right of a nurse to manage pain. e. Teach patients about pain control methods.

ANS: A, B, C, E Performing organized pain assessment, recording results of analgesia, giving adequate discharge information about pain, relief and teaching patients about pain control methods are all standards for pain management published by the Joint Commission. The standards include recognizing the right of the patient to assess and manage pain, not the nurse. DIF: Cognitive Level: Knowledge REF: p. 212 OBJ: 8 TOP: TJC Standards KEY: Nursing Process Step: Implementation

27. What instruction should the nurse provide to a patient who has had a rhizotomy for leg pain? (Select all that apply.) a. Relief may not be permanent. b. The leg will tingle and burn occasionally. c. The foot may discolor and twitch at times. d. Snug shoes should be worn at all times. e. Caution should be taken to prevent injury to the leg.

ANS: A, E The relief may not be permanent because of the regeneration of nerve tissue. Extra caution should be taken to prevent injury because pain perception is altered. Snug shoes would cause injury. Tingling and twitching are not usual with a rhizotomy. DIF: Cognitive Level: Comprehension REF: p. 214 OBJ: 8 TOP: Rhizotomy KEY: Nursing Process Step: Implementation

11. A nurse administers nalbuphine (Nubain), an opioid agonist-antagonist, to a 78-year-old patient. The family is worried about the patient and thinks that this drug is too strong and will cause harm. What should the nurse assure the family regarding this drug? a. Does not accumulate in the body b. Blocks the side effects observed in opioid agonists c. Does not affect the CNS d. Can only be given orally

ANS: B A drug classified as an agonist-antagonist is able to relieve pain at the CNS level and is able to block some side effects of opioid agonists. The drug can be given intramuscularly or orally. DIF: Cognitive Level: Application REF: p. 226 OBJ: 9 TOP: Use of Opioids KEY: Nursing Process Step: Implementation

5. A nurse notices that a patient seems calm and peaceful despite an assessment that the patient's injuries might be causing severe pain. The patient tells the nurse that using yoga and meditation lessens the perceptions of pain to tolerable levels. Which other alternative intervention should the nurse suggest to help relax this patient for pain relief? a. Indulging in a favorite food b. Music by a favorite artist c. Reading exciting science fiction d. Self-administration of drugs

ANS: B Alternate methods of pain relief are effective for many patients. Activities such as yoga, meditation, and listening to music are helpful and relaxing. DIF: Cognitive Level: Application REF: p. 223-224 OBJ: 3 TOP: Alternate Methods of Pain Relief KEY: Nursing Process Step: Assessment

6. What intervention of pain control exemplifies the gate control methods of pain relief? a. Assisting the patient to ambulate b. Giving a massage c. Providing an ice cold beverage d. Instructing the patient in stretching exercises

ANS: B Massage, position change, hot or cold applications, and distraction all can close the gate. DIF: Cognitive Level: Comprehension REF: p. 213 OBJ: 2 TOP: Gate Theory KEY: Nursing Process Step: Implementation

25. When a patient with sciatica seats himself in a chair, he gasps and complains of a burning and shooting pain in his hip. What type of pain does this represent? a. Referred b. Neuropathic c. Visceral d. Acute

ANS: B Neuropathic pain is characterized by burning and shooting sensations without a stimulus. This situation is not an example of acute pain because neuropathic pain does not follow a nociceptor path as do both visceral and referred pain. DIF: Cognitive Level: Comprehension REF: p. 216 OBJ: 2 TOP: Neuropathic Pain Perception KEY: Nursing Process Step: Assessment

7. To perform a nursing assessment correctly, a nurse must remember that pain perception involves several central nervous system (CNS) processes. Which are examples of CNS processes? a. Afferent pathways carry messages to the spinal cord. b. Efferent pathways stimulate the spinal cord to recognize the location of pain. c. Nociceptors in the brain stimulate the spinal cord. d. Pain receptors in muscle, skin, and subcutaneous tissue stimulate efferent pathways.

ANS: B Pain perception ascends to the brain and back down again to imprint the pain. These are functions of the CNS. Efferent pathways carry pain impulses to the body via the spinal cord. Afferent pathways carry messages to the brain for interpretation. DIF: Cognitive Level: Comprehension REF: p. 213 OBJ: 2 TOP: Pain Pathways KEY: Nursing Process Step: Assessment

22. What is the most common result of prolonged and unrelieved pain? a. Release of endorphins b. Lowered pain threshold c. Stimulated gate control d. Lowered blood pressure

ANS: B Pain that is unrelieved lowers the pain threshold because the patient becomes anxious that the pain may not ever be relieved. The blood pressure increases, and the effects of endorphins and gate control have been exhausted. DIF: Cognitive Level: Comprehension REF: p. 213 OBJ: 4 TOP: Pain Unrelieved KEY: Nursing Process Step: Assessment

21. A nurse is notified when a patient, newly admitted with liver and gallbladder disease, complains of pain in the right middle back and asks for some pain medication. What is the best interpretation of this reported assessment by the nurse? a. The patient is just complaining to see whether the staff will give out pain medications. b. The patient has referred pain sensations. The nurse should follow orders for administering pain medication. c. The patient has an injury on the back from an unknown cause that needs immediate assessment. d. The patient is a chronic complainer with anxieties about his condition.

ANS: B Referred pain is a very real physical complaint, and the nurse should give the patient the pain medication as ordered. DIF: Cognitive Level: Application REF: p. 218 OBJ: 2 | 5 TOP: Referred Pain KEY: Nursing Process Step: Assessment

13. Every time the right arm is raised, a patient reports to the nurse that pain is triggered in the right shoulder. How should the nurse document this description? a. Referred pain b. Aggravating factor c. Alleviating factor d. Past experience with the pain

ANS: B The aggravating factor that is causing pain is important information to gather by the nurse and to communicate specifically in the chart, as well as to the registered nurse. DIF: Cognitive Level: Comprehension REF: p. 219 OBJ: 2 TOP: Factors Defining the Pain Description KEY: Nursing Process Step: Assessment

18. Which steps should the LPN/LVN follow when performing a pain assessment? a. Assess vital signs, status of pain, and aggravating factors. b. Assess location, quality, and intensity on an identified scale. c. Assess the intensity on an identified scale and record findings. d. Assess vital signs and location, and report to the RN.

ANS: B The assessment of pain requires the nurse assess location, quality, and intensity based on an identified scale. Vital signs are important in addition but are not part of the six steps. DIF: Cognitive Level: Application REF: p. 218 OBJ: 7 TOP: Nurse's Pain Assessment KEY: Nursing Process Step: Assessment

8. A nurse is teaching a patient how to use a transcutaneous electrical nerve stimulation (TENS) unit and how it works. What is the most appropriate information for the nurse to relay? a. "The stimulation of the skin seeks to localize the acute pain and will last for several minutes after the unit is applied." b. "This unit stimulates both the skin and the underlying tissues to decrease the intensity of the pain." c. "The mechanism for use of this unit is well known and can be read." d. "During those days when using the TENS unit, no analgesic can be given."

ANS: B The exact mechanism for the pain relief is unknown. The effects last for the time that the unit is applied to the patient and a short time thereafter. DIF: Cognitive Level: Application REF: p. 223 OBJ: 8 TOP: TENS Units KEY: Nursing Process Step: Implementation

10. A patient continues to report pain after the administration of the prescribed analgesic. Why should the nurse change the nursing care plan? a. Patient's pain threshold has risen. b. Patient's pain threshold has lowered. c. Patient has become addicted. d. Patient is seeking attention.

ANS: B The sensation of pain is perceived as increased when the pain threshold is lowered. Insufficient data exists in this situation to assume addiction or the need for attention. DIF: Cognitive Level: Comprehension REF: p. 213 OBJ: 10 TOP: Lowered Pain Threshold KEY: Nursing Process Step: Planning

1. The length of time that a nurse should leave heat to an injured hip of a patient is no longer than: a. 15 minutes. b. 20 minutes. c. 30 minutes. d. 1 hour.

ANS: C If a heating device is left on more than 30 minutes, the effectiveness of the treatment is diminished, and injury to the tissues may occur. DIF: Cognitive Level: Comprehension REF: p. 223 OBJ: 8 TOP: Timing of Heat Application KEY: Nursing Process Step: Implementation

4. A health care provider has prescribed both heat and cold treatments for an older adult patient with a leg injury. The nursing care plan reflects secondary diagnoses of peripheral vascular disease (PVD), diabetes, and an allergy to latex. Which of the prescribed treatments should the nurse administer and why? a. The nurse will use cold treatment because patients with diabetes and a latex allergy cannot tolerate heat. b. The nurse will use cold treatment for this patient with a fracture because cold will help set the cast. c. The nurse will use heat treatment because cold is contraindicated for patients with PVD. d. The nurse will use heat treatment because heat will increase circulation and increase the threat of infection in the injured part.

ANS: C Patients with PVD have blood flow problems that physiologically slow circulation. This problem would be exacerbated by cold. Heat will increase the circulation, which would be a desired effect. DIF: Cognitive Level: Application REF: p. 222-223 OBJ: 6 TOP: Thermal Applications with Secondary Diagnosis KEY: Nursing Process Step: Planning

23. A nurse is administering morphine IM, which was prescribed for a patient reporting severe pain. What should be the nurse's primary assessment focus on to evaluate the patient's response to this drug? a. Cardiac rhythms for tachycardia b. Respiratory rate for tachypnea c. Increased bowel sounds in the gastrointestinal system d. Sedative effects in the neurologic system

ANS: D Morphine initially produces sedation that allows the patient to sleep and rest from the pain. This result is considered a side effect. DIF: Cognitive Level: Application REF: p. 228 OBJ: 9 TOP: Morphine IM for Pain Relief KEY: Nursing Process Step: Assessment

16. Morphine sulfate (30 mg) IM PRN was prescribed for pain for an 80-year-old patient with emphysema who weighs 100 lb. What is the most appropriate action for the licensed practical/vocational nurse (LPN/LVN)? a. Transcribe the order and wait to see if the patient needs it. b. Transcribe the order for an oral dose instead of IM dose. c. Call the physician and clarify the order. d. Tell the RN about the order.

ANS: D Morphine is usually given in a dose of 10 mg (one-sixth grain) IM. The usual oral dose is 0.5 gr (30 mg). The order should be called to the attention of the RN so that the intent can be clarified before transcribing the order for the older patient, who usually requires a smaller dose. DIF: Cognitive Level: Application REF: p. 227 OBJ: 6 TOP: Morphine Dosage KEY: Nursing Process Step: Planning

19. Two patients are hospitalized with the same diagnosis, but one is 23 years old, with acute recent pain from an injury, and the other is 64 years old, with pain of long-standing duration of several years. What is the difference in the anticipated assessments? a. Acute pain for young patients is more intense at the same level, but these patients experience few changes in vital signs. b. Young patients with acute pain exhibit fewer changes in vital signs but still report true levels of pain at levels 8 to 10. c. Older adult patients with chronic pain exhibit increased changes in vital signs and report levels of pain lower than reality. d. Older adult patients with chronic pain usually report lower levels of pain much less severe than they really are.

ANS: D Older adult patients with chronic pain do not report pain as severe at the same level as younger patients do for several reasons. For example, older adult patients believe that pain comes with old age, or they do not want to bother the staff. Frequently, chronic long-standing pain does not change normal values of the vital signs. DIF: Cognitive Level: Comprehension REF: p. 214 | p. 216 OBJ: 6 TOP: Age-Related Assessments of Pain KEY: Nursing Process Step: Assessment

14. A patient who had a myocardial infarction 2 days earlier has been eating well, is ambulating with assistance, and is receiving antibiotics and morphine by intravenous (IV) drip. The patient complains of constipation this morning. What should the nurse assess as the probable cause of the constipation? a. Inadequate fluid intake b. Lack of exercise c. Administration of antibiotics d. Administration of an analgesic medication

ANS: D Opioid administration frequently causes constipation. This patient is eating, taking IV fluids, and walking. Antibiotics rarely cause constipation. DIF: Cognitive Level: Application REF: p. 228 OBJ: 9 TOP: Side Effects of Opioids KEY: Nursing Process Step: Assessment

17. What assessment should a nurse make to evaluate the presence of pain in a patient who is cognitively impaired? a. Amount of time spent sleeping during the day b. Consistent stoic facial expression c. Increased social interaction d. Increasing confusion

ANS: D Patients who are cognitively impaired may show pain by increased confusion, reduction in social contacts, grimacing, or squinting the eyes. DIF: Cognitive Level: Application REF: p. 217-218 OBJ: 6 TOP: Pain Assessment in Cognitively Impaired KEY: Nursing Process Step: Assessment

24. A nurse explains to a patient the gate control theory of pain. Where does the perception of pain originate in the gate control theory? a. Large arteries b. Vena cava c. Large nerve fibers d. Small nerve fibers

ANS: D The perception of pain is made through small nerve fibers, which transmit impulses up to the brain, where they are interpreted as pain. Large nerve fiber receptors block the gate to decrease transmission to the interpretive brain area. DIF: Cognitive Level: Knowledge REF: p. 213 OBJ: 2 TOP: Pain Perception/Gate Control Theory KEY: Nursing Process Step: Implementation

2. A patient with an extensive abdominal surgical procedure is assessed by the nurse as having predictable pain. How often should the nurse administer analgesics to this patient to be most effective? a. As needed (PRN) b. Once a day c. Twice a day d. Around the clock

ANS: D Using a preventive approach for managing this patient's pain management is the best plan for the nurse because the pain is predictable and major. DIF: Cognitive Level: Application REF: p. 224 OBJ: 1 | 8 TOP: Predictable Pain and Analgesic Administration KEY: Nursing Process Step: Implementation