Chapter 9: Pain Management

A nurse is caring for a client with pain. What should the nurse monitor for when administering intravenous acetaminophen?

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

The client is taking continuous-release oxycodone for chronic pain and now reports constipation. What should be the first question the nurse asks the client?

"Can you take bisacodyl?" "What do you usually take for constipation?" "When was your last bowel movement?" "Are you able to increase fluids and fiber in your diet?" "When was your last bowel movement?" Explanation: Constipation is a common side effect of opioids. The nurse needs to assess the situation first before intervening. Asking about date of last bowel movement is most important. Once the history of constipation is completed, it would then be appropriate for the nurse to ask about effectiveness of past interventions and begin teaching about interventions, such as increasing fluids and fiber.

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 He is withdrawn, grimaces, and turns away during the dressing change.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?

"You are so brave to not take your pain medication when the dressing change will hurt." "If you need pain relief, I can give you some medication when I have completed the dressing change." "I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication." "You are so right to not take your pain medication. You can become dependent on the medication." "I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication." Explanation: 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 is to administer meperidine 75 mg intramuscularly to a client. The medication is supplied in an ampule of 50 mg/mL. How many milliliters should the nurse administer to the client? Enter the correct number ONLY.

1.5 Explanation: The dose ordered is 75 mg. The dose available is 50 mg. The quantity is 1 mL. 75 mg/50 mg x 1 mL = 1.5 mL.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?

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

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.

Appendicitis Angina Intervertebral disk herniation A migraine headache Intervertebral disk herniation Explanation: 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.

A client recovering from hip surgery is receiving morphine through a patient-controlled analgesia (PCA) infusion pump with a set basal rate. What action is most important for the nurse to implement?

Ask the client about pain status Assess the client's respiratory status Instruct the client about bolus doses Obtain consent for PCA by proxy Assess the client's respiratory status Explanation: A basal rate is a continuous infusion of the medication. Assessment of the client's respiratory status is a major nursing responsibility and the most important one listed per Maslow's hierarchy of needs. The nurse will instruct the client about bolus doses for increased pain or painful activities and assess pain status. There is no information in the stem of the question to support the need for consent for PCA by proxy.

About which issue should the nurse inform clients who use pain medications on a regular basis?

Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. Minimize fiber intake during the therapy. 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. Consume the medications just before or along with meals. 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. Explanation: 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.

Which of the following nursing interventions contributes to achieving a client's goal for pain relief?

Collaborate with the client about his or her goal for a level of pain relief. Prevent the client from self-administering analgesics. Use all forms of available pain management techniques. Minimize the client's description of pain or need for pain relief. Collaborate with the client about his or her goal for a level of pain relief. Explanation: The nurse should collaborate with each client about his or her goal for a level of pain relief; this helps implement interventions for achieving the goal. The client's description of pain or need for pain relief should never doubted or minimized. The client need not refrain from self-administering analgesics; providing a client with equipment to self-administer analgesics promotes a more consistent level of pain relief. The nurse should also inform the client of available pain management techniques and incorporate any preferences or objections to interventions for pain management that the client may have when establishing a plan of care; using all forms of available pain management techniques is not necessary.

Which of the following is the appropriate intervention to avoid physical withdrawal on drugs in a client?

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

An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client?

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

When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose?

Insomnia Confusion Hyperalertness Hyperventilation Confusion Explanation: Patients should be informed about signs and symptoms of fentanyl overdose such as shallow or difficulty breathing, extreme sleepiness, confusion, sedation. Hyperalertness, hyperventilation, and insomnia would not occur.

Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain?

Monitor blood counts and liver function tests Avoid caffeine or other stimulants, such as decongestants Monitor weight, vital signs, and serum glucose concentration Do not administer if respirations are less than 12 breaths per minute Do not administer if respirations are less than 12 breaths per minute Explanation: 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 is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient?

Older people are expected to experience chronic pain. Older people have increased sensory perception. Older people have a decreased pain threshold. Older people experience reduced sensory perception. Older people experience reduced sensory perception. Explanation: Pain affects individuals of every age, sex, race, and socioeconomic class

Which is a true statement regarding placebos?

Placebos should never be used to test a client's truthfulness about pain. Placebos should never be used to test a client's truthfulness about pain. Explanation: 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, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing?

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

A 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

That the client has become dependent on drugs from her previous experience of burns That based on her past experiences the client's perception of pain should be less That the client is experiencing pain relating to the burn injuries from several years ago That the client's past experiences with pain may influence her perception of current pain That the client's past experiences with pain may influence her perception of current pain Explanation: 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.

A client comes to the clinic expressing the need for more analgesics for chronic pain. Stating that the medication is not as strong, the client reports requiring more than the prescribed dose. What does the nurse suspect is occurring with the client?

Tolerance Explanation: Tolerance is a condition in which a client needs increasingly larger doses of a drug to achieve the same effect as when the drug was first administered. Addiction refers to a chronic, relapsing, treatable disease characterized by craving, dysfunctional behaviors, inability to control impulses regarding consumption of a substance, and compulsive use despite harmful consequences (Oliver et al., 2012). Physical dependence means that a person experiences physical discomfort, known as withdrawal symptoms.

Which phase of pain transmission occurs when the one is made aware of pain?

Transmission Modulation Transduction Perception Perception Explanation: Perception is the pain process where one becomes aware of the pain as a result of neural activity. Modulation involves the response to noxious stimuli. Transduction refers to the processes by which noxious stimuli activate primary afferent neurons called nociceptors. Transmission describes the action potential that is created by transduction being transmitted along fibers.

The nurse is caring for a client with kidney stones who reports severe pain. What type of pain does the nurse understand this client is experiencing?

Visceral pain Chronic pain Neuropathic pain Somatic pain Visceral pain Explanation: Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Somatic pain is caused by mechanical, chemical, thermal, or electrical injuries or disorders affecting bones, joints, muscles, skin, or other structures composed of connective tissue. Neuropathic pain is pain that is processed abnormally by the nervous system. Chronic pain is discomfort that lasts longer than 6 months and is almost totally opposite from those of acute pain.

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?

the use of non-pharmacologic pain interventions to minimize use of the PCA the limits on dose and frequency that are programmed into the PCA the importance of limiting the use of the PCA to no more than twice per hour the fact that naloxone will be kept readily available at all times the limits on dose and frequency that are programmed into the PCA Explanation: 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 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?

visceral pain somatic pain neuropathic pain referred pain neuropathic pain Explanation: 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 client's level of pain. How is the pain best described?

An unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery. A chronic, unpleasant sensation that occurs due to disease affecting one or more body systems. An unpleasant sensation that occurs due to malfunctioning of the nervous system. An unpleasant sensation created by emotional states such as fear, frustration, anger, or depression. An unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery. Explanation: Pain is a privately experienced, unpleasant sensation usually associated with disease, injury, or surgery. Although pain can have an emotional component, referred to as suffering, this is not the source of all pain. Although pain can be the result of disease, it can also be caused by injury, surgery, emotional or mental conditions, or other causes. Pain is a normal aspect of nervous system functioning. Neuropathic pain is pain that is processed abnormally by the nervous system.

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

Administer the prescribed dose of morphine. Assist the client out of bed and into a chair. Administer the prescribed alprazolam (Xanax). Assess the reason for the client's anxiety. Assess the reason for the client's anxiety. Explanation: 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.

Which intervention is appropriate for a nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?

Changing the administration route to P.O. if the client can tolerate fluids Assisting with a naloxone challenge test before therapy begins Discontinuing the drug immediately if signs of dependence appear Obtaining baseline vital signs before administering the first dose Obtaining baseline vital signs before administering the first dose Explanation: The nurse should obtain the client's baseline blood pressure and pulse and respiratory rates before administering the initial dose and then continue to monitor vital signs throughout therapy. A naloxone challenge test may be administered before using an opioid antagonist, not an opioid agonist. The nurse shouldn't discontinue an opioid agonist abruptly because withdrawal symptoms may occur. Morphine commonly is used as a continuous infusion in clients with severe pain regardless of the ability to tolerate fluids.

When taking a client history, the nurse notes that the client has been taking herbal remedies in addition to acetaminophen for several years. Based on the admission history, the nurse understands that the client is experiencing which type of pain?

Chronic pain Breakthrough pain Acute pain Neuropathic pain Chronic pain Explanation: Chronic pain persists over a course of time, in this case several years. Acute pain has a relatively short duration. Breakthrough pain is acute exacerbations of pain periodically experienced by clients with a normally controlled pain management regimen.

Acute pain can be distinguished from chronic pain by assessing which characteristic?

Chronic pain is symptomatic of primary injury. Acute pain is specific and localized. Chronic pain diminishes with healing. Acute pain responds poorly to drug therapy. Acute pain is specific and localized. Explanation: Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury.

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?

Gabapentin Tramadol Hydromorphone Ketamine Gabapentin Explanation: 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.

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain?

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

The nurse is administering a narcotic analgesic for the control of a newly postoperative client's pain. What medication will the nurse administer to this client?

Ibuprofen Acetaminophen Midazolam Fentanyl Fentanyl Explanation: Opioid and opiate analgesics such as morphine and fentanyl are controlled substances referred to as narcotics. The other medications are not opioid analgesics and should not be given for a newly postoperative client.

A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling?

Ice bag Injection of a steroid into the joint space Elevation of the extremity Warm compresses Ice bag Explanation: Pain associated with injury is best treated initially with cold applications such as an ice bag or chemical pack. The cold decreases vasodilation which reduces localized swelling, which may be useful for minor or moderate pain. Heat will increase vasodilation. Elevation of the extremity will not decrease vasodilation. It is beyond the scope of practice for the nurse to inject steroids into the joint space.

Which of the following is a disadvantage to using the IV route of administration for analgesics?

Slower entry into bloodstream No risk of respiratory depression Long duration Short duration Short duration Explanation: Disadvantages of using the IV route for analgesic administration include short duration, the occurrence of possible respiratory depression, and that careful dosage calculations are needed. Intramuscular analgesics have a slower entry into the bloodstream.

Which of the following is a reliable source for quantifying pain?

The extent of the client's injury The client's vital signs The nature of the client's injury or condition The client's description of the pain The client's description of the pain Explanation: The client's description of the pain is the only reliable source for quantifying pain. Physiologic data such as vital signs or the extent or nature of the injury do not indicate the amount of pain.

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?

Visual Analog Scale (VAS) Wong-Baker FACES Pain Rating Scale Verbal Descriptor Scales (VDS) Numeric Rating Scale (NRS) Numeric Rating Scale (NRS) Explanation: 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.