CP chapter 35: comfort and pain management
A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as "You will need more pain medication as the days progress." "Your present pain is worse because you had your packing removed." "I will call your doctor because you may have loosened sutures when walking." "Acute pain tends to increase during the day and is called a routine pain response"
"Acute pain tends to increase during the day and is called a routine pain response" Acute pain occurs abruptly after an injury or disease and persists until healing occurs. Acute pain also may be associated with anxiety and fear. Acute pain consistently increases at night and during wound care, ambulation, coughing, and deep breathing.
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain? "Can you describe the type of pain you are having?" "When did your pain begin?" "Could you please rate your pain on a 1-10 scale?" "How long have you experienced this pain?"
"Can you describe the type of pain you are having?" Asking the client to describe the pain establishes quality. Asking the client to rate pain on a 1-10 scale reflects intensity. Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset.
A nurse is conducting discharge teaching for a postoperative client prescribed oral pain medication. The client states that pain medications always causes nausea. What is the appropriate response by the nurse? "Take the pain medication with an antacid." "Do not take the pain medication." "Does the nausea go away after a while?" "Do you take the medication on an empty stomach?"
"Do you take the medication on an empty stomach?" The nurse should ask the client whether the pain medication is taken on an empty stomach, as this can be the reason for the nausea. Clients should be taught to avoid taking pain medication on an empty stomach. The nurse should not encourage the client to not take the medication if it is helping with the pain. Taking the medication with an antacid is not warranted because the antacid will neutralize acid, not stop the overproduction of the acid. Asking the client if the nausea goes away is not the right question to determine the cause of the nausea.
The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain? "Have you had this pain before?" "When did your pain begin?" "How long have you experienced this pain?" "Could you please rate your pain on a 1-10 scale?"
"How long have you experienced this pain?" Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset. Asking if the client has had this pain before reflects patterns. Asking the client to rate pain on a 1-10 scale reflects intensity.
The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain? "When did your pain begin?" "Have you had this pain before?" "Could you please rate your pain on a 1-10 scale?" "How long have you experienced this pain?"
"How long have you experienced this pain?" Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset. Asking if the client has had this pain before reflects patterns. Asking the client to rate pain on a 1-10 scale reflects intensity.
After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what? "Wearing the TENS unit should not interfere with my daily activities." "I could use the TENS unit if I feel pain somewhere else on my body." "I may need fewer pain medications with the TENS unit in place." "One advantage of the TENS unit is it increases blood flow."
"I could use the TENS unit if I feel pain somewhere else on my body." The client needs further instruction when they say they can use the TENS unit on other areas of the body. Such a statement would indicate that the client does not understand that the unit should be used as prescribed by the physician in the location defined by the physician. The TENS unit will decrease the amount of the pain medication used by the client as it increases the blood supply to the injured area and will not interfere with the activities of daily living.
The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement? "This will allow me to control my own pain medication." "I should only take medication when my pain is intense." "I give myself the pain medication by pushing the button." "The pump is programmed to limit the chance of overmedicating."
"I should only take medication when my pain is intense." PCA pumps allow the client to control the amount and timing of pain medication by pushing a button when the sensation of pain occurs versus waiting until the pain becomes intense. The pump is programmed with a lockout period that limits the chance of clients overmedicating themselves.
The nurse has completed a preoperative teaching session with a client who will receive morphine via a patient-controlled analgesia (PCA) pump after surgery. Which statement by the client indicates the need for further teaching? -"I will remind my family member to push the PCA pump button for me if I doze off during the day." -"I will let my nurse know if the pain medication is not effective enough to help me move after surgery." -"I can push the button whenever I feel pain." -"I will use the PCA pump until oral pain medication controls my pain."
"I will remind my family member to push the PCA pump button for me if I doze off during the day." Sedation occurs before clinically significant respiratory depression. Thus, if the client is too sleepy to push the button (or ask that it be pushed), the button should not be pushed. The other answers are all correct.
A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse? -"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to decrease the risk of severe migraine headaches." -"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to prevent accidental dislodgement of the catheter." -"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." -"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to increase the effectiveness of the spinal analgesia."
"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." The rationale for keeping the head of the bed elevated 30 degrees is that this position helps to minimize the upward migration of the opioid in the spinal cord, thereby minimizing the risk of respiratory depression. The nurse does not keep the head of the bed elevated to decrease the risk of migraines as migraines are not a common problem with epidural analgesia. Positioning of the client does not increase the effectiveness of the medication. Positioning also does not prevent accidental dislodgement of the catheter; this is accomplished by a secure dressing and taping the tubing so that it is not pulled.
The nurse is giving a back massage to a client who is having trouble sleeping. Which nursing actions are performed appropriately? Select all that apply. -The nurse places hands at the base of the spine and strokes upward to the shoulder and back down to the buttocks. -The nurse assists the client to a prone position and drapes the client's body as needed with the bath blanket. -The nurse applies warmed lotion to client's shoulders, back, and sacral area. -The nurse massages the client's shoulder, entire back, areas over iliac crests, and sacrum with light vertical stroking motions. -The nurse completes the massage with additional short, stroking movements that eventually become heavier in pressure. -The nurse kneads the client's skin using continuous grasping and pinching motions.
-The nurse assists the client to a prone position and drapes the client's body as needed with the bath blanket. -The nurse applies warmed lotion to client's shoulders, back, and sacral area. -The nurse places hands at the base of the spine and strokes upward to the shoulder and back down to the buttocks.
A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating? 2 3 1 S
1 Using a sedation scale, 1 indicates that the client is alert and awake. S is used to document that the client is sleeping but easy to arouse. 2 is used to denote that the client is slightly drowsy but easy to arouse. 3 is used to denote that the client is frequently drowsy, arousable but drifts off to sleep during a conversation.
Which of the following is considered to be the most potent neuromodulators? Endorphins Enkephalins Efferent Afferent
Endorphins Endorphins and enkephalins are opioid neuromodulators. Endorphins are powerful pain blocking chemicals with prolonged analgesic effects. Enkephalins are considered less potent. There are no neuromodulators called efferent or afferent.
After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client? 3 4 1 2
3 The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows: 1 = awake and alert; no action necessary 2 = occasionally drowsy but easy to arouse; requires no action 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.
Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy? Physical therapy referral A chronic opioid therapy plan A walking aid Acupuncture
A chronic opioid therapy plan Opioids are not contraindicated in older adults but are rarely used in chronic pain prior to nonpharmacologic measures.
The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? A client with chest pain who is having a myocardial infarction A client who has a sprained ankle A client suspected to have a perforated peptic ulcer A client who has appendicitis
A client who has a sprained ankle Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Visceral pain is one of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed such as with a ruptured peptic ulcer or appendicitis. A client having a myocardial infarction with chest pain is experiencing referred pain.
Which medical client is most likely to be experiencing diffuse pain? A client who has been prescribed antibiotics for the treatment of strep throat A client who has presented to the emergency department with a stab wound A client with shingles affecting her entire torso A client who is undergoing diagnostic testing for appendicitis
A client with shingles affecting her entire torso Diffuse pain is pain that covers a large area and, usually, the client is unable to point to a specific area without moving the hand over a large surface, such as the client's entire torso. Pain related to appendicitis, a stab wound, or strep throat is more likely to be localized and sharp.
A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique? A nurse applies intermittent heat and cold to a client's leg. A nurse distracts the client by playing his favorite music. A nurse guides a client to use imagery. A nurse uses deep-breathing exercises to distract a client from his pain.
A nurse applies intermittent heat and cold to a client's leg. Cutaneous stimulation is the intermittent application of heat or cold, or both. Heat accelerates the inflammatory response to promote healing, reduces muscle tension to promote relaxation, and helps to relieve muscle spasms and joint stiffness. Cold reduces muscle spasm, alters tissue sensitivity, and promotes comfort by slowing the transmission of pain stimuli. Distraction such as playing a client's favorite music, deep breathing exercises, and imagery are diversional activities that assist coping with the pain.
A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety? -Palpating the client's abdomen during a head-to-toe assessment -Administering a glycerin suppository to treat the client's constipation -Administering an oral dose of morphine to treat the client's breakthrough pain -Feeding the client food and fluids while in a semi-Fowler's (partially upright) position
Administering an oral dose of morphine to treat the client's breakthrough pain It is unsafe to administer narcotics or adjuvant drugs without the approval of the clinician responsible for the epidural injection. Suppositories, abdominal palpation, and feeding are not contraindicated when the client has an epidural in place.
The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention? -Document what the client states. -Call the pharmacy to attempt to identify the pill. -Tell the healthcare provider that the client is unsure of the pain medication taken. -Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.
Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.
A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse? Assess the client for signs of narcotic addiction. Assess for medication prescription for breakthrough pain. Tell the client he or she will have to wait for 1 hour. Administer the next dose of the pain medication.
Assess for medication prescription for breakthrough pain. Breakthrough pain is a temporary flare-up of moderate to severe pain that occurs even when the client is taking pain medication around the clock. It can occur before the next dose of analgesic is due (end of dose pain). It is treated most effectively with supplemental doses of a short-acting opioid taken on an "as needed basis." Therefore, the nurse should check for a prescription for breakthrough pain medication. Telling the client that he or she has to wait is not a therapeutic action by the nurse. Administering the next dose of pain medication is a violation of nursing practice and does not follow the standard of care. The nurse needs to assess for the therapeutic effects of the pain medication and not narcotic addiction.
The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply. -Assess for pain control 30 minutes after administering an analgesic. -Delegate pain assessment to the UAP. -Infer that the client who does not complain has no pain. -Consider cultural implications of the perception of pain. -Provide pain medication before activity that may increase pain.
Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain. Pain assessment should never be delegated to a UAP. Pain medication should be given in advance of an activity that may increase pain. The nurse should consider cultural implications associated with pain and assess for pain control after medication is given. Assumptions should not be made about pain.
A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action? -Avoid massaging the area and apply a thin layer of a topical antibiotic ointment. -Avoid massaging this area and report the finding to the health care provider. -Gently massage the region, document the finding, and verbally report it to the health care provider. -Massage the area in an attempt to restore adequate circulation.
Avoid massaging this area and report the finding to the health care provider. Nonblanching reddened areas should not be massaged and should be documented and reported to the client's health care provider. Antibiotic ointments are not applied to areas of possible skin breakdown.
A client reports a dull, aching pain to his right flank where he was struck during a football game one week ago. What is responsible for the transmission of such pain? A-delta fibers Frontal lobe C-fibers Spinal dorsal horn
C-fibers Stimulation of C-fibers, which are slow conducting fibers, is responsible for the dull and poorly localized pain persistent after the injury. A-delta fibers give rise to bright, sharp, and well-localized pain that is immediately associated with the injury. The frontal lobe of the brain is not directly involved in the physiology of the pain response. The spinal dorsal complex horn is the site where complex processing of messages occurs.
A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain? PAINAD Scale Wong-Baker CRIES Pain Scale FLACC Scale
CRIES Pain Scale The CRIES scale is appropriate for neonates (0 to 6 months). The Wong-Baker Faces Pain Rating scale requires children to be at least 3 years old. The FLACC scale is used for infants and children (2 months to 7 years) unable to validate the presence of or quantify pain severity; and the PAINAD scale is specific to the needs of clients with dementia.
The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action is an example of this type of intervention? Closing the client's room door to reduce unnecessary noises Offering the client an appropriate book to read or music to listen to Smoothing out the wrinkles in the client's bed linen Assisting the client to change positions to maintain body alignment
Closing the client's room door to reduce unnecessary noises A noisy environment, even talking, can be a source of stimuli that causes discomfort; therefore, closing the client's room door is a way to adjust the environment to make it quieter. Assisting the client to change positions or smoothing out wrinkles in the bed linen is implementation of physical adjustment techniques to promote comfort. Offering the client a book or music is using a technique of distraction to help the client not focus on the discomfort.
A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure? Biofeedback mechanism Cutaneous stimulation Patient-controlled analgesia (PCA) Guided imagery
Cutaneous stimulation Cutaneous stimulation techniques include acupressure, massage, application of heat and cold, and transcutaneous electrical nerve stimulation (TENS).
The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply. -Client is allowed to have one drink of alcohol each day. -For better absorption, take your pain medication on an empty stomach. -You must check with your primary care provider before breast-feeding your infant. -Do not drive a vehicle while taking this medication. -Keep a diary to record level of pain and time medication is taken. -You may smoke cigarettes during the day but not at night.
Do not drive a vehicle while taking this medication. You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken. The nurse will provide instructions about the medication prescribed for pain relief. This medication is an opioid, and extra precautions are required. The client is not to drive a vehicle while taking an opioid due to slowed reflexes and decreased cognitive thinking. The client is not to breast-feed her infant without checking with her primary care provider. The opioid may be absorbed into the breast milk and fed to the infant, which may adversely affect the infant. The client is to keep a diary about her pain experiences, which includes level of pain and time the medication was taken. This provides a more accurate documentation of the pain experience and prevents overdosage from taking the medication too frequently. The client is not to drink alcohol. Alcohol will depress the central nervous system when taken with an opioid and may lead to respiratory failure. The client may smoke, but someone will need to be present (for safety reasons) since the client may fall asleep due to the opioid. It does not matter whether it is day or night. The medication is not better absorbed when taken on an empty stomach. The client takes the pain medication with food, since nausea is a frequent side effect when the opioid is taken on an empty stomach.
While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate? Massage the area using lotion. Apply a warm compress to the area. Document the finding. Stop the back massage immediately.
Document the finding. The nurse should document this finding after completion of the back massage and client care and report it to the health care provider. The nurse would also position the client to remove any pressure from that area. The nurse should not apply a warm compress or massage the reddened area.
A client in pain believes that the pain is a punishment from God, and feels angry and resentful. Which is the most appropriate action by the nurse? Encourage client to confer with a spiritual advisor. Consult a psychiatric nurse practitioner. Encourage the client to pray for oneself. Encourage visitors to pray for the client.
Encourage client to confer with a spiritual advisor. The most appropriate action by the nurse would be to encourage the client to confer with a spiritual advisor to work through feelings of anger and resentment as it relates to God and the pain experience. Consulting a psychiatric nurse practitioner may help the client work through feelings of anger and resentment, but may not address the underlying feelings/beliefs related to God and the client's experience of pain. Encouraging the client to pray or to have visitors pray for the client may not help the client work through feelings of anger and resentment related to God and the experience of pain.
A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client? -Do not provide analgesia if there is any doubt about the likelihood of pain occurring. -Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. -Increase and decrease the serum level of the analgesic as needed. -Treat the pain only as it occurs to prevent drug addiction.
Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. The client would benefit from the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. The phantom pain is real pain and should be treated as such. The nurse would not increase and decrease the serum level of the analgesic as needed. The nurse would not doubt the client's report of pain and would not withhold analgesia if she doubted the likelihood of the pain occurring.
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort? Serotonin Endorphins Melatonin Dopamine
Endorphins Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that certain measures, such as skin stimulation and relaxation techniques, release endorphins. Serotonin is an important chemical and neurotransmitter in the human body. It is believed that serotonin helps regulate mood and social behavior, appetite and digestion, sleep, memory, and sexual desire and function. Melatonin is a hormone that is produced by the pineal gland in humans and animals and regulates sleep and wakefulness. Dopamine is a neurotransmitter that helps control the brain's reward and pleasure centers.
While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant? Apgar score FLACC scale Braden scale FACES scale
FLACC scale The FLACC scale (face, legs, activity, cry, and consolability) is used to measure pain for children between the ages of 2 months and 7 years. The Braden scale is used to predict pressure sore risk. The FACES scale is used to assess pain in older children using a series of faces, ranging from a happy face to a crying face. Apgar score is done at birth to assess how well the baby tolerated the birthing process.
A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? Guarding of the chest area Increased respiratory rate Decreased heart rate High blood pressure
Guarding of the chest area A person's behavioral response to pain can be demonstrated by protecting or guarding the painful area, grimacing, crying, or moaning. Increased blood pressure and respiratory rate are typical physiologic (sympathetic) responses to moderate pain. Decreased heart rate is a typical physiologic (parasympathetic) response to severe pain.
The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data? How does the pain develop and progress? How would you rate the pain on a scale of 0 to 10? What do you do to alleviate your pain and how well does it work? How would you describe your pain?
How does the pain develop and progress? When assessing the chronology of the client's pain, the nurse could ask the client how the pain develops and progresses. To assess the quality of the client's pain, the nurse could ask for the client to describe the pain. To assess the quantity of the pain, the client could be asked to rate the pain on a scale of 0 to 10. To assess the alleviating factor of the pain, the nurse could ask what the client does to alleviate the pain and how well it works.
Nurses assess clients who have physiologic responses to pain. Which examples of pain response are physiologic responses? Select all that apply. Nausea and vomiting Increased blood pressure Grimacing and moaning Protecting the painful area Exaggerated weeping and restlessness Muscle tension and rigidity
Increased blood pressure Muscle tension and rigidity Nausea and vomiting Increased blood pressure, muscle tension and rigidity, and nausea and vomiting are examples of physiologic responses to pain. Exaggerated weeping and restlessness are examples of affective responses to pain. Protecting the painful area, grimacing, and moaning are examples of behavioral responses to pain.
A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? Diphenhydramine Naloxone Epinephrine Atropine
Naloxone Naloxone is an opioid antagonist that reverses the respiratory-depressant effect of an opioid. Diphenhydramine is an antihistamine mainly used to treat allergies. Atropine is a medication to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate and to decrease saliva production during surgery. It is typically given intravenously or by injection into a muscle. Epinephrine injection is used for emergency treatment of severe allergic reactions (including anaphylaxis) to insect bites or stings, medicines, foods, and other options but not for opioids.
The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit? Naloxone Furosemide Lisinopril Digoxin
Naloxone The nurse should ensure that naloxone is readily available on the unit, as it can reverse the respiratory depressant effects of opioids. Naloxone is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids. Furosemide is a loop diuretic and used to treat hypertension (high blood pressure) and edema. Lisinopril is an angiotensin converting enzyme (ACE) inhibitor used for treating high blood pressure, heart failure and for preventing kidney failure due to high blood pressure and diabetes. Digoxin is used to treat congestive heart failure.
A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client? Corticosteroids Opioid analgesics NSAIDs Nonopioid analgesics
Opioid analgesics The nurse would expect to administer opioid analgesics to a client with severe pain following a mastectomy. Nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are usually the drugs of choice for both acute and persistent moderate chronic pain. Corticosteroids would be used to address inflammation and swelling.
The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care? Assessing for impaired urinary elimination Observing for diarrhea Observing for bowel incontinence Preventing constipation
Preventing constipation The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use. Urinary elimination and bowel incontinence are not affected by opioid use.
The nurse is performing a physical assessment on a client in moderate pain. Which findings should the nurse determine is a sympathetic response to the pain? Select all that apply. Pupil dilation Decreased blood pressure Muscle rigidity Increased pulse rate Pallor
Pupil dilation Muscle rigidity Increased pulse rate Pallor The nurse should determine that the client's pupil dilation, muscle rigidity, increased pulse rate, and pallor are sympathetic responses to the client's pain. Other sympathetic responses include increased blood pressure, increased respiratory rate, increased adrenaline output, and increased blood glucose.
A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action? -Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. -Discontinue the client's pain medication until his or her level of consciousness improves. -Increase the frequency of the client's vital signs assessment to every 2 hours for the next 6 hours. -Administer a dose of naloxone and report this finding to the primary care provider.
Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. The sedation score for this client is 3. This requires collaboration with the primary care provider to decrease the analgesic dose. Naloxone is not likely necessary, nor is it appropriate to completely discontinue the client's pain control.
When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation, scoring a 4 on the Pasero & McCaffery Sedation Scale. What is the nurse's best action? -Stop the PCA infusion, increase the frequency of sedation and respiratory rate monitoring to every 15 minutes, rouse the client, and encourage deep breathing. -Stop the PCA infusion, check the medication level, and restart the infusion at a lower dose. -Stop the infusion and report the incident to the nurse manager in charge; follow the protocol of oxygen and naloxone administration. -Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and naloxone.
Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and naloxone. If a client receiving a PCA infusion becomes somnolent, with a sedation score of 4, the nurse should stop the medication infusion immediately and notify the primary care provider. The nurse should prepare to administer oxygen and a narcotic antagonist, such as naloxone.
A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? -The dose that is delivered when the client activates the machine is preset. -Thorough client education is necessary to prevent overdoses. -An antidote is automatically delivered if the client exceeds the recommended dose. -Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression.
The dose that is delivered when the client activates the machine is preset. PCAs are designed to make it impossible for the client to exceed the client-specific dosing parameters programmed into the machine. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics. The client does not need to be educated about overdoses.
A nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique? -The nurse plays soft music in the client's room. -The nurse assists the client to focus on something pleasant rather than on pain. -The nurse gives the client a massage before bed. -The nurse teaches the client deep breathing techniques for relaxation.
The nurse gives the client a massage before bed. Some forms of cutaneous stimulation include the following: massage, application of heat or cold (or both intermittently), acupressure, transcutaneous electrical nerve stimulation (TENS). All the options listed are examples of complementary and alternative relief measures, but only massage is an example of cutaneous stimulation.
Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain? -This approach can only be used with oral analgesics. -A PCA pump must be used and monitored in a health care facility. -The PCA pump is not effective for chronic pain. -The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval.
The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. This approach can be used with oral analgesic agents as well as with infusions of opioid analgesic agents by intravenous, subcutaneous, epidural, and perineural routes. This drug delivery system may be used to manage acute and chronic pain in a health care facility or the home.
The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate? They occupy cell receptors for neurotransmitters. They bind to opioid receptor sites throughout the CNS. They react with acetylcholine and serotonin. They block glutamate receptors and peptides.
They bind to opioid receptor sites throughout the CNS. When endogenous opioids are released, they are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the central nervous system (CNS), blocking the release or production of pain-transmitting substances.
The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client? Use massage and heat application to the lower back Administer opioid analgesics Have the client perform active exercises to stretch the back muscles Encourage the client to have an epidural steroid injection
Use massage and heat application to the lower back The gate theory appears to explain why mechanical and electrical interventions or heat and pressure may provide effective pain relief. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Teaching self-management techniques that activate closing the gate may also minimize the experience of pain. Pain medication and epidural anesthesia are not a part of gate theory interventions. Stretches and active exercises may cause further injury to the client.
You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so? The first question you ask the patient When obtaining patient vital signs Before the patient is discharged At several points throughout your history-taking
When obtaining patient vital signs Pain should be addressed during your first encounter with the patient. However, you will probably want to start a professional conversation prior to addressing pain. Vital signs are often collected in the beginning of the patient visit. This would be the most appropriate time to address pain.
The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use? Wong-Baker FACES® scale word scale visual analog scale numeric scale
Wong Baker FACES scale
The nurse is assessing clients with common pain syndromes that cause neuropathic pain. Which clients would the nurse identify are at risk for neuropathic pain? Select all that apply. a client with postherpetic neuralgia a client with diabetic neuropathy a client who has a tooth abscess a client with phantom limb pain a client who has lung cancer A client with complex regional pain syndrome
a client with postherpetic neuralgia a client with phantom limb pain a client with diabetic neuropathy A client with complex regional pain syndrome Neuropathic pain would include postherpetic neuralgia, phantom limb pain, diabetic neuropathy, and complex regional pain syndrome. A tooth abscess and lung cancer would not be neuropathic pain, rather nociceptive pain.
The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? rates pain an 8 on a 0 to 10 scale right shoulder immobilizer in place B/P 178/92 and pulse 118 confused to time and place
confused to time and place Clients must be cognitively and physically capable of using the PCA equipment safely. Confusion in a client would lead the nurse to question the client's ability to correctly use the PCA.
A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. drug regimen as an effective method of pain control would be the client: experiencing chronic pain. in the early postoperative period. experiencing acute pain. in the postoperative stage with occasional pain.
in the postoperative stage with occasional pain. A p.r.n. (as needed) medication would be most appropriate for a client in the postoperative stage with occasional pain. A client in the early postoperative period would benefit from the dosage of pain medication with around the clock dosing. A client experiencing chronic pain would benefit from the dosage of pain medication with around the clock dosing. A client experiencing acute pain would benefit from the dosage of pain medication with around the clock dosing.
The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point? reviewing and revising the pain management treatment plan judging whether the client is in pain or is just depressed administering a placebo and performing a reassessment of the pain beginning pain medications before the pain is too severe
reviewing and revising the pain management treatment plan The nurse's focal point should be on reviewing and revising the pain management treatment plan presently in place. The client is status-post bowel resection, so administering a placebo is not the correction option, and could be ethically wrong. The nurse would possibly do a depression assessment, but if the client is reporting constant pain, the pain management plan must be reviewed and revised. The question does not address if the client is taking pain medications, so the option addressing beginning pain medications before the pain is too severe is not correct.
A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention? -stool softeners and increased fluid intake -supplementary oxygen and chest physiotherapy -calorie restriction and dietary supplements -frequent turns and application of skin emollients
stool softeners and increased fluid intake The most common side effect of opioid use is constipation. Consequently, stool softeners and increased fluid intake may be indicated. Opioids may cause respiratory depression, but this fact in and of itself does not create a need for oxygen supplementation or chest physiotherapy. The use of opioids does not create a need for calorie restriction, supplements, frequent turns, or the use of skin emollients.
A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain? the nurse's impression of the client's pain the client's recent responses to pain and to pain medication nonverbal cues of the client the client's pain based on a pain rating
the client's pain based on a pain rating The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, but which are not more important than the pain rating. Pain relief after nursing intervention is appropriate, but is a part of evaluation.
A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing? visceral pain referred pain cutaneous pain somatic pain
visceral pain Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial. Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix.
A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing: neuropathic pain. somatic pain. visceral pain. cutaneous pain.
visceral pain. The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.
