FN - Unit 2 - Chapter 36: Comfort and Pain Management

The nurse is caring for a client newly diagnosed with chronic pain. When preparing to educate the client regarding chronic pain and management they ask who should be involved in the teaching. Which response is best? "Your spouse or caregiver." "Your best friend." "Anyone you think needs to know." "One of your neighbors will do."

"Anyone you think needs to know." Teaching about pain should include anyone the client identifies as needing the information so that they understand the concept of pain and are able to help the person in pain. Designated people can be family members, caregivers, friends, or neighbors; therefore, the correct answer is whomever the client identifies as needing the information.

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? "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." "I may need fewer pain medications with the TENS unit in place." "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." 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 health care provider in the location defined by the health care provider. 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.

A client who recently underwent amputation of a leg reports pain in the amputated part. What would be the nurse's best response? "Your pain cannot exist because the leg has been amputated." "Your pain is a phenomenon known as 'ghost pain.'" "Your pain is a real experience." "You are experiencing central pain syndrome."

"Your pain is a real experience." The pain that is often referred to an amputated leg where receptors and nerves are clearly absent is a real experience for the client. This type of pain is called phantom pain or phantom limb pain and is without demonstrated physiologic or pathologic substance. One theory suggests that sensory misrepresentations from the missing limb may still remain in the brain, thereby causing phantom pain. The pain is a real experience. This pain is not known as central pain syndrome. This pain is not referred to as "ghost pain".

A nurse is assessing an adult client with back pain. The client is unable to speak the dominant language. Which pain scale is most appropriate for the nurse to use in assessing the client's pain? PAINAD scale 0 to 10 numeric rating scale Payen behavioral pain scale FLACC scale

0 to 10 numeric rating scale The 0 to 10 numeric rating scale can be used in adults and children (>9 years old) who are able to use numbers to rate the intensity of their pain. The PAINAD scale is used in clients whose dementia is so advanced that they cannot verbally communicate. The FLACC scale is used in infants and children (2 months-7 years) who are unable to validate the presence of, or quantify, the severity of pain. The Payen behavioral pain scale is used with intubated, critically ill clients, including measurement of bodily indicators of pain and tolerance of intubation.

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? S 1 2 3

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.

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? 1 2 3 4

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 walking aid Acupuncture A chronic opioid therapy plan

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 suspected to have a perforated peptic ulcer A client who has a sprained ankle A client with chest pain who is having a myocardial infarction 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.

A sudden blow to the head results in pain that is transmitted by which type of fibers? A-delta B-gamma C fibers D-delta

A-delta A-delta fibers give rise to bright, sharp, well-localized pain that is immediately associated with injury.

The nurse is caring for a client with chronic back pain due to inoperable spinal stenosis. Which strategies, suggested by the nurse, may help to decrease the client's back pain? Adding the use of hot or cold packs for pain control Requesting an opioid prescription from the health care provider Referring for a surgical consult to validate the diagnosis Maintaining strict bed rest to relieve pain

Adding the use of hot or cold packs for pain control Chronic, inoperable back pain is difficult to manage. Treatment response is individual. Adding hot or cold packs with other measures, such as anti-inflammatory agents, may help to reduce pain. Opioids should be avoided due to the tendency of developing tolerance over time, as well as addiction. Getting a surgical consultation may be helpful but will not help with the acute pain that the client is experiencing. Bed rest alone may worsen back symptoms.

A client is alert but nonverbal after a motor vehicle accident. Which action(s) will the nurse include in the assessment of pain for this client? Select all that apply. Observing for grimacing and other signs of pain Using the Wong Baker FACES pain rating scale Checking for loss of function of the extremities Communicating with the client in writing Performing vital signs

Observing for grimacing and other signs of pain Using the Wong Baker FACES pain rating scale Checking for loss of function of the extremities Communicating with the client in writing Performing vital signs The nurse will complete a thorough pain assessment including observation for signs of pain such as grimacing and loss of function in the extremities, attempting communication with the client via writing, and utilizing a written pain scale for the client to choose from, either the Wong-Baker FACES Pain Rating Scale or the numeric pain rating scale. Abnormal vital signs can indicate that a person is in pain.

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? Administer a dose of naloxone and report this finding to the primary care provider. Discontinue the client's pain medication until his or her level of consciousness improves. Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. Increase the frequency of the client's vital signs assessment to every 2 hours for the next 6 hours.

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.

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first? Notify the health care provider. Stop the PCA pump. Administer naloxone. Increase the primary IV rate.

Stop the PCA pump. A side effect of morphine is respiratory depression. In this situation, the nurse should first stop the PCA pump and then notify the health care provider. Naloxone is used to reverse the sedative effects of opioids, but this is not the first step.

The nurse is caring for a client who reports nausea and vomiting for 1 week. How will the nurse document this type of pain? Select all that apply. visceral referred neuropathic acute chronic

visceral acute Visceral pain is associated with disease or injury. Acute pain lasts for a few seconds to less than 6 months. Therefore, the nurse in the scenario documents the client's pain as visceral and acute. Cutaneous, somatic, referred, neuropathic, and chronic pain are not represented in this scenario.

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.

Which client statements would indicate to the nurse that the client needs additional teaching regarding prn pain medication and management? Select all that apply. "I should wait until my pain gets worse before asking for pain medications." "It's better to put up with the pain than deal with side effects of medication." "If I ask for pain medication, I may become addicted." "I should ask for my pain medication when I am feeling pain." "The nurse will know when my medication is due and will give it to me automatically."

"I should wait until my pain gets worse before asking for pain medications." "It's better to put up with the pain than deal with side effects of medication." "If I ask for pain medication, I may become addicted." "The nurse will know when my medication is due and will give it to me automatically." The nurse should determine that additional teaching is needed relating to prn pain medication and management if the client states, "I should wait until my pain gets worse before asking for pain medications"; "It's better to put up with the pain than deal with the side effects of medication"; or "If I ask for pain medication, I may become addicted."

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 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 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 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 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." 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 witnesses a caregiver interacting with a client with chronic pain. When helping the client get dressed, the caregiver appears hurried and frustrated, and speaks to the client angrily. What is the appropriate nursing response? "Stop talking to your loved one like that." "You are clearly angry and should not be here." Use therapeutic silence and let the caregiver and client continue interacting. "Let me help you dress the client while we talk about home health resources that can assist when the client goes home."

"Let me help you dress the client while we talk about home health resources that can assist when the client goes home." Caregivers of clients with chronic pain may become frustrated or overwhelmed and may display negative reactions. The nurse can intervene by acting as a client advocate to assist in the dressing process, and also teach the caregiver about resources that can be of assistance later. Using silence does not address the issue. Directive statements do not offer assistance or opportunity to assess the caregiver's feelings.

Two hours after receiving a pain medication, the client reports still suffering from pain. Which response is most appropriate? "Do you need your pain medication now?" "Have you ever had pain like this before?" "Tell me where your pain is located." "Tell me more about your pain."

"Tell me more about your pain." Pain intensity indicates the magnitude or amount of pain perceived. Terms used to describe pain intensity include none, mild, slight, moderate, severe, and excruciating. Pain intensity also may be described on a numeric scale. The most appropriate assessment is one which allows for all information and is broad.

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client? "If you feel severe pain, either push the button yourself or ask one of your family members to push the button." "I'll have the unit's care aide come check on you every few minutes after I set up the system." "We'll be monitoring your use of the system closely, to ensure you don't develop an addiction to your pain medication." "The pump is programmed with safeguards to limit the possibility overmedication."

"The pump is programmed with safeguards to limit the possibility overmedication." The parameters programmed into the PCA pump prevent accidental overdose. Addiction is not a realistic risk for most clients. Care related to a PCA is not delegated to unlicensed care providers. The button should be pushed only by the client.

The nurse is preparing to administer an NSAID to a client for pain relief. The nurse notices that the client is diagnosed with a bleeding disorder. What should the nurse do? Administer the medication. Contact the health care provider. Ask the client if the medication is desired. Administer the medication with food.

Contact the health care provider. The nurse should contact the health care provider regarding the diagnosis of a bleeding disorder and the prescription for the NSAID. NSAIDs are contraindicated in clients with bleeding disorders, because the action of the NSAID can interfere with the client's platelet function. Administering the medication is not warranted because the nurse has identified a problem that can affect the safety of the client. Asking the client if the medication is desired will not change the risk. Administering the medication with food can affect the safety of the client.

The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief? Acknowledge the pain as the client reports it and administer pain medication as prescribed. Observe the client's behavior when the nurse is not with the client. Take the client's vital signs often to observe for changes that may indicate pain. Report the client to the health care provider for seeking drugs.

Acknowledge the pain as the client reports it and administer pain medication as prescribed. Pain is subjective and the nurse must acknowledge pain as the client reports it. Observing the client's behavior is not an appropriate nursing intervention, as pain is a self-reported finding. Taking the client's vital signs would help in administering pain medications, as pain medicine can lower a client's blood pressure and heart rate. The nurse will not report the client to the health care provider; this is making assumptions about the client.

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse? Hold the pain medication. Administer the pain medication. Reassess the client's pain in 30 minutes. Contact the client's health care provider.

Administer the pain medication. Pain is considered to be present whenever the client states it is. Therefore, the nurse should administer the client's pain medication. It is important that the nurse understand that clients have different ways to manage their pain. It would be inappropriate to delay administration or to hold the medication. There is no indication that the client's health care provider needs to be notified at this time.

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety? 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 Administering a glycerin suppository to treat the client's constipation Palpating the client's abdomen during a head-to-toe assessment

Administering an oral dose of morphine to treat the client's breakthrough pain It is unsafe to administer opioids 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.

What will the nurse place at the bedside of a client receiving epidural analgesia? Ampule of 0.4 mg naloxone Ampule of 0.4 mg epinephrine An extra chest drainage system Bottle of sterile saline

Ampule of 0.4 mg naloxone At the bedside of a client receiving epidural analgesia, the nurse should ensure that an ampule of 0.4 mg naloxone and a syringe are present. This medication reverses the respiratory depressing effects of opioids when needed and should be readily available. Epidural analgesia does not usually affect the neurotransmitter epinephrine and, therefore, is not needed at the bedside. A chest drainage system and a bottle of sterile saline would be at the bedside of a client with a chest tube but is not indicated for epidural analgesia.

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. 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. Call the pharmacy to attempt to identify the pill.

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. The priority nursing intervention is to ask the client for the original bottle that the drug was dispensed into from the pharmacy. This will provide the most accurate identification of the medication. Other interventions can subsequently be implemented.

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 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 the client for signs of opioid addiction.

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 opioid 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. Delegate pain assessment to the UAP. Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Infer that the client who does not complain has no 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? Gently massage the region, document the finding, and verbally report it to the health care provider. 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. 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.

When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response? Behavioral Physiologic Affective Psychosomatic

Behavioral Behavioral (voluntary) responses would include moving away from painful stimuli, grimacing, moaning, crying, restlessness, protecting the painful area, and refusing to move the limb. Physiologic (involuntary) responses would include increased blood pressure, increased pulse and respiratory rates, pupil dilation, muscle tension and rigidity, pallor (due to peripheral vasoconstriction), increased adrenaline output, and increased blood glucose. Psychological responses would include exaggerated weeping and restlessness, withdrawal, stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, and powerlessness.

The nurse is performing assessments for an assigned client. Which methods are appropriate ways for the nurse to gather objective data related to a client's pain? Select all that apply. By checking the vital signs By observing facial expressions By eliciting factual information By diagnostic tests and procedures By using pain assessment questionnaires

By checking the vital signs By observing facial expressions By diagnostic tests and procedures Physical assessment is a mode of gathering objective data about a client's pain perception. It involves assessing the client's vital signs and observing facial expressions of pain. Diagnostic tests and procedures can provide objective data by validating painful events and identifying the source of pain. Eliciting factual information, such as the intensity and type of pain, as well as use of pain assessment questionnaires, are strategies to obtain subjective data about the client's pain perception.

A client is receiving opioid analgesia for pain control. The nurse is assessing the client for possible respiratory depression. Which method would be most reliable for the nurse to use to identify impending respiratory depression? Capnography Pulse oximetry Respiratory rate Lung sounds

Capnography End tidal CO2 is considered a highly reliable measure of the quality of ventilation and, unlike pulse oximetry, is an early indicator of impending respiratory depression. Although respiratory rate and lungs sounds help evaluate the client's respiratory status, they are not reliable indicators of impending respiratory depression.

In which client would a back massage be contraindicated? Client who has a fractured rib Client who is ambulatory Client who is experiencing anxiety Client who has diabetes mellitus

Client who has a fractured rib A back massage would be contraindicated in a client who has a fractured rib as the massage could accidently dislodge the fracture and cause injury to nearby organs. Back massage is also contraindicated in clients with severe burns because of the risk of disturbing the wounds and in clients who have recently had open heart surgery because of the risk of injury to the new sternal incision. None of the other clients present a contraindication to back massage. Back massage does not present a risk for the client who is ambulatory, experiencing anxiety, or has diabetes mellitus. In fact, it could be quite beneficial, as massage helps the client to relax and helps relieve muscle tension, hopefully helping him or her to rest and sleep better while hospitalized.

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 Assisting the client to change positions to maintain body alignment Smoothing out the wrinkles in the client's bed linen Offering the client an appropriate book to read or music to listen to

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 client who suffered multiple trauma in a motor vehicle accident is receiving care in an orthopedic trauma unit. The client has a documented history or opioid addiction and the hospital's advanced pain control team has become involved in his pain control plan. Which of the following are aspects of addiction? Select all that apply. Compulsive use of a particular drug Presence of an unusually low pain threshold The need to use opioids for purposes other than pain relief The need for increasing size or frequency of opioid doses to achieve pain relief The use of more than 30 mg of morphine or 15 mg of hydromorphone in a 24 hour period

Compulsive use of a particular drug The need to use opioids for purposes other than pain relief The American Pain Society (2008) defines addiction as "a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief." Drug tolerance is not synonymous with addiction and increased tolerance does not lead to addiction. Addiction is not defined in absolute terms of opioid doses and it is not related to a low pain threshold.

The nurse is preparing to initiate PCA therapy for a client with sleep apnea. What is the correct action by the nurse? Contact the health care provider. Initiate the therapy. Increase the lock out time. Decrease the loading dose.

Contact the health care provider. The nurse should contact the health care provider, as PCA therapy for pain management is contraindicated for clients with sleep apnea. This is due to the fact that oversedation in clients with sleep apnea poses a significant health risk. PCA therapy is also contraindicated in confused clients, infants and very young children, cognitively impaired clients, and clients with asthma.

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? Decreased heart rate Guarding of the chest area Increased respiratory 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 that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.) Heat Massage Pressure Percocet Acetaminophen

Heat Massage Pressure The gate theory supports that the signals at the gate in the spinal cord determine which impulses eventually reach the brain. A limited amount of sensory information can be processed by the nervous system at any given moment. When there is too much information sent through, certain cells in the spinal column interrupt the signal as if closing a gate. The theory appears to explain why mechanical and electrical interventions such as heat, pressure, and massage provide effective pain relief. Percocet and acetaminophen are medications that can be used for pain.

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 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).

Deep somatic

Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, muscles and nerves. The nurse is demonstrating splinting, which will help minimize muscular pain caused by coughing and deep breathing after abdominal surgery. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Neuropathic pain caused by a lesion or disease of the peripheral or central nerves. Cutaneous or superficial pain usually involves the skin or subcutaneous tissue.

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. Do not drive a vehicle while taking this medication. Client is allowed to have one drink of alcohol each day. You may smoke cigarettes during the day but not at night. You must check with your primary care provider before breast-feeding your infant. For better absorption, take your pain medication on an empty stomach. Keep a diary to record level of pain and time medication is taken.

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.

The nurse is massaging an older adult client's back and notices a reddened area on the client's sacrum. What actions would the nurse perform in response? Select all that apply. Lightly massage the area. Document the reddened area on the client's medical record. Following the massage, position the client on the sacral area. Report the finding to the primary care provider. Institute a turning schedule. Do not massage the client's back; immediately report the area to the health care provider.

Document the reddened area on the client's medical record. Report the finding to the primary care provider. Institute a turning schedule. The nurse would document the reddened area on the client's medical record, report the finding to the primary care provider, and institute a turning schedule. The nurse should not massage the area or position the client on the sacral area. The nurse would not immediately report the area to the health care provider until further assessment is completed.

Evelyn is a 90-year-old woman who just returned from the operating room to your medical unit. She is otherwise healthy and has a history of some mild arthritis. As you examine Evelyn, you know that all of the following are signs of pain EXCEPT which? Elevated blood pressure Elevated serum glucose Elevated lactic acid production Elevated kidney function

Elevated kidney function Kidney function would be temporarily suppressed by acute pain.

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) Encourage deep breathing. Play the client's favorite music. Promote a restful environment. Encourage increased protein. Encourage the use of a sitter.

Encourage deep breathing. Play the client's favorite music. Promote a restful environment. Anxiety, lack of sleep, and muscle tension may all increase the client's perceived intensity of pain. Therefore, the client's plan of care should include measures to promote sleep and decrease anxiety and muscle tension. These include relaxation techniques, such as deep breathing, favorite music, and restful environment. Use of a sitter, someone to be paid to stay with the client in the room at all times, is not indicated and may cause the client's anxiety level to increase. Encouraging increased protein does not aid in the client's perceived intensity 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? Treat the pain only as it occurs to prevent drug addiction. Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen. Increase and decrease the serum level of the analgesic as needed. 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. 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? Endorphins Serotonin 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.

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? Compare the client's current assessment with previous admission assessment Educate the client/caregiver about signs of impending death Assess the client's serum albumin level Examine the effectiveness of the current pain regimen

Examine the effectiveness of the current pain regimen When a client has a painful diagnosis and is nearing the end of life, pain management is the priority. Education is important along with assessment and comparison, however, these are not the priority.

When implementing the gate-control theory of pain, which intervention will enhance the closing of the gate to the client's pain? Position the client on several pillows. Teach the client relaxation techniques. Give the client a back rub. Darken the room.

Give the client a back rub. The gate-control theory of pain involves cutaneous nerve fibers, which are large diameter fibers carrying impulses to the CNS. When the skin is stimulated, pain is believed to be controlled by closing the gating mechanism in the spinal cord. This decreases the number of pain impulses that reach the brain for perception. A back rub will stimulate this mechanism. Pillows do not provide enough pressure for stimulation. Darkening the room and relaxation techniques do not involve touching the skin.

The nurse has provided a hot pack to a client who has been experiencing neck pain. According to the gate control theory of pain transmission, why is this intervention likely to be effective? Heat stimulates the large-diameter fibers that inhibit pain transmission. Heat and pressure open the gates that conduct pain-relieving endorphins to the brain. Heat overwhelms the small-diameter pain fibers and they stop transmitting pain signals. Heat opens nerve gates so that they can transmit pain-inhibiting enkephalins.

Heat stimulates the large-diameter fibers that inhibit pain transmission. Warmth stimulates large nerve fibers to close the gating mechanism that is thought to be located in substantia gelatinosa cells in the dorsal horn of the spinal cord. As a result, pain impulses from that area are blocked. The gate control theory does not encompass the actions of endorphins and enkephalins as medications affect the action of these. Heat does not overwhelm small-diameter, pain-conducting fibers.

The spouse of a client with cancer asks why the client's breakthrough doses of morphine have recently needed to be higher and more frequent for the client to achieve pain relief? Which response by the nurse is appropriate? Higher doses are needed because the client has developed a tolerance to the morphine. The client is now addicted to the morphine and requires higher doses. The higher dose is due to the client's physical dependence on the morphine. The morphine is having more drug interactions with the client's other medications, requiring a higher dose.

Higher doses are needed because the client has developed a tolerance to the morphine. This client is likely developing drug tolerance, which occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief. This is not a pathologic finding and does not necessarily indicate physical dependence. Addiction is the fact or condition of being addicted to a particular substance, thing, or activity. Tolerance does not indicate addiction or a heightened risk for addiction. A drug interaction is a reaction between two (or more) drugs or between a drug and a food or beverage.

The client is a new admission who reports lower right quadrant abdominal pain. The client is scheduled for an emergency appendectomy. What question(s) will the nurse ask the client in relation to the pain? Select all that apply. How do you rate your pain on a scale of 0 to 10? Does anything make the pain worse? How would you describe the pain? When did your pain begin? What medication have you taken to relieve the pain?

How do you rate your pain on a scale of 0 to 10? Does anything make the pain worse? How would you describe the pain? When did your pain begin? What medication have you taken to relieve the pain? All of these questions are appropriate for a pain assessment. They are part of a comprehensive pain assessment, which is to be performed on the client's admission to a clinical facility. The nurse wants to quantify the client's pain as well as wants to qualify the client's pain by asking for a description of the pain in the client's own words. The nurse asks about the onset, which is when the pain began. It is important to know what medications the client has taken for pain relief. For this client, it is extremely important, because the client is going for emergency surgery. These medications could affect the client's outcome for the surgery.

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 describe your pain? 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 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.

A 77-year-old woman is on the nurse's unit s/p left knee replacement. The client typically stools every morning but has not had a bowel movement in 3 days. The nurse knows that which medication places the client at increased risk for constipation? Hydromorphone Psyllium Acetaminophen Furosemide

Hydromorphone Hydromorphone is an opioid agent which is often constipating in older adults. Psyllium helps promote regular bowel elimination. Acetaminophen is not linked to constipation. Furosemide is used as a diuretic. It does not cause constipation.

The nurse provides a cool glass of water to a client with inflamed throat tissue. What condition should the nurse caution the client to avoid when drinking very hot liquids while having an inflamed throat? Allodynia Hyperreflexia Hyperalgesia Desensitization

Hyperalgesia Swallowing very hot fluid would produce hyperalgesia pain in inflamed pharyngeal tissue.

The nurse is caring for client prescribed morphine who is experiencing constipation. What intervention should the nurse recommend to the client? (Select all that apply.) Increased fluids Increased fiber Stool softener Increased protein Enema

Increased fluids Increased fiber Stool softener Most side effects of morphine disappear with prolonged use, but if constipation persists, it usually responds to increased fluids and fiber and use of a mild laxative or stool softener. Increased protein will not help the client's constipation. An enema is not indicated at this time.

The nurse recognizes which statement is true of chronic pain? It can be easily described by the client. It is always present and intense. It may cause depression in clients. It disappears with treatment.

It may cause depression in clients. Chronic pain may lead to withdrawal, depression, anger, frustration, and dependency. Clients have difficulty describing chronic pain because it may be poorly localized. Moreover, health care personnel have difficulty assessing it accurately because of the unique responses of individual clients to persistent pain. Chronic pain is commonly characterized by periods of remission and exacerbation.

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? Naloxone Diphenhydramine Atropine Epinephrine

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.

A 92-year-old woman is on an inpatient unit following hip replacement surgery. The nurse asks her if she is in pain, and she tells the nurse that she is fine. The nurse knows what to be true regarding pain in the older adult? Select all that apply. Older adults are less likely to feel pain than younger adults. Older adults have decreased opioid receptors. Older adults often believe that pain is a consequence of growing older. Older adults are more likely to be disabled by pain than younger adults.

Older adults have decreased opioid receptors. Older adults often believe that pain is a consequence of growing older. Older adults are more likely to be disabled by pain than younger adults. Although peripheral nerves may be less sensitive to painful stimuli, older adults very much experience pain. However, this pain is often underreported.

The nurse is administering oxycodone to a client. To which category of analgesics does this belong? Opioid Nonsteroidal anti-inflammatory Cyclooxygenase 2 inhibitor Antibiotic

Opioid Opioids analgesics are used to manage moderate to severe pain. These include morphine, codeine, oxycodone, meperidine, hydromorphone, and methadone. The most prominent non steroid anti-inflammatory drugs (NSAIDs) are aspirin, ibuprofen and naproxen. NSAIDs work by inhibiting the activity of cyclooxygenase enzymes (COX-1 and/or COX-2). Cyclooxygenase 2 inhibitors (COX 2) are celecoxib, valdecoxib and rofecoxib. Antibiotics target destruction of bacterial cells and one grouping is the penicillins.

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered? standing order PRN order one-time order stat order

PRN order A PRN order is one that is given to a client on an "as needed" basis.

Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients? Pain assessment may require multiple methods in order to ensure accurate pain data. The developing neurologic system of children transmits less pain than in older clients. Pharmacologic pain relief should be used only as an intervention of last resort. A numeric scale should be used to assess pain if the child is older than 5 years of age.

Pain assessment may require multiple methods in order to ensure accurate pain data. It is often necessary to use more than one technique for pain assessment in children. Though their neurologic system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all clients above a certain age; the assessment tool should reflect the client's specific circumstances, abilities, and development.

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? Preventing constipation Observing for diarrhea Assessing for impaired urinary elimination Observing for bowel incontinence

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 caring for a client receiving epidural opioids . What side effects of the medication should the nurse assess for? Select all that apply. Pruritis Urinary retention Nausea Hypertension Infection

Pruritis Urinary retention Nausea Infection The nurse should assess for side effects that include, hypotension, pruritus, urinary retention, nausea and vomiting, infection, and respiratory depression.

Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take? Administer pain medications in smaller doses but more frequently. Decrease external stimuli in the room during painful episodes. Reposition the client and gently massage the client's back. Advise the client to try to sleep following administration of pain medication.

Reposition the client and gently massage the client's back. The nurse would reposition the client and gently massage the client's back using the gate-control theory of pain. The gate-control theory provides the most practical model regarding the concept of pain. It describes the transmission of painful stimuli and recognizes a relationship between pain and emotions. 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. Decreasing the dosage of the pain medication—but giving the doses more frequently—does not follow this theory. Decreasing external stimuli in the room during painful episodes would not address the gate-control theory. Advise the client to sleep following administration of pain medication does not address the gate-control theory.

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? Respiratory Cardiovascular Peripheral Vascular Neuromuscular

Respiratory The priority assessment for the nurse caring for a client with a PCA pump is respiratory, with particular attention to the respiratory rate and pattern. Too much opioid or a displaced catheter may allow the medication to have a depressant effect on the brainstem center, causing life-threatening respiratory depression. The cardiac system can be affect by a opioid PCA by decreasing the blood pressure and heart rate as the pain decreases. It is expected but not the priority. The neuromuscular and peripheral vascular system are not affected by the PCA.

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? When obtaining client vital signs Before the client is discharged The first question you ask the client At several points throughout your history-taking

When obtaining client vital signs Pain should be addressed during your first encounter with the client. However, you will probably want to start a professional conversation prior to addressing pain. Vital signs are often collected in the beginning of the client visit. This would be the most appropriate time to address pain.

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment? Respiratory status, oxygen saturation, pain, and sedation level Heart rate, capillary refill, bowel sounds and pedal pulses Temperature, pedal pulses, and assessment of cranial nerves Gastrointestinal status, bowel movements, and urine output

Respiratory status, oxygen saturation, pain, and sedation level Respiratory status, oxygen saturation, pain, and sedation level are the best description of the priority of the hourly assessments for this client. The priority concern for this client is the risk of respiratory depression because of the use of analgesia; therefore, the priority assessments during the first 12 hours of epidural therapy include assessing the client's vital signs, respiratory status, pain status, sedation level, oxygen saturation at least once per hour during the first 12 hours of therapy. If there are no complications after 12 hours, the assessments should continue every 2 hours and then decrease per facility policy. Airway, breathing, and circulation are the top priorities in the care of any client, and in this client, breathing is a concern because of the risk of respiratory depression from the epidural analgesia. Although important, the other options do not best describe the priority assessments because the main concern, the risk of respiratory depression, is not the focus of the other options.

A nurse is assessing the pain of a client who has been diagnosed with a sprained ankle. The client describes the pain as aching and is able to identify the pain as occurring in his left ankle. The nurse identifies this as which type of pain? Somatic Visceral Neuropathic Persistent

Somatic Somatic pain originates in bone, skin, and soft tissue and is often well localized. Clients will describe somatic pain as aching or throbbing; when asked if they can point to the location of their pain, they are often able to specifically pinpoint where it hurts. Examples of somatic pain include soft tissue injury such as a contusion from a sprained ankle. Visceral pain originates internally and is the result of stretching, distention, inflammation, or damage to the hollow and solid organs. Clients tend to describe visceral pain as aching, throbbing, cramping, pressure, deep, or radiating. This type of pain is often diffuse and difficult for clients to pinpoint. Neuropathic pain arises from damage to the peripheral nerves or the CNS and, unlike nociceptive pain, is the result of abnormal sensory input. Clients describe neuropathic pain as tingling, itching, burning, cold, prickly, or "shock-like." Unlike acute pain, which follows the normal nociceptive pain process, persistent (chronic) pain serves no useful purpose. Health care providers are using the term persistent pain in place of chronic pain to help avoid the negative and often inaccurate assumptions associated with chronic pain clients. Persistent pain is an abnormal pain-signaling process with origins that can occur both peripherally and centrally. Persistent pain is cyclical and irreversible and generally persists longer than 3 to 6 months.

A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action? Turn on the unit shortly before applying the electrodes to the client's skin. Start with the lowest intensity and gradually increase it to the appropriate level. Disinfect with chlorhexidine the areas where the electrodes will be applied Administer analgesia 30 minutes before beginning a TENS session.

Start with the lowest intensity and gradually increase it to the appropriate level. After applying the electrodes, the nurse should turn on the unit and adjust the intensity setting to the lowest intensity and determine if the client can feel a tingling, burning, or buzzing sensation. The nurse should then adjust the intensity to the prescribed amount or the setting most comfortable for the client. Skin should be clean before applying the electrodes, but it is unnecessary to use disinfectant. Analgesia may or may not be necessary before a TENS session.

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate? If the client develops a headache, an opioid analgesic may be administered along with the epidural analgesia. The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. If a client is experiencing adverse effects, a peripheral IV line should be inserted to allow immediate administration of emergency drugs, if warranted. The nurse should expect slight resistance during the removal of the epidural catheter.

The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. The anesthesiologist/pain management team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min or has unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache. No other medications should be administered; a peripheral IV line should already be in place. Resistance should not be felt when removing an epidural catheter.

An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug? The client is unable to sleep without medication the following night. The client experiences respiratory depression after the drug takes effect. The client exhibits restless, uncharacteristic behavior after receiving the drug. In the morning, the client is unable to identify his location or the day of the week.

The client exhibits restless, uncharacteristic behavior after receiving the drug. Paradoxical effects of hypnotics involve a stimulating effect or mental changes. Tolerance, somnolence, and respiratory depression are not indicative of paradoxical effects.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? The client obtains pain relief slowly and steadily. The client requires less nursing care. The client is able to have long hours of rest. The client is actively involved in pain management.

The client is actively involved in pain management. Patient-controlled analgesia (PCA) gives the client the advantage of playing an active role in pain management, as the client is allowed to self-administer medication. Pain relief is rapid, not slow and steady, because the drug is delivered intravenously. PCA does not replace nursing care or reduce the amount of care that the client requires.

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. Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. An antidote is automatically delivered if the client exceeds the recommended dose.

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.

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 massages the client's shoulder, entire back, areas over iliac crests, and sacrum with light vertical stroking motions. 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 completes the massage with additional short, stroking movements that eventually become heavier in pressure. 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.

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. When giving a massage to the client, the nurse would assist the client to a prone position and drape the client's body as needed with the bath blanket. The nurse would apply warmed lotion to the client's shoulders, back, and sacral area. The nurse would place hands at the base of the spine and stroke upward to the shoulder and back down to the buttocks. The nurse would not use continuous grasping and pinching motions. The nurse would use long, stroking movements, not short ones.

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 bind to opioid receptor sites throughout the CNS. They react with acetylcholine and serotonin. They occupy cell receptors for neurotransmitters. 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.

A 5-year-old client reports abdominal pain. Which action(s) will the nurse take to assess the pain? Select all that apply. Ask the parents if the client is in pain. Use the numeric rating scale. Use the Wong-Baker FACES pain rating scale. Observe the client. Ask the client to describe the pain.

Use the Wong-Baker FACES pain rating scale. Observe the client. Ask the client to describe the pain. The Wong-Baker FACES Pain Rating Scale is useful for assessing children, although children as young as 8 years can use a 0 to 10 numeric scale. The nurse should ask the client to describe the pain but should be aware that a 5-year-old child may not be able to describe the pain. Asking the parents about the client's pain can cloud the nursing process of assessment. Observing the behaviors of the child is important; however, the nurse needs to remember that the client may have diversional activities when coping with pain, such as laughing or talking, which can alter the nurse's assessment of the pain by the client.

When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: document the client's lack of medication. assume the client does not need medication. ask the client's family if he ever uses pain medicines. actively solicit information about the client's pain level.

actively solicit information about the client's pain level. Some cultures see pain tolerance as a virtue; often men are expected to tolerate pain more stoically than women do. Health care providers need to recognize the client's cultural beliefs and not impose their own judgments.

The nurse is caring for a client who reports throbbing pain at the site of a recent laceration from a pocketknife. How will the nurse document this type of pain? Select all that apply. acute somatic neuropathic chronic cutaneous

acute cutaneous Cutaneous pain originates at the skin level and is commonly experienced as a sensation resulting from some form of trauma. Acute pain (discomfort that lasts a short duration) lasts for a few seconds to less than 6 months.

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as: biofeedback. transcutaneous electrical nerve stimulation (TENS). hypnosis. Therapeutic Touch (TT).

biofeedback. Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin. The unit transforms the data into a visual display, and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers. Hypnosis is an alteration in a person's state of consciousness so that pain is not perceived as it normally would be. Therapeutic Touch involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief.

The nurse is caring for a client who has had back pain for 2 years, following a fall from a ladder. How does the nurse going off-shift report this kind of pain to the oncoming nurse? Select all that apply. acute chronic cutaneous somatic visceral

chronic somatic Somatic pain develops from injury to structures such as muscles, tendons, and joints. Chronic pain is discomfort that lasts longer than 6 months.

The health care provider has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? B/P 178/92 and pulse 118 confused to time and place right shoulder immobilizer in place rates pain an 8 on a 0 to 10 scale

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.

Endogenous opioids such as endorphins: excite neural pathways. contribute to analgesia. cause muscle spasms. release neurotensin.

contribute to analgesia. The opioid receptors, important for the inhibition of pain perception, are sites where endogenous opioids and exogenous opioids bind. Three groups of endogenous opioids relieve pain: enkephalins, endorphins, and dynorphins.

A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? Select all that apply. cutaneous somatic neuropathic acute chronic

cutaneous acute Cutaneous pain originates at the skin level and is commonly experienced as a sensation resulting from some form of trauma. Acute pain lasts for a few seconds to less than 6 months. Therefore, the nurse documents that the client has acute, cutaneous pain. Somatic, visceral, referred, chronic, and neuropathic pain are not demonstrated in this scenario.

A client comes to the facility reporting acute pain. When assessing the client, the nurse understands that moderate, superficial acute pain can result in which sympathetic physiologic response(s)? Select all that apply. cool, moist skin increased blood pressure fainting or unconsciousness increased pulse increased respiratory rate

increased blood pressure increased pulse increased respiratory rate Sympathetic physiologic responses to moderate superficial acute pain can include increased blood pressure, pulse, and respiratory rate.

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing? transduction transmission perception modulation

modulation The client is in the modulation phase of pain, during which the brain interacts with the spinal nerves in a downward fashion to subsequently alter the pain experience. Transduction phase refers to the conversion of chemical information at the cellular level into electrical impulses that move toward the spinal cord. In transmission phase, the stimuli move from the peripheral nervous system toward the brain. The perception phase occurs when the pain threshold is reached.

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Gate Control Theory? asking if pain is produced by smells or sounds providing temple massage when head hurts teaching the client to remove items from the home that remind them of work contacting the health care provider to prescribe opioid medication

providing temple massage when head hurts Administering temple massage reflects the Gate Control Theory. The other actions support other theories.

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain? acute pain chronic pain referred pain limited pain

referred pain Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage. Acute pain is distinct from chronic pain and is relatively more sharp and severe and lasts from 3 to 6 months. Chronic pain is often defined as any pain lasting more than 12 weeks. Limited pain is not usually a term used.

A client with recurrent episodes of migraine headaches tells the nurse, "I am not comfortable taking medication for my pain." Which pain relief technique(s) can the nurse teach the client to implement at home? Select all that apply. relaxation massage meditation biofeedback hypnosis

relaxation massage meditation biofeedback Relaxation, meditation, massage, and biofeedback are pain relief techniques that the nurse can teach the client to implement at home. Relaxation techniques involve a combination of a quiet environment, a comfortable position, a passive attitude, and a focus of concentration. Meditation is a technique in which the person focuses on a single thought or sound. In biofeedback, the client learns voluntary control over autonomic functions such as heart rate, hand temperature, and muscle tension. Massage is a pain relief technique used to relax muscles and reduce tension. For migraines, the client can self-implement massage or ask a family member or friend to provide the massage. Hypnosis is a cognitive pain relief technique that blocks the awareness of pain through suggestions or by substituting another feeling for pain. Hypnosis cannot be implemented at the home; this techniques requires a professional to perform the action.

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? judging whether the client is in pain or is just depressed beginning pain medications before the pain is too severe administering a placebo and performing a reassessment of the pain reviewing and revising the pain management treatment plan

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 nurse is caring for a client who was administered an opioid. The client reports constipation. What is another potential side effect of opioid use? sedation anxiety diarrhea insomnia

sedation Opioids and opiates can cause sedation, nausea, and constipation. They also can cause respiratory depression, which is the main side effect to watch for with opioid use. Opioids and opiates do not lead to anxiety, diarrhea, or insomnia in clients.

The nurse is caring for a client who reports muscular and joint pain after an ankle sprain when playing soccer last week. How will the nurse document this type of pain? Select all that apply. cutaneous somatic visceral referred acute

somatic acute Based on the information about the client, the nurse documents the pain as somatic, acute pain. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Cutaneous, visceral, referred, chronic, and neuropathic pain are not reflected in this scenario.

The nurse is caring for a client who has had unrelieved back pain for 3 years. How will the nurse document this type of pain? Select all that apply. somatic visceral neuropathic acute chronic

somatic chronic Chronic pain is discomfort that lasts longer than 6 months. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Therefore, the nurse appropriately documents this client's pain as somatic and chronic. Cutaneous, visceral, referred, neuropathic, and acute pain are not being depicted in this scenario.

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 client's recent responses to pain and to pain medication nonverbal cues of the client the nurse's impression of the client's pain 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 nurse is caring for a client whose injured cells are releasing chemicals such as prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing? transduction transmission modulation perception

transduction The client is going through the transduction phase, which is the first phase of pain in which injured cells release chemicals such as prostaglandins, bradykinin, histamine, and glutamate. Transmission is the phase during which stimuli move from the peripheral nervous system toward the brain. Perception occurs when the pain threshold is reached. Modulation is the last phase of pain impulse transmission, during which the brain interacts with the spinal nerves to alter the pain experience.

The nurse is performing an assessment for a client related to pain. To determine the need for pain medication, on what primary source will the nurse base the decision? generalized increase in metabolism increased respiratory rate verbal report nonverbal clues

verbal report Verbal reports of pain, although subjective, are the most dependable indicators of pain in people who are able to communicate verbally. Therefore, the nurse should use them as the primary source of data, even if they vary from other objective information. The nurse also collects objective data. Pain often increases respiratory and heart rates, as well as blood pressure. Pain often sets off a generalized increase in metabolism, such as an increase in oxygen consumption, blood glucose, free fatty acids, blood lactate, and ketones. Nonverbal cues, such as grimacing and increased muscle tension, may also be used.

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: visceral pain. cutaneous pain. somatic pain. neuropathic 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.