Lewis Ch. 9 pain ch
A patient with chronic pain who has been receiving morphine sulfate 20 mg IV over 24 hours is to be discharged home on oral sustained-release morphine (MS Contin), which will be administered twice a day. What dosage of MS Contin will be needed for each dose to obtain an equianalgesic dose for the patient? (Morphine sulfate 10 mg IV is equianalgesic to morphine sulfate 30 mg orally.)
ANS: MS Contin 30 mg/dose Morphine sulfate 20 mg IV over 24 hours will be equianalgesic to MS Contin 60 mg in 24 hours. Since the total dose needs to be divided into two doses, each dose should be 30 mg.
A patient who uses a fentanyl (Duragesic) patch for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone (Vicodin) tablets, but the patient is asleep when the nurse returns with the medication. Which action is best for the nurse to take? a. Wake the patient and administer the hydrocodone. b. Wait until the patient wakes up and reassess the pain. c. Suggest the use of nondrug therapies for pain relief instead of additional opioids. d. Consult with the health care provider about changing the fentanyl (Duragesic) dose.
ANS: A Because patients with chronic pain frequently use withdrawal and decreased activity as coping mechanisms for pain, sleep is not an indicator that the patient is pain free. The nurse should wake the patient and administer the hydrocodone
A patient with chronic back pain has learned to control the pain with the use of imagery and hypnosis. The patient's spouse asks the nurse how these techniques work. Which response by the nurse is best? a. "The strategies work by affecting the perception of pain." b. "These techniques block the pain pathways of the nerves." c. "Both strategies prevent transmission of painful stimuli to the brain." d. "The therapies slow the release of chemicals in the spinal cord that cause pain."
ANS: A Cognitive therapies affect the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn
A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic arthritic joint pain following a traumatic injury complains of nausea and abdominal fullness. Which action should the nurse take initially? a. Administer the ordered antiemetic medication. b. Tell the patient that the nausea will subside in about a week. c. Order the patient a clear liquid diet until the nausea decreases. d. Consult with the health care provider about using a different opioid.
ANS: A Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics usually are prescribed to treat this expected side effect. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops and the nausea will subside in about a week, it is not appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea, but the best choice would be to administer the antiemetic medication and allow the patient to eat
The nurse is caring for a 1-day postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority? a. Check the respiratory rate. b. Assess for nausea after eating. c. Inspect the abdomen and auscultate bowel sounds. d. Evaluate the sacral and heel areas for signs of redness.
ANS: A The patient's respiratory rate is the highest priority of care while using PCA medication because of the possible respiratory depression. The other information may also require intervention but is not as urgent to report as the respiratory rate
A nurse assesses a postoperative patient 2 days after chest surgery. What findings indicate that the patient requires better pain management (select all that apply)? a. Confusion b. Hypoglycemia c. Poor cough effort d. Shallow breathing e. Elevated temperature
ANS: A, C, D, E Inadequate pain control can decrease tidal volume and cough effort, leading to complications such as pneumonia with increases in temperature. Poor pain control may lead to confusion through a variety of mechanism, including hypoventilation and poor sleep quality. Stressors such as pain cause increased release of corticosteroids that can result in hyperglycemia.
Which question asked by the nurse will give the most information about the patient's metastatic bone cancer pain? a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How much medication do you take for the pain?" d. "How many times a day do you take medication for the pain?"
ANS: B Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain will elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning "How would you describe your pain?" is the best initial question
Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? a. Check the skin under the heating pad. b. Take the respiratory rate every 2 hours. c. Monitor sedation using the sedation assessment scale. d. Ask the patient about whether pain control is effective.
ANS: B Obtaining the respiratory rate is included in UAP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice
The following medications are prescribed by the health care provider for a middle-aged patient who uses long-acting morphine (MS Contin) for chronic back pain, but still has ongoing pain. Which medication should the nurse question? a. Morphine (Roxanol) b. Pentazocine (Talwin) c. Celecoxib (Celebrex) d. Dexamethasone (Decadron)
ANS: B Opioid agonist-antagonists can precipitate withdrawal if used in a patient who is physically dependent on mu agonist drugs such as morphine. The other medications are appropriate for the patient
A patient with second-degree burns has been receiving hydromorphone through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. What action by the nurse is most appropriate? a. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. Consult with the health care provider about using a different treatment protocol to control the patient's pain. c. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.
ANS: B PCAs are best for controlling acute pain. This patient's history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.
A patient who is using a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? a. Obtain vital signs. b. Remove the fentanyl patch. c. Notify the health care provider. d. Administer the prescribed PRN naloxone (Narcan).
ANS: B The assessment data indicate a possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring are also needed, but the patient's data indicate that more rapid action is needed. The respiratory rate alone is an indicator for immediate action before obtaining blood pressure, pulse, and temperature
A patient with terminal cancer-related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? a. Use distraction by talking about things the patient enjoys. b. Administer the prescribed PRN immediate-acting morphine. c. Suggest the use of alternative therapies such as heat or cold. d. Consult with the doctor about increasing the MS Contin dose.
ANS: B The patient's pain requires rapid treatment and the nurse should administer the immediate-acting morphine. Increasing the MS Contin dose and use of alternative therapies may also be needed, but the initial action should be to use the prescribed analgesic medications
The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which nursing actions regarding opioid administration are appropriate at this time (select all that apply)? a. Assess for signs that the patient is becoming addicted to the opioid. b. Monitor for therapeutic and adverse effects of opioid administration. c. Emphasize that the risk of some opioid side effects increases over time. d. Teach the patient about how analgesics improve postoperative activity levels. e. Provide instructions on decreasing opioid doses by the second postoperative day.
ANS: B, D Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain. Although postoperative patients usually need a decreasing amount of opioids by the second postoperative day, each patient's response is individual. Tolerance may occur, but addiction to opioids will not develop in the acute postoperative period. The patient should use the opioids to achieve adequate pain control, and so the nurse should not emphasize the adverse effects
The nurse reviews the medication orders for an older patient with arthritis in both hips who is complaining of level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse use as initial therapy? a. Naproxen (Aleve) 200 mg orally b. Oxycodone (Roxicodone) 5 mg orally c. Acetaminophen (Tylenol) 650 mg orally d. Aspirin (acetylsalicylic acid, ASA) 650 mg orally
ANS: C Acetaminophen is the best first-choice medication. The principle of "start low, go slow" is used to guide therapy when treating older adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Nonopioid analgesics are used first for mild to moderate pain, although opioids may be used later. Aspirin and the NSAIDs are associated with a high incidence of gastrointestinal bleeding in older patients
The nurse teaches a student nurse about the action of ibuprofen. Which statement, if made by the student, indicates that teaching was effective? a. "The drug decreases pain impulses in the spinal cord." b. "The drug decreases sensitivity of the brain to painful stimuli." c. "The drug decreases production of pain-sensitizing chemicals." d. "The drug decreases the modulating effect of descending nerves."
ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by NSAIDs
When visiting a hospice patient, the nurse assesses that the patient has a respiratory rate of 11 breaths/minute and complains of severe pain. Which action is best for the nurse to take? a. Inform the patient that increasing the morphine will cause the respiratory drive to fail. b. Tell the patient that additional morphine can be administered when the respirations are 12. c. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief. d. Administer a nonopioid analgesic, such as a nonsteroidal antiinflammatory drug (NSAID), to improve patient pain control.
ANS: C The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient's respiratory rate.
The nurse reviews the medication administration record in order to choose the most appropriate pain medication for a patient with cancer who describes the pain as "deep, aching and at a level 8 on a 0 to 10 scale". Which medication should the nurse administer? a. Fentanyl (Duragesic) patch b. Ketorolac (Toradol) tablets c. Hydromorphone (Dilaudid) IV d. Acetaminophen (Tylenol) suppository
ANS: C The patient's pain level indicates that a rapidly acting medication such as an IV opioid is needed. The other medications also may be appropriate to use, but will not work as rapidly or as effectively as the IV hydromorphone
The nurse is caring for a patient who has diabetes and complains of chronic burning leg pain even when taking oxycodone (OxyContin) twice daily. When reviewing the orders, which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain? a. Aspirin (Ecotrin) b. Celecoxib (Celebrex) c. Amitriptyline (Elavil) d. Acetaminophen (Tylenol)
ANS: C The patient's pain symptoms are consistent with neuropathic pain and the tricyclic antidepressants are effective for treating this type of pain. The other medications are more effective for nociceptive pain
The nurse assesses that a patient receiving epidural morphine has not voided for over 10 hours. What action should the nurse take initially? a. Monitor for withdrawal symptoms. b. Place an indwelling urinary catheter. c. Ask if the patient feels the need to void. d. Document this allergic reaction in the patient's chart.
ANS: C Urinary retention is a common side effect of epidural opioids. Assess whether the patient feels the need to void. Since urinary retention is a possible side effect, there is no reason for concern of withdrawal symptoms. Placing an indwelling catheter requires an order from the health care provider. Usually an in and out catheter is performed to empty the bladder if the patient is unable to void because of the risk of infection with an indwelling catheter. Urinary retention does not indicate that this reaction is an allergic reaction
A patient who has fibromyalgia tells the nurse, "I feel depressed because I ache too much to play golf." The patient says the pain is usually at a level 7 (0 to 10 scale). Which patient goal has the highest priority when the nurse is developing the treatment plan? a. The patient will exhibit fewer signs of depression. b. The patient will say that the aching has decreased. c. The patient will state that pain is at a level 2 of 10. d. The patient will be able to play 1 to 2 rounds of golf.
ANS: D For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse should also assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play 1 or 2 rounds of golf is the most appropriate
A nurse assesses a patient with chronic cancer pain who is receiving imipramine (Tofranil) in addition to long-acting morphine. Which statement, if made by the patient, indicates to the nurse that the patient is receiving adequate pain control? a. "I'm not anxious at all." b. "I sleep 8 hours every night." c. "I feel much less depressed since I've been taking the Tofranil." d. "The pain is manageable and I can accomplish my desired activities.
ANS: D Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication is also prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level
The nurse is completing the medication reconciliation form for a patient admitted with chronic cancer pain. Which medication is of most concern to the nurse? a. Amitriptyline (Elavil) 50 mg at bedtime b. Ibuprofen (Advil) 800 mg 3 times daily c. Oxycodone (OxyContin) 80 mg twice daily d. Meperidine (Demerol) 25 mg every 4 hours
ANS: D Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management
A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain suddenly complains of rapid onset pain at a level 9 (0 to 10 scale) and requests "something for pain that will work now." How will the nurse document the type of pain reported by this patient? a. Somatic pain b. Referred pain c. Neuropathic pain d. Breakthrough pain
ANS: D Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue
A patient with chronic neck pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Can you describe the quality of your pain?" b. "Has there been a change in the pain location?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does the pain keep you from doing things you enjoy?"
ANS: D The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions are also appropriate to ask, but information about patient function is more useful in evaluating effectiveness
A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is best? a. Provide amitriptyline (Elavil) 10 mg orally. b. Administer lorazepam (Ativan) 1 mg orally. c. Offer ibuprofen (Motrin) 400 to 800 mg orally. d. Give immediate-release morphine 30 mg orally.
ANS: D The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. Lorazepam and amitriptyline may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of antianxiety agents for pain control is inappropriate because this patient's anxiety is caused by the pain
Which patient with pain should the nurse assess first? a. Patient with postoperative pain who received morphine sulfate IV 15 minutes ago b. Patient with neuropathic pain who has a dose of hydrocodone (Lortab) scheduled now c. Patient who received hydromorphone (Dilaudid) 1 hour ago and currently has a sedation scale of 2 d. Patient who returned from the postanesthesia care unit 2 hours ago and has a respiratory rate of 10
ANS: D This patient's respiratory rate indicates possible respiratory depression. The risk for oversedation is greatest in the first 4 hours after transfer from the postanesthesia care unit. Patients should be reassessed 30 minutes after receiving IV opioids for pain. A scheduled oral mediation does not need to be administered exactly at the scheduled time. A sedation scale of 2 indicates adequate pain control from hydromorphone