PrepU ch. 35 Fundamentals

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?

"The pump is programmed with safeguards to limit the possibility overmedication."

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?

Cutaneous stimulation

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?

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

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client:

in the postoperative stage with occasional pain.

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

"Acute pain tends to increase during the day and is called a routine pain response"

The nurse is administering medications to a client with neuropathic pain. The client asks why an antidepressant medication is prescribed when the client is not depressed. Which is the best response by the nurse?

"Antidepressants have been shown to be effective in treating and managing neuropathic pain."

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?

"How long have you experienced this pain?"

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?

"I should only take medication when my pain is intense."

A nurse is evaluating the effectiveness of the preoperative education regarding pain control. Which statement by the client would indicate a need for further education?

"I will have my wife push the PCA button when I'm asleep."

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."

The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question will the nurse ask? Select all that apply.

"What pain level reflects an acceptable goal for you if total pain relief is not possible?" "How do you prefer to manage your back pain?" "How has your life changed since experiencing back pain?" "Do you use recreational drugs to relieve your 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?

0 to 10 numeric rating scale

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?

1 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.

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?

A client who has a sprained ankle

Which medical client is most likely to be experiencing diffuse pain?

A client with shingles affecting her entire torso

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

An adolescent client is experiencing menstrual pain. Which action(s) will the nurse take to assist the client with decreasing pain? Select all that apply.

Administer analgesic medication Apply heat to the pelvic area Recommend avoidance of sugar Provide chamomile tea Encourage exercise

The nurse caring for a client receiving opioid therapy notes that the client's respirations are 7. What is the first action by the nurse?

Administer naloxone.

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication.

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?

Administration of 0.4 mg of naloxone

A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse's best intervention in this situation?

Ask the boy to draw a cartoon about the color or shape of his pain.

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.

A nurse works with an older adult client who has two broken femurs. The client does not report pain. Which action will the nurse take?

Assess the client for nonverbal cues of pain.

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

CRIES Pain Scale

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

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Document the finding.

A client in pain believes that the pain is a punishment from God, and feels angry and resentful. Which is the most appropriate action by the nurse?

Encourage client to confer with a spiritual advisor.

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

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

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?

Examine the effectiveness of the current pain regimen

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant?

FLACC scale

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.

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

The nurse recognizes which statement is true of chronic pain?

It may cause depression in clients.

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.

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.

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.)

Massage Heat Pressure

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?

Opioid analgesics

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?

PRN order

Which guideline regarding pain should be included in the nurse's education plan for a group of parents with infants and toddlers?

Pain can be a source of fear and threat to the toddler's security.

A nurse has attended a pain control workshop and learned about the psychological and physiological basis of placebos. What principle should guide the use of placebos in the treatment of pain?

Placebos involve the use of deception and are considered unethical in most circumstances.

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.)

Play the client's favorite music. Promote a restful environment. Encourage deep breathing.

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

Respiratory

A nurse is working with a 12-year-old boy who was involved in an MVA. He has several broken bones and contusions. He rates his pain as a 7/10. The nurse plans to administer intravenous hydromorphone to relieve the pain. What side effect is the nurse most worried about?

Respiratory depression

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?

Start with the lowest intensity and gradually increase it to the appropriate level.

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate?

The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.

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 exhibits restless, uncharacteristic behavior after receiving the drug.

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 is actively involved in pain management.

Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain?

The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval.

A cancer client's care plan includes the use of a transcutaneous electrical nerve stimulation (TENS) unit. Which action should be included in the plan?

The unit should be turned off whenever repositioning the electrodes.

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.

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 patient vital signs

The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use?

Wong-Baker FACES® scale

At 1930 the client reports experiencing neuropathic pain in the legs. The client has a history of neuropathic pain following chemotherapy. The client describes the pain as burning and rates the pain as a 7 on the pain scale 1 to 10. Based on the client's medication orders (above), which medication would the nurse administer to the client for report of pain?

acetaminophen/codeine 1 tablet

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:

actively solicit information about the client's pain level.

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.

The client has just returned from surgery. The client asks you for an extra dose of pain medication. What would be some signs that the client is in severe pain? Select all that apply.

elevated respiratory rate decreased blood pressure

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?

increased blood pressure

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

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 pain based on a pain rating