PrepU quizzes Chapter 35: Comfort and Pain Management

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

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. Explanation: 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 opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?

sedation

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." Explanation The client needs further instruction when they say they can use the TENS unit on other areas of the body. Such a statement would indicate that the client does not understand that the unit should be used as prescribed by the physician in the location defined by the physician. The TENS unit will decrease the amount of the pain medication used by the client as it increases the blood supply to the injured area and will not interfere with the activities of daily living.

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement? -"This will allow me to control my own pain medication." -"I should only take medication when my pain is intense." -"I give myself the pain medication by pushing the button." -"The pump is programmed to limit the chance of overmedicating."

"I should only take medication when my pain is intense." Explanation: PCA pumps allow the client to control the amount and timing of pain medication by pushing a button when the sensation of pain occurs versus waiting until the pain becomes intense. The pump is programmed with a lockout period that limits the chance of clients overmedicating themselves.

The nurse is assessing a client who is experiencing pain. The nurse notes the client is experiencing acute rather than chronic pain when the client makes which statement?

"The pain is really sharp in this one spot."

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 client has been reluctant to ask for breakthrough doses of the opioid prescribed, despite showing signs of pain. The client states to the nurse, "I don't want to become addicted to the medication." How should the nurse respond to the client's statement?

"There's only an extremely small chance that you will become addicted to this drug."

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply.

- Assess for pain control 30 minutes after administering an analgesic. - Consider cultural implications of the perception of pain. - Provide pain medication before activity that may increase pain.

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. Explanation: 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.

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 Explanation: 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?

3

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 Explanation: Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Visceral pain is one of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed such as with a ruptured peptic ulcer or appendicitis. A client having a myocardial infarction with chest pain is experiencing referred pain.

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

A client with shingles affecting her entire torso

A sudden blow to the head results in pain that is transmitted by which type of fibers?

A-delta

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

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?

Administer the pain medication.

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? -Hold the pain medication at this time. -Administer the pain medication. -Reassess the need for pain medication in 30 minutes. -Encourage the client to use alternative pain relief measures.

Administer the pain medication. Explanation: Pain is present whenever the client perceives being in pain. The client is prescribed the medication, the client's vital signs are within acceptable range, and the client reports being in pain. Therefore, the nurse should administer the pain medication as prescribed. Holding the pain medication is an inappropriate action. The nurse should reassess the pain in 30 after giving the pain medication. The client can use alternative pain relieve measures to assist with the effects of 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? -Administer a lower dose of the analgesic for the next dose -Begin CPR -Place the client in the supine position -Administration of 0.4 mg of naloxone

Administration of 0.4 mg of naloxone Explanation: The client is experiencing impending respiratory arrest due to the effect of the medication and this should be reversed immediately prior to arrest. This is the priority action and will correct the respiratory depression immediately. CPR is not indicated at this time, because the client is not in full arrest. Placing the client in the supine position may decrease respirations further.

What will the nurse place at the bedside of a client receiving epidural analgesia?

Ampule of 0.4 mg naloxone

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. Explanation: 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.

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.

The nurse is evaluating pain of several clients who had hip replacement surgery. Which client is most likely to have the greatest perceived pain?

Client who is anxious about discharge

The nurse is reviewing relaxation techniques with the client who has chronic back pain that radiates to the legs. What information does the nurse include? -Sit in a wood chair with a straight back. -Take shallow abdominal breaths. -Tighten and relax muscles starting with the upper body. -Close your eyes while practicing the relaxation exercises.

Close your eyes while practicing the relaxation exercises. Explanation: Closing the eyes will help the client focus on relaxation and not be distracted by visual cues. The client should assume a comfortable position. This may be in a chair or a bed. A straight back wood chair is unlikely to allow the client to assume a comfortable position that would promote relaxation. The client takes deep abdominal breaths, not shallow breaths; this promotes relaxation. The client would tighten and relax muscles, starting with the toes and working up towards the head.

The nurse is preparing to initiate PCA therapy for a client with sleep apnea. What is the correct action by the nurse?

Contact the physician.

The demonstration provided by the nurse is directed at helping the postsurgical client manage what type of pain? -Splanchnic -Deep somatic -Neuropathic -Superficial

Deep somatic Explanation: 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.

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.

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. -Apply a warm compress to the area. -Massage the area using lotion. -Stop the back massage immediately.

Document the finding. Explanation: The nurse should document this finding after completion of the back massage and client care and report it to the health care provider. The nurse would also position the client to remove any pressure from that area. The nurse should not apply a warm compress or massage the reddened area.

A client 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. Explanation: 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.

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

Examine the effectiveness of the current pain regimen

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 Explanation: 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.

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? -FACES scale -FLACC scale -Braden scale -Apgar score

FLACC scale Explanation: The FLACC scale (face, legs, activity, cry, and consolability) is used to measure pain for children between the ages of 2 months and 7 years. The Braden scale is used to predict pressure sore risk. The FACES scale is used to assess pain in older children using a series of faces, ranging from a happy face to a crying face. Apgar score is done at birth to assess how well the baby tolerated the birthing process.

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? -Decreased heart rate -Guarding of the chest area -Increased respiratory rate -High blood pressure

Guarding of the chest area Explanation: A person's behavioral response to pain can be demonstrated by protecting or guarding the painful area, grimacing, crying, or moaning. Increased blood pressure and respiratory rate are typical physiologic (sympathetic) responses to moderate pain. Decreased heart rate is a typical physiologic (parasympathetic) response to severe pain.

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data? How does the pain develop and progress? How would you 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? Explanation: 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.

The nurse recognizes which statement is true of chronic pain?

It may cause depression in clients.

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

Opioid analgesics

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 Explanation: 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 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

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

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 Explanation: 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.

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.

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

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.

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 -Before the patient is discharged -The first question you ask the patient -At several points throughout your history-taking

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

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. Explanation: 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.

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 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 assessing a client's pain. The nurse notes which database finding that is indicative of acute pain? -pupil constriction -decreased pulse rate -increased blood pressure -decreased respiratory rate

increased blood pressure Explanation: The increase in blood pressure that may accompany acute pain is believed to be due to overactivity of the sympathetic nervous system.

A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing? -cutaneous pain -visceral pain -chronic pain -neuropathic pain

neuropathic pain Explanation: The client is experiencing neuropathic pain or functional pain. Neuropathic pain is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. In cutaneous pain, the discomfort originates at the skin level. In visceral pain, the discomfort arises from internal organs caused from a disease or injury. In chronic pain, the discomfort lasts longer than 6 months.

A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?

phantom pain

A nurse observes that a client who underwent knee surgery 2 weeks ago needs progressively larger doses of analgesics to get relief from pain. The nurse interprets this as: -addiction -tolerance -dependence -sedation

tolerance Explanation: The client is manifesting tolerance, which is characterized by the need for larger doses of analgesics to produce the original effect. The client is not manifesting addiction, dependence, or sedation. Addiction is a psychological condition characterized by a drive to obtain and take substances for other than the prescribed value. Dependence is a physiologic response wherein a person who is dependent on opioids responds to abrupt discontinuation with characteristic withdrawal symptoms. Sedation is an adverse effect of administration of opioid analgesics.