CH 40 & 43

CH 43. 2. A patient has pain caused by a chronic condition. The patient is reluctant to take opioids because of a fear of addiction. The primary care NP should tell the patient that opioids: a. carry a high risk of psychological dependence when used long-term. b. will help to improve the patient's functional outcomes and quality of life. c. will eventually become ineffective for treating pain when used over a long period. d. may require switching from one type of opioid to another to prevent tolerance over time.

ANS B: Chronic pain requires routine administration of drugs, and addiction is generally not a concern, especially for patients with chronic pain or terminal illness. Opioid analgesics will help the patient improve function and quality of life. Tolerance may develop, and higher dosesmay be required to maintain effectiveness. Randomized, controlled trials are lacking to support switching opioids to manage tolerance and side effects

CH 40. 4.A patient with lower back pain and right-sided sciatica has taken an NSAID and a TCA for 1 week. The patient reports some decrease in pain but is experiencing increased tingling and numbness of the right leg. The primary care NP should: a.order a magnetic resonance imaging (MRI) study. b.order physical therapy. c.refer the patient to a neurologist. d.continue the TCA for 1 more week.

ANS: A Acute episodes of low back pain should be treated with an analgesic for 1 to 2 weeks. A muscle relaxant is used to treat spasms. Patients with sciatica should be treated for 6 weeks. If a neurologic deficit progresses, MRI should be ordered. Physical therapy is not indicated until serious injury is ruled out. A neurology consultation is necessary in urgent conditions and conditions with bilateral neurologic findings. The TCA may be continued, but the progression of symptoms necessitates radiologic evaluation.

CH 40. 7. A patient has acute low back pain caused by lifting a heavy object. The patient reports having one or two drinks with meals each day. The primary care NP should prescribe: a. an NSAID. b. diazepam (Valium). c. metaxalone (Skelaxin). d. acetaminophen (Tylenol)

ANS: A Skeletal muscle relaxants should not be taken with alcohol because effects are additive. Acetaminophen has toxic effects on the liver, and patients who consume alcohol regularly should avoid acetaminophen and diazepam.

CH 43. 5. A patient has been taking intramuscular (IM) meperidine 75 mg every 6 hours for 3 days after surgery. When the patient is discharged from the hospital, the primary care NP should expect the patient to receive a prescription for _____ mg orally every _____ hours. a. hydrocodone 30; 6 b. hydrocodone 75; 6 c. meperidine 300;12 d. meperidine 75; 6

ANS: A When patients are switched from one opiate to another, an equianalgesic table should be used to convert the dosage of the current drug to the equivalent dosage of the new drug. An oral dose of 30 mg of hydrocodone is equivalent to an IM dose of 75 mg of meperidine

CH 43. 3. A patient is diagnosed with a condition that causes chronic pain. The primary care NP prescribes an opioid analgesic and should instruct the patient to: a.wait until the pain is at a moderate level before taking the medication. b.take the medication at regular intervals and not just when pain is present. c.start the medication at higher doses initially and taper down gradually. d.take the minimum amount needed even when pain is severe to avoid dependency.

ANS: B Chronic pain requires routine administration of drugs, and patients should take analgesics routinely without waiting for increased pain.

CH 43. 7. A patient who is taking an antibiotic to treat bronchitis reports moderate rib pain associated with frequent coughing. The primary care NP should consider prescribing: a. morphine. b. hydrocodone c. hydromorphone. d. oxycodone CR.

ANS: B Hydrocodone is used for cough suppression as well as pain. Morphine can cause profound respiratory depression.

CH 40. 6.A patient comes to the clinic complaining of low back pain unrelieved by NSAIDs. The patient has a history of angle-closure glaucoma and renal disease. The primary care NP shouldprescribe: a.tizanidine (Zanaflex). b.metaxalone (Skelaxin). c.acetaminophen (Tylenol). d.cyclobenzaprine (Flexeril).

ANS: B Metaxalone may be taken by patients with angle-closure glaucoma and is metabolized by the liver, so it is safe for this patient. Tizanidine should not be given to patients with renal disease because clearance may be reduced by more than 50%. After using NSAIDs with no relief, recommendations are to change to a muscle relaxant. Cyclobenzaprine is not recommended inpatients with glaucoma.

CH 40. 3.A patient who was in a motor vehicle accident has been treated for lower back muscle spasms with metaxalone (Skelaxin) for 1 week and reports decreased but persistent pain. A computed tomography scan is normal. The primary care NP should: a.suggest ice and rest. b.order physical therapy. c.prescribe diazepam (Valium). d.add an opioid analgesic medication.

ANS: B Physical therapy may be used as an injury begins to heal. This patient is experiencing improvement of symptoms, so physical therapy may now be helpful. Ice and rest are useful in the first 24 to 48 hours after injury. Diazepam is used on a short-term basis only.Opioid analgesics are used for severe pain.

CH 43. 1. A patient has been taking an opioid analgesic for chronic pain and tells the primary care nurse practitioner (NP) that the medication doesn't work as well anymore. The NP should suspect drug: a.addiction. b.tolerance. c.modulation. d.dependence.

ANS: B Tolerance is characterized by decreasing drug effect over time, meaning that more drug is needed to achieve the same effect. Addiction is an overwhelming obsession with obtaining and using a drug for non-medically approved purposes. Dependence is the development of abstinence syndrome or withdrawal symptoms.

CH 43. 6. A patient has been taking an opioid analgesic for 2 weeks after a minor outpatient procedure. At a follow-up clinic visit, the patient tells the primary care NP that he took extra doses for the past 2 days because of increased pain and wants an early refill of the medication. The NP should suspect: a. dependence. b. drug addiction. c. possible misuse. d. increasing pain

ANS: C Unsanctioned dose increases are a sign of possible drug misuse. Dependence refers to an abstinence or withdrawal syndrome. Drug addiction is an obsession with obtaining and using the drug for nonmedical purposes. The patient should not have increased pain at 2 weeks

CH 40. 1.The primary care nurse practitioner (NP) is seeing a patient who reports chronic lower back pain. The patient reports having difficulty sleeping despite taking ibuprofen at bedtime each night. The NP should prescribe: a.diazepam (Valium). b.metaxalone (Skelaxin). c.methocarbamol (Robaxin). d.cyclobenzaprine (Flexeril).

ANS: D Cyclobenzaprine (Flexeril) is indicated for chronic low back pain and provides an added benefit of aiding sleep, which is a common problem among patients with back pain. The other medications are used for acute lower back pain.

CH 40. 2.A patient reports having an acute onset of low back pain associated with lifting a heavy object the day before. Besides advising the patient to rest and apply ice, the primary care NP should prescribe: a.an opioid analgesic. b.metaxalone (Skelaxin) c.cyclobenzaprine (Flexeril). d.a nonsteroidal antiinflammatory drug (NSAID).

ANS: D NSAIDs and acetaminophen are first-line analgesic treatments for low back pain. Opioidsare used for severe low back pain. The other two medications are not first-line treatments.

CH 40. 5.A 70-year-old patient has low back pain and will begin taking metaxalone (Skelaxin). The primary care NP should counsel this patient to: a.drink extra fluids. b.avoid taking NSAIDs. c.get up from a chair slowly. d.take care to avoid slips and falls.

ANS: D Use of any muscle relaxant puts elderly patients at risk for falls, so patients should be advised to take precautions. It is not necessary to increase fluids or avoid NSAIDs. This drug does not have hypotensive effects, so it is not necessary to provide the caution to rise out of chairs slowly

CH 43. 4. A patient who is a recovering alcoholic is preparing for surgery and expresses fears about using opioid analgesics postoperatively for pain. The primary care NP should tell the patient: a. that opioids should not be used. b. to take a very low dose of the opioid. c. that nonsteroidal antiinflammatory drugs will be the only safe option. d. that opioids are safe when taken as directed

ANS:D Fear of drug dependency or addiction does not justify withholding of opiates or inadequate managementof pain. As long as the medication is taken as directed, it is saf