Chapter 35 Comfort and Pain Management
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? A. sedation B. anxiety C.diarrhea D.insomnia
A. Sedation Explanation: 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 narcotics. Opioids and opiates do not lead to anxiety, diarrhea, or insomnia in clients.
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? A.word scale B.numeric scale C.visual analog scale D.Wong-Baker FACES® scale
D.Wong-Baker FACES® scale Explanation: Children as young as 3 years of age can use the Wong-Baker FACES® scale. A word, numeric, or visual analog scale is more appropriate for adults.
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? A. The dose that is delivered when the client activates the machine is preset. B. Thorough client education is necessary to prevent overdoses. C. Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. D. An antidote is automatically delivered if the client exceeds the recommended dose.
A. The dose that is delivered when the client activates the machine is preset. Explanation: 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 assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data? A.How does the pain develop and progress? B.How would you describe your pain? C.How would you rate the pain on a scale of 0 to 10? D.What do you do to alleviate your pain and how well does it work?
A.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.
A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as A."Your present pain is worse because you had your packing removed." B."Acute pain tends to increase during the day and is called a routine pain response" C."I will call your doctor because you may have loosened sutures when walking." D."You will need more pain medication as the days progress."
B."Acute pain tends to increase during the day and is called a routine pain response" Explanation: Acute pain occurs abruptly after an injury or disease and persists until healing occurs. Acute pain also may be associated with anxiety and fear. Acute pain consistently increases at night and during wound care, ambulation, coughing, and deep breathing.
Which medical client is most likely to be experiencing diffuse pain? A. A client who is undergoing diagnostic testing for appendicitis B.A client with shingles affecting her entire torso C.A client who has presented to the emergency department with a stab wound D.A client who has been prescribed antibiotics for the treatment of strep throat
B.A client with shingles affecting her entire torso Explanation: Diffuse pain is pain that covers a large area and, usually, the client is unable to point to a specific area without moving the hand over a large surface, such as the client's entire torso. Pain related to appendicitis, a stab wound, or strep throat is more likely to be localized and sharp.
When implementing the gate-control theory of pain, which intervention will enhance the closing of the gate to the client's pain? A. Position the client on several pillows. B.Teach the client relaxation techniques. C.Give the client a back rub. D. Darken the room.
C. Give the client a back rub. Explanation: 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 recognizes which statement is true of chronic pain? A. It can be easily described by the client. B. It disappears with treatment. C. It is always present and intense. D. It may cause depression in clients.
Correct response: D. It may cause depression in clients. Explanation: 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.
Which of the following is considered to be the most potent neuromodulators? A. Endorphins B. Enkephalins C. Efferent D. Afferent
Correct response: A. Endorphins Explanation: Endorphins and enkephalins are opioid neuromodulators. Endorphins are powerful pain blocking chemicals with prolonged analgesic effects. Enkephalins are considered less potent. There are no neuromodulators called efferent or afferent.
Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients? A. Pharmacologic pain relief should be used only as an intervention of last resort. B. A numeric scale should be used to assess pain if the child is older than 5 years of age. C. The developing neurologic system of children transmits less pain than in older clients. D. Pain assessment may require multiple methods in order to ensure accurate pain data.
Correct response: D. Pain assessment may require multiple methods in order to ensure accurate pain data. Explanation: 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.
Endogenous opioids such as endorphins: A. cause muscle spasms B. release neurotensin. C. excite neural pathways. D. contribute to analgesia.
Correct response: D. contribute to analgesia. Explanation: 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 severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client? A. Opioid analgesics B. Corticosteroids C. Nonopioid analgesics D. NSAIDs
Correct response: A. Opioid analgesics Explanation: The nurse would expect to administer opioid analgesics to a client with severe pain following a mastectomy. Nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are usually the drugs of choice for both acute and persistent moderate chronic pain. Corticosteroids would be used to address inflammation and swelling.
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: A. document the client's lack of medication. B. assume the client does not need medication. C. ask the client's family if he ever uses pain medicines. D.actively solicit information about the client's pain level.
D.actively solicit information about the client's pain level. Explanation: 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 three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. a. A patient cradles a wrist that was injured in a car accident b. A child is moaning and crying due to a stomachache c. A patient's pulse is increased following a myocardial infarction d. A patient in pain strikes out at a nurse who attempts to provide a bath e. A patient who has chronic cancer pain is depressed and withdrawn f. A child pulls away from a nurse trying to give an injection
a, b, f. Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature.
A nurse is monitoring patients in a hospital setting for acute and chronic pain. Which patients would most likely receive analgesics for chronic pain from the nurse? Select all that apply. a. A patient is receiving chemotherapy for bladder cancer b. An adolescent is admitted to the hospital for an appendectomy c. A patient is experiencing a ruptured aneurysm d. A patient who has fibromyalgia requests pain medication e. A patient has back pain related to an accident that occurred last year f. A patient is experiencing pain from second-degree burns
a, d, e. Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns.
When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end-of-life care is most effectively relieved through which method? a. Using the highest effective dose of an opioid on a PRN (as needed) basis b. Using nonopioid drugs conservatively c. Using consistent nonpharmacologic and nonopioid pharmacologic therapies d.Administering a continuous intravenous infusion on a regular basis
c. Nonpharmacologic and nonopioid pharmacologic therapies are the preferred choices for chronic pain that is not related to active cancer, palliative care, or end-of-life care. If progression to opioids becomes necessary, the lowest effective dose of an immediate-release opioid should be initiated first. Ongoing assessment and careful monitoring should guide the prescription of opioids for the management of chronic pain (Dowell et al., 2016). A PRN (as needed) drug regimen has not been proven effective for people experiencing chronic or acute pain. In the early postoperative period, when pain is expected, this protocol may result in an intense pain experience for the patient. Later, however, in the postoperative course, a PRN schedule may be acceptable to relieve occasional pain episodes.
A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? a. "It's not a good idea to ask for pain medication regularly as it can be addictive." b. "It is better to wait until the pain is severe before asking for pain medication." c. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." d. "Your doctor has prescribed pain medications for you, which you should request when you have pain."
d. Many pain medications are ordered on a PRN (as needed) basis. Therefore, nurses must be diligent to assess patients for pain and administer medications as needed. A patient should not be afraid to request these medications and should not wait until the pain is unbearable. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time.
The nurse has completed a preoperative teaching session with a client who will receive morphine via a patient-controlled analgesia (PCA) pump after surgery. Which statement by the client indicates the need for further teaching? A."I will remind my family member to push the PCA pump button for me if I doze off during the day." B."I will let my nurse know if the pain medication is not effective enough to help me move after surgery." C."I can push the button whenever I feel pain." D."I will use the PCA pump until oral pain medication controls my pain."
A."I will remind my family member to push the PCA pump button for me if I doze off during the day." Explanation: Sedation occurs before clinically significant respiratory depression. Thus, if the client is too sleepy to push the button (or ask that it be pushed), the button should not be pushed. The other answers are all correct.
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? A. Assess for medication prescription for breakthrough pain. B.Tell the client he or she will have to wait for 1 hour. C.Administer the next dose of the pain medication. D. Assess the client for signs of narcotic addiction.
A.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 narcotic addiction.
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? A.Encourage client to confer with a spiritual advisor. B.Consult a psychiatric nurse practitioner. C.Encourage the client to pray for oneself. D.Encourage visitors to pray for the client.
A.Encourage client to confer with a spiritual advisor. Explanation: The most appropriate action by the nurse would be to encourage the client to confer with a spiritual advisor to work through feelings of anger and resentment as it relates to God and the pain experience. Consulting a psychiatric nurse practitioner may help the client work through feelings of anger and resentment, but may not address the underlying feelings/beliefs related to God and the client's experience of pain. Encouraging the client to pray or to have visitors pray for the client may not help the client work through feelings of anger and resentment related to God and the experience of pain.
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? A.Endorphins B.Serotonin C.Melatonin D.Dopamine
A.Endorphins Explanation: 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.
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? A.Naloxone B.Diphenhydramine C.Atropine D.Epinephrine
A.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.
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? A.They bind to opioid receptor sites throughout the CNS. B.They react with acetylcholine and serotonin. C.They occupy cell receptors for neurotransmitters. D.They block glutamate receptors and peptides.
A.They bind to opioid receptor sites throughout the CNS. Explanation: 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.
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? A.Hold the pain medication. B.Administer the pain medication. C.Reassess the client's pain in 30 minutes. D.Contact the client's health care provider.
B.Administer the pain medication. Explanation: 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 client tells a nurse, "I have this pounding feeling on the side of my head, like someone is hitting my head with a hammer." The nurse should identify what characteristic of pain assessment? A.frequency B.quality C.temporal pattern D.threshold
B.quality Explanation: The client is describing the quality of pain in his head. Quality refers to how the pain feels to the client or words that describe the pain's nature. Pain intensity indicates the magnitude or amount of pain perceived. It is described on a numeric scale or by terms such as none, mild, moderate, severe, or excruciating. Onset and duration are components of temporal pain pattern. Pain threshold is the amount of pain stimulation a person requires before feeling it.
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? A.1 B.2 C.3 D.4
C.3 Explanation: 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.
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? A.Document what the client states. B.Tell the healthcare provider that the client is unsure of the pain medication taken. C.Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. D.Call the pharmacy to attempt to identify the pill.
C.Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. Explanation: 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 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? A.Gently massage the region, document the finding, and verbally report it to the health care provider. B.Avoid massaging the area and apply a thin layer of a topical antibiotic ointment. C.Avoid massaging this area and report the finding to the health care provider. D.Massage the area in an attempt to restore adequate circulation.
C.Avoid massaging this area and report the finding to the health care provider. Explanation: 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.
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? A. Naloxone B. Furosemide C. Digoxin D. Lisinopril
Correct response: A. Naloxone Explanation: 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.
Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain? A. The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. B. This approach can only be used with oral analgesics. C. A PCA pump must be used and monitored in a health care facility. D. The PCA pump is not effective for chronic pain. -
Correct response: A. The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. Explanation: 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 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? A. Use massage and heat application to the lower back B. Administer opioid analgesics C. Encourage the client to have an epidural steroid injection D. Have the client perform active exercises to stretch the back muscles
Correct response: A. Use massage and heat application to the lower back Explanation: 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 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? A. referred pain B. chronic pain C. acute pain D. limited pain
Correct response: A. referred pain Explanation: 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.
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. A. somatic B. visceral C. acute D. chronic E. neuropathic
Correct response: A. somatic D. chronic Explanation: 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.
In which client would a back massage be contraindicated? A. Client who is experiencing anxiety B. Client who has a fractured rib C. Client who has diabetes mellitus D. Client who is ambulatory
Correct response: B. Client who has a fractured rib Explanation: 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 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? A. Temperature, pedal pulses, and assessment of cranial nerves B. Respiratory status, oxygen saturation, pain, and sedation level C. Gastrointestinal status, bowel movements, and urine output D. Heart rate, capillary refill, bowel sounds and pedal pulses -
Correct response: B. Respiratory status, oxygen saturation, pain, and sedation level Explanation: 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 implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique? A. The nurse plays soft music in the client's room. B. The nurse gives the client a massage before bed. C. The nurse teaches the client deep breathing techniques for relaxation. D. The nurse assists the client to focus on something pleasant rather than on pain.
Correct response: B. The nurse gives the client a massage before bed. Explanation: Some forms of cutaneous stimulation include the following: massage, application of heat or cold (or both intermittently), acupressure, transcutaneous electrical nerve stimulation (TENS). All the options listed are examples of complementary and alternative relief measures, but only massage is an example of cutaneous stimulation.
A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain? A. decreased pulse rate B. increased blood pressure C. decreased respiratory rate D. pupil constriction
Correct response: B. 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 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? A. referred pain B. phantom pain C. cutaneous pain D. visceral pain
Correct response: B. phantom pain Explanation: The nurse should document the pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client perceives that the amputated limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed. The client is not experiencing referred pain, visceral pain, or cutaneous pain. Visceral pain is associated with disease or injury. Referred pain is not experienced in the exact site where an organ is located. Cutaneous pain originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma.
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? A. contacting the health care provider to prescribe opioid medication B. providing temple massage when head hurts C. teaching the client to remove items from the home that remind them of work D. asking if pain is produced by smells or sounds
Correct response: B. providing temple massage when head hurts Explanation: Administering temple massage reflects the Gate Control Theory. The other actions support other theories.
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: A. addiction B. tolerance C. dependence D. sedation
Correct response: B. 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.
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? A. Disinfect with chlorhexidine the areas where the electrodes will be applied B. Administer analgesia 30 minutes before beginning a TENS session. C. Start with the lowest intensity and gradually increase it to the appropriate level. D. Turn on the unit shortly before applying the electrodes to the client's skin. -
Correct response: C. Start with the lowest intensity and gradually increase it to the appropriate level. Explanation: 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.
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: A. Therapeutic Touch (TT) B. transcutaneous electrical nerve stimulation (TENS) C. biofeedback D. hypnosis
Correct response: C. 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 male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing? A. cutaneous pain B. referred pain C. visceral pain D. somatic pain
Correct response: C. visceral pain Explanation: Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial. Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix.
The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client? A.Acute B.Chronic C.Diffuse D.Intractable
D.Intractable Explanation: Malignant pain is acute pain episodes, persistent chronic pain, or both associated with a progressive malignant-type process. The etiology for malignant pain is resistant to cure, and the pain may be described as intractable.
A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors? a. An older adult on bedrest following cervical spine surgery b. A patient with a severe sunburn being treated for dehydration c. An industrial worker who has burns caused by a caustic acid d. A patient experiencing cardiac disturbances from an electrical shock
a. Receptors in the skin and superficial organs may be stimulated by mechanical, thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores is a mechanical stimulant. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. An electrical shock is an electrical stimulant.
The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? a. CRIES scale b.COMFORT scale c. FLACC scale d.FACES scale
a. The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC Scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES Scale is used for children who can compare their pain to the faces depicted on the scale.
When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse is aware that the patient has consistently refused pain medication. What would be a priority nursing diagnosis for this patient? a. Acute Pain related to fear of taking prescribed postoperative medications b. Impaired Physical Mobility related to surgical procedure c. Anxiety related to outcome of surgery d. Risk for Infection related to surgical incision
a. The patient's immediate problem is the pain that is unrelieved because the patient refuses to take pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation.
A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. a. Pain is whatever the health care provider treating the pain says it is b. Pain exists whenever the person experiencing it says it exists c. Pain is an emotional and sensory reaction to tissue damage d. Pain is a simple, universal, and easy-to-describe phenomenon e. Pain that occurs without a known cause is psychological in nature f. Pain is classified by duration, location, source, transmission, and etiology
b, c, f. Margo McCaffery offers the classic definition of pain that is probably of greatest benefit to nurses and their patients, "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (1968, p. 95). The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 2014b). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.
When assessing pain in a child, the nurse needs to be aware of what considerations? a. Immature neurologic development results in reduced sensation of pain b.Inadequate or inconsistent relief of pain is widespread c.Reliable assessment tools are currently unavailable d.Narcotic analgesic use should be avoided
b. Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored.
Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? a. Encouraging regular use of analgesics b. Applying a moist heating pad to the area at prescribed intervals c.Reviewing the pain experience with the patient d. Ambulating the patient after administering medication
b. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory.
A nurse is assessing a patient receiving a continuous opioid infusion. For which related condition would the nurse immediately notify the primary care provider? a. A respiratory rate of 10/min with normal depth b.A sedation level of 4 c.Mild confusion d.Reported constipation
b. Sedation level is more indicative of respiratory depression because a drop in level usually precedes it. A sedation level of 4 calls for immediate action because the patient has minimal or no response to stimuli. A respiratory level of 10 with normal depth of breathing is usually not a cause for alarm. Mild confusion may be evident with the initial dose and then disappear; additional observation is necessary. Constipation should be reported to the health care provider, but is not the priority in this situation.
A patient reports abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a. Cutaneous b. Visceral c. Superficial d. Somatic
b. The patient's pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep 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.
A patient who is having a myocardial infarction reports pain that is situated in the neck. The nurse documents this as what type of pain? a. Transient pain b. Superficial pain c. Phantom pain d. Referred pain
d. Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. Superficial pain originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically.
A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of what side effect? a. Pruritus b. Urinary retention c.Vomiting d. Respiratory depression
d. Too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening.
A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in the patient's legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? a. Prostaglandins b. Substance P c. Endorphins d. Serotonin
c. Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells.