comfort and pain chapter 35
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"
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?
Guarding of the chest area
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 caring for a client who has had back pain for 2 years, following a fall from a ladder. How does the nurse going off-shift report this kind of pain to the oncoming nurse? Select all that apply.
chronic somatic
The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?
confused to time and place
Endogenous opioids such as endorphins:
contribute to analgesia.
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?
referred pain
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?
reviewing and revising the pain management treatment plan
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?
"Can you describe the type of pain you are having?"
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?"
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?
"I could use the TENS unit if I feel pain somewhere else on my body."
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 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."
Two hours after receiving a pain medication, the client reports still suffering from pain. Which question is most appropriate to ask the client?
"Tell me more about your pain."
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 so that it's not possible for you to overdose on your pain medication."
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
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?
Avoid massaging this area and report the finding to the health care provider.
A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation; however, he can be aroused. What would be the sedation score for this client?
3
Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?
A chronic opioid therapy plan
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
A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse?
Administer the medication if respiratory rate is > 9.
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.
A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety?
Administering an oral dose of morphine to treat the client's breakthrough pain
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opiod 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
What will the nurse place at the bedside of a client receiving epidural analgesia?
Ampule of 0.4 mg naloxone
The nurse is caring for an older client with chronic pain due to osteoarthritis, hypertension, and mild dementia. The client reports blurred vision, and the spouse states, "I'm worried. Today I noticed that there was blood in the stool, and there is more confusion than usual." What is the priority nursing action?
Ask the client and caregiver for a medication history.
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?
Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.
A client is postoperative day 1 and the nurse's assessment reveals signs of pain, such as grimacing and guarding. Which is the most reliable method for assessing the client's pain?
Ask the client to describe and rate his or her pain.
The nurse prepares to promote the client's comfort using guided imagery. Which actions should the nurse take? Select all that apply.
Ask the client to imagine oneself in a favorite place. Ask the client to concentrate on the details of a pleasant image
The nurse manager hears a nurse and a nurse aide talking about a female client who reports pain of 8 out of 10 on a 1-10 scale after a Caesarean birth to deliver twins. The nurse states, "I don't believe this client has any pain at all. I'm sure she is just drug seeking." What is the appropriate nurse manager action?
Ask the nurse to speak privately for a moment, and educate about bias in pain treatment.
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.
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.
When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response?
Behavioral
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
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.
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 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. 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.
A client with peripheral neuropathy states, "Sometimes I get the worst pain from just a bedsheet brushing over my foot." What is the nurse's most appropriate action?
Document the client's allodynia.
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.
How should the nurse position the head of the bed for a client receiving epidural opioids?
Elevated 30 degrees
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.
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.
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
Which of the following is considered to be the most potent neuromodulators?
Endorphins
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
When implementing the gate-control theory of pain, which intervention will enhance the closing of the gate to the client's pain?
Give the client a back rub.
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.)
Heat Massage Cold
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 recognizes which statement is true of chronic pain?
It may cause depression in clients.
A nurse assesses a client who is being given an opioid analgesic and finds the client unresponsive to shaking or other stimuli. What drug might be ordered to reverse this state?
Naloxone
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
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
Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take?
Reposition the client and gently massage the client's back.
Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?
Respiratory
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?
Respiratory status, oxygen saturation, pain, and sedation level
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.
A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first?
Stop the PCA pump.
When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation, scoring a 4 on the Pasero & McCaffery Sedation Scale. What is the nurse's best action?
Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and naloxone.
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.
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.
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.
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?
Use massage and heat application to the lower back
A nurse is preparing to give a client a massage. What action should the nurse perform during this intervention
Using a light, gliding stroke, apply lotion to the client's shoulders, back, and sacral area.
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
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.
Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy?
gabapentin
The action of ibuprofen is to a) Enhance the endorphins of the CNS b) Have a antiprostaglandin effect on the CNS c) Close the gate of the A-delta fibers d) Provide narcotic pain relief
have an antiprostaglandin effect on the CNS.
A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. 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 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?
providing temple massage when head hurts
Who is the authority on the presence and extent of pain experienced by a client?
the client
A nurse is caring for a client with cancer who is experiencing pain. What would be the mostappropriate assessment of the client's pain?
the client's pain based on a pain rating
The nurse is caring for a client who reports having "kidney pain from a urinary tract infection" for 3 days. How will the nurse describe this pain when reporting off via SBAR? Select all that apply
visceral acute
The nurse is caring for a client who reports nausea and vomiting for 1 week. How will the nurse document this type of pain? Select all that apply.
visceral acute
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.