Pathophysiology Ch 35
Which clients would be considered an example of referred pain? Select all that apply.
-One with a myocardial infarction who states, "an elephant is sitting on my chest." -One with renal calculi who describes a cramping colicky pain in the scrotum. Explanation: Referred pain is pain originating in one area of the body that is perceived at a different site. Organs of the chest and abdomen commonly refer pain to other locations. Heart pain commonly refers to the chest, left arm, and neck. The kidneys refer pain to the flank and groin. The bladder may refer to the inner thighs. The lungs and diaphragm may refer to the shoulder. Diabetic foot ulcers produce numbness in the lower leg which is the location of the problem and not referred pain. Page 864
A 25-year-old woman who works as an air-traffic controller presents with facial pain and severe headache. She reports that she sometimes feels the pain in her neck or ear and that it is particularly bad during very busy times at the airport. What is the most likely diagnosis?
Temporomandibular joint syndrome Explanation: Temporomandibular joint syndrome causes pain that originates in the temporomandibular joint and is usually referred to the face, neck, or ear. Headache is also common. It is aggravated by jaw function and can be particularly severe in people under stress, especially if they grind their teeth. Page 875
An older adult tells the nurse, "My friend just developed shingles and has a lot of pain. Is there a way for me to protect myself from it?" Which of the following is an appropriate response from the nurse?
"Get a Zostavax vaccination." Explanation: Herpes zoster is the viral infection caused by the varicella zoster virus. The first infection is called chicken pox. When there is a recurrence it is called shingles. The virus is believed to remain dormant in the nerve root until the patient has a decline in cellular immunity when the virus will replicate. The pain is often described as throbbing, burning, or stabbing. The best prevention is a vaccine for adults age 60 and older. Antivirals will lessen the severity at the time but will not prevent infection. Page 870
A client is being taught how to use a TENS unit .The nurse determines that teaching was effective when the client states:
"I should take my medication and apply the TENS unit to the painful area as soon as I feel the pain." Explanation: Early intervention for pain relief is the best practice. The client should understand that he or she should take his or her pain medication and apply the TENS unit. TENS units are noninvasive and should be applied as soon as the client starts to perceive pain. It is often used in conjunction with pain-relieving medication. Page 867
A client asks if pain threshold and pain tolerance are the same. The best response by the health care provider would be:
"Pain threshold is the point at which a stimulus is perceived as painful." Explanation: Pain threshold is closely associated with the point at which a nociceptive stimulus is perceived as painful. Pain tolerance relates more to the total pain experience; it is defined as the maximum intensity or duration of pain that a person is willing to endure before the he or she wants something done about the pain. Psychological, familial, cultural, and environmental factors significantly influence the amount of pain a person is willing to tolerate. The threshold for pain is fairly uniform from one person to another, whereas pain tolerance is extremely variable. Page 861
Which of the following hospital patients is most likely to be diagnosed with complex regional pain syndrome II (CRPS II)?
A man who has been admitted for treatment of continuing hyperalgesia after sustaining a nerve injury in a motor vehicle accident. Explanation: CRPS is marked the presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve with evidence at some time of edema, changes in skin blood flow, or abnormal sensorimotor activity in the region of pain. Pain related to shingles is an example of postherpetic neuralgia, while a need for analgesia prior to dressing changes would not indicated CRPS. Sudden attacks of pain accompanied by facial tics and spasms may be indicative of trigeminal neuralgia. Page 871
The nurse is caring for a client who has returned from surgery after having a colon resection. What is the best method for the nurse to use when administering an opioid for pain in order to optimize pain control?
Administer the opioid preemptively and before pain becomes extreme. Explanation: When giving opioids for relief of severe pain, such as that occurring after surgery, there is much evidence that opioids given routinely before the pain starts (preemptive analgesia) or becomes extreme are far more effective than those administered in a sporadic manner. People who are treated in this manner seem to require fewer doses and are able to resume regular activities sooner. Page 868
Staff at the care facility note that a woman has started complaining of back pain in recent weeks and occasionally groans in pain. She has many co-morbids that require several prescription medications. The nurse knows that which of the following factors is likely to complicate the clinician's assessment and treatment of the client's pain?
Assessment and treatment are possibly complicated by the large number of drugs that the client receives. Explanation: Polypharmacy complicates both assessment and treatment of pain in the older adult. While minor changes in pain pathways do occur as an age-related change, these do not mean that treatment is unsuccessful. Pain assessment is more difficult in clients with cognitive deficits, but it is not impossible. Reports of pain in the elderly, as with any client, may signal an underlying health problem. Page 876
The nurse on the pediatric unit is implementing distraction strategies for a child who is experiencing pain. Which strategies would be best for the nurse to implement? Select all that apply.
Bubbles Television Music Games Explanation: Distraction helps children of any age divert their attention away from pain and onto other activities. Common attention diverters include bubbles, music, television, conversation, and games. Page 876
What can the nurse assume about a child's behavior when faced with the need to repeat a painful procedure?
Children act to avoid pain based on their memory of past painful events. Explanation: Children do feel pain and have been shown to reliably and accurately report pain. They also remember pain. This is evidenced in studies of children with cancer, whose distress during painful procedures increases over time without intervention, and in neonates in intensive care units, who demonstrate protective withdrawal responses to a heel stick after repeated episodes. The other options may not necessarily be true of most children. Page 875
The client asks the health care provider to explain what the purpose is for the application of cold to a sprained ankle. The best response would be:
Cold provides pain relief and suppresses the release of products from tissue damage. Explanation: Cold prevents the release of products of tissue damage and provides pain relief (produces vasoconstriction at the site). Application of heat would cause blood vessels to dilate and more blood to be drawn to the local area. Page 877
When giving pain medicine for acute pain, health care workers are reluctant to provide much needed opioid pain medicine. What is the major concern of health care workers when providing opioid pain relief?
Fear of addiction Explanation: Part of the reluctance of health care workers to provide adequate relief for acute pain has been fear of addiction. However, addiction to opioid medications is thought to be virtually nonexistent when these drugs are prescribed for acute pain. The other answers are not the major concern. Page 875
The nurse knows that chronic pain lacks which of the characteristic pain-related reactions?
Increased heart rate Explanation: Characteristics of chronic pain do not include autonomic responses like increased heart and respiratory rate. Loss of appetite, disturbed sleep patterns and depression are common among people dealing with chronic pain. Page 866
In describing the ideal analgesic, what factors would be included? (Select all that apply.)
Inexpensive Effective Have minimal adverse effects Explanation: The ideal analgesic would be effective, nonaddictive, and inexpensive. In addition, it would produce minimal adverse effects and not affect the person's level of consciousness. Page 867
A patient reports a sudden intense headache. Which of the following factors would indicate the presence of a possible subarachnoid hemorrhage?
Intractable pain Explanation: Subarachnoid hemorrhage causes a severe intractable headache. Headaches that disturb sleep or occur with exercise or sexual activity may be caused by neurologic lesions. Migraine headaches tend to run in families but do not contribute to hemorrhage. Page 872
A nurse on a post-surgical unit is providing care for a 76 year-old female client who is two days post-hemiarthroplasty (hip replacement) and who states that her pain has been out of control for the last several hours, though she is not exhibiting signs of pain. Which of the following guidelines should the nurse use for short-term and long-term treatment of the client's pain?
Knowing that the client's self-report of pain is the most reliable indicator of pain. Explanation: Clinically, the patient's self-report of pain is the most reliable indicator of pain. The risk of addiction to opioids is extremely low and since the client's pain is acute rather than chronic, it is likely self-limiting. Page 867
A woman with severe visual and auditory deficits is able to identify individuals by running her fingers lightly over their face. Which of the following sources is most likely to provide the input that allows for the woman's unique ability?
Meissner corpuscles Explanation: Meissner corpuscles, which are present on the hair-free areas like palms and fingers, are responsible for fine tactile sensation. Pacinian corpuscles provide input on vibration, while Ruffini end organs exist in deeper structures that signal continuous states of deformation. Free nerve endings also detect touch and pressure, but not to the highly-differentiated degree of Meissner corpuscles. Page 858
A nurse is assessing a patient for manifestations of chronic pain. Which of the following is characteristic of chronic pain? Select all that apply.
Mental depression Withdrawal from activities Loss of appetite Explanation: Acute pain generally is classified as being of short duration and arises from a specific pathologic process that resolves. Acute pain may lead to tachycardia, increased sympathetic activity such as sweating, decreased mobility, and shallow breathing. Chronic pain lasts longer than expected and may fluctuate. Signs of chronic pain include insomnia, depression, and loss of appetite. Patients may withdraw from outside activities. Page 865
If the patient's dorsal columns are not functioning, the nurse will observe which of the following responses during neuro testing, where the nurse asks the patient to close their eyes and then proceeds to touch corresponding parts of the body on each side simultaneously with two sharp points?
No response to two-point discrimination. Explanation: When comparing discriminative dorsal column-medial lemniscus pathway compared with anterolateral tactile pathways with testing (with eyes closed), gently brush the skin with cotton, touch an area with 1-2 sharp points, touch corresponding parts of the body on each side simultaneously or random sequence, and passively bend the person's finger one way and then another. If dorsal columns are not functioning, the tactile threshold 2-point discrimination and proprioception are missing and the person has difficulty discriminating which side of the body received stimulation. Page 856
When a peripheral nerve is irritated enough, it becomes hypersensitive to the noxious stimuli, which results in increased painfulness or hyperalgesia. Health care professionals recognize both primary and secondary forms of hyperalgesia. What is primary hyperalgesia?
Pain sensitivity that occurs directly in damaged tissues Explanation: Primary hyperalgesia describes pain sensitivity that occurs directly in damaged tissues. The other answers are incorrect. Page 869
Which of the following factors influence pharmacologic choices for pain management in older adults? Select all that apply.
Polypharmacy may cause drug interactions. Poor nutrition may lead to poor drug distribution. Organ function may be less efficient. Explanation: Older adults may experience less effective organ function that interferes with medication function. Organ changes may include reduced drug absorption from the gastrointestinal tract, slower renal clearance, impaired liver function, and reduced blood flow. In addition, other illnesses requiring medication may create a situation of polypharmacy where multiple drugs interact to increase side effects. While acetaminophen is considered a first line drug for mild to moderate pain, opioids are generally used for several pain and palliative care and not restricted as a result of potential addiction. Addiction potential is reduced in any client with adequate pain control. Page 876
Which of the following patients is exhibiting headache symptoms that indicate a need for further evaluation?
Pregnant mother with drowsiness and unrelenting headache Primary headaches such as migraine, tension headache, cluster headache, and chronic daily headache do not require additional evaluation. Patients with secondary headaches should receive further evaluation. Possible causes of secondary headaches are cerebral hemorrhage or aneurysm, meningitis, cancer, and nerve lesions. Additional patients requiring further evaluation are those with sudden onset or progression of headaches or someone who is immunosuppressed or pregnant. Page 872
A client is experiencing deep somatic pain would manifest which clinical symptoms? Select all that apply.
Radiation of pain Pain reproduced by stimuli Explanation: Deep somatic pain originates in deep body structures, such as the periosteum, muscles, tendons, joints, and blood vessels. This pain is more diffuse than cutaneous pain. Various stimuli, such as strong pressure exerted on bone, ischemia to a muscle, and tissue damage, can produce deep somatic pain. Radiation of pain from the original site of injury can occur. Cutaneous pain is a sharp pain with a burning quality, abrupt or slow in onset, and can be localized. Page 864
The nurse is studying sensory systems. She understands that signal transduction of an impulse to the thalamus for processing is accomplished by which of the following?
Second-order neurons Explanation: Second-order neurons communicate with various reflex networks and sensory pathways in the spinal cord and travel directly to the thalamus. First-order neurons transmit sensory information from the periphery to the CNS. Third-order neurons relay information from the thalamus to the cerebral cortex. Page 855
A client with migraines asks the nurse about symptoms of an aura. Which manifestations are characteristic of a migraine aura? Select all that apply.
Seeing flickering lights or spots Feeling numbness in fingers Slurred speech Explanation: Migraine with aura has reversible symptoms that may include flickering lights, spots and lines, loss of vision, sensation of numbness, or pins and needles and speech disturbances. These symptoms occur from 5 to 20 minutes before the headache and last up to an hour. The definition of a chronic migraine is getting it 15 or more days per month. Page 873
A client is experiencing a cluster headache. The client would most likely manifest:
Severe pain behind the eye Explanation: Symptoms of cluster headache include severe, unrelenting unilateral pain located in the orbital area. The pain radiates behind the eye to the ipsilateral trigeminal nerve. The client may also experience symptoms such as restlessness or agitation, conjunctival redness, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, and eyelid edema. The other options are all associated with migraine headache. Page 874
A student is feeling inside her backpack to find her mobile phone. There are a number of other items in the bag other than the phone. The nurse knows that which of the following terms best describes one's ability to sense of shape and size of an object in the absence of visualization?
Stereognosis. Explanation: The sense of shape and size of an object in the absence of visualization is known as stereognosis. Astereognosis is a deficit whereby a person can correctly describe the object but does not recognize that it is a screwdriver. Modalities is a term used for qualitative, subjective distinctions between sensations such as touch, heat, and pain. Somesthesia describes most of the perceptive aspects of body sensation and requires the function of the parietal association cortex. Page 856
A client who works in a high stress job presents with facial pain and severe headache. She reports that she sometimes feels the pain in her neck or ear and that it is particularly bad during very busy times at work. Which diagnosis is most likely associated with these symptoms?
Temporomandibular joint syndrome Explanation: Temporomandibular joint syndrome causes pain that originates in the temporomandibular joint and is usually referred to the face, neck, or ear. Headache is also common. It is aggravated by jaw function and can be particularly severe in people under stress, especially if they grind their teeth. Migraine, sinus, and cluster headaches less commonly affect the ear. Page 875
The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to non-medication centered therapy?
Tension Explanation: Tension-type headaches often are more responsive to nonpharmacologic techniques, such as biofeedback, massage, acupuncture, relaxation, imagery, and physical therapy, than other types of headache. For people with poor posture, a combination of range-of-motion exercises, relaxation, and posture improvement may be helpful. The other options are usually best treated with medications that focus on the cause of the pain. Page 867
A client has recently been diagnosed with chronic back pain that requires the daily use of hydromorphone, an opioid analgesic. For the first few weeks, the client achieved relief with 4 mg every 6 hours. However, the client now requires 6 mg doses to achieve the same effect. How should the nurse best interpret this phenomenon?
The client is developing opioid tolerance, which is expected Explanation: The client is developing a tolerance to the opioid, which is not unexpected and which is not synonymous with addiction. There may be a need to include nonpharmacologic interventions or NSAIDs, but these do not need to replace the opioid. Page 867
Following a knee injury, a football player is taking ibuprofen, a non-steroidal anti-inflammatory drug, for the control of pain. Which of the following drug actions is most likely to result in diminished sensation of pain for the player?
The drug inhibits the enzyme needed for prostaglandin synthesis. Explanation: Analgesia can be achieved by inhibition of prostaglandin synthesis, as in the case many NSAIDs. These drugs do not affect the function of third order neurons, the action potential of C fibers or the conduction velocity of Aδ fibers.
A mother is placing her child into the bathtub. The child immediately jumps out of the tub and begins to cry, stating their feet are 'burning'. The nurse in the emergency department knows that the child's response is based on which of the following pathophysiological principles listed below?
The tactile sensation occurs well in advance of the burning sensation. The local withdrawal reflex reacts first. Explanation: If a person places a foot in a tub of hot water, the tactile sensation occurs well in advance of the burning sensation. The foot has been removed from the hot water by the local withdrawal reflex well before the excessive heat is perceived by the forebrain. All other responses are incorrect. Page 858
The health care provider is assessing the functional integrity of all spinal nerves utilizing a pinpoint pressed against the skin. A normal response would be interpreted as:
The withdrawal reflex is activated. Explanation: Observation of a normal withdrawal reflex rules out peripheral nerve disease, disorders of the dorsal root and ganglion, disease of the myoneural junction, and severe muscle diseases. Having no response is abnormal and may identify neurological damage. A verbal response is not a reflex response. Page 855
A 58-year-old woman comes to the clinic for evaluation of a sharp, intermittent, severe, stabbing facial pain that she describes as, "like an electric shock." The pain occurs only on one side of her face; it seems to be triggered when she chews, brushes her teeth, or sometimes when she merely touches her face. There is no numbness associated with the pain. What is most likely causing her pain?
Trigeminal neuralgia Explanation: Her symptoms are characteristic of trigeminal neuralgia, caused by damage to the fifth cranial nerve, which carries impulses of touch, pain, pressure, and temperature to the brain from the face and jaw. Page 870
A client comes to the clinic for evaluation of a sharp, intermittent, severe, stabbing facial pain that she describes as "like an electric shock." The pain occurs on only one side of her face. It seems to be triggered when she chews, brushes her teeth, or sometimes when she merely touches her face. Often it is accompanied by involuntary grimacing. What diagnosis is most likely?
Trigeminal neuralgia Explanation: Her symptoms are characteristic of trigeminal neuralgia, caused by damage to the fifth cranial nerve, which carries impulses of touch, pain, pressure, and temperature to the brain from the face and jaw. Postherpetic neuralgia is a complication of shingles, migraine headache symptoms feel as if they occur in one or more regions of the head, not the face, and complex regional pain syndrome affects either one arm or leg. Page 870
Which is considered the most accurate method of assessing pain in children ages 8 years and older?
Using a numeric 1-10 scale Explanation: Children between ages 3 and 8 years can accurately point to a scale of faces that ranges from very tearful to very happy to indicate their pain level. Children older than 8 are accurately able to report pain on a numeric scale, or using words ranging from "none" to "the most I have ever had." The older child may consider the faces scale juvenile. Physiologic responses to pain, such as tachycardia and guarding, are not very accurate because they are nonspecific and may not occur with chronic pain. A parent may say that their child is acting differently, but the child is the best person to describe his or her pain. Page 876
While batting, a baseball player is struck in the ribs by a pitch. Place the following components of the player's pain pathway in the chronological order as they contribute to the player's sensation of pain. Use all the options.
• Thalamus • Dorsal root ganglion body • Dorsal root ganglion periphery • Axon • Cerebral cortex Explanation: All somatosensory information from the limbs and trunk shares a common class of sensory neurons called dorsal root ganglion neurons. Somatosensory information from the face and cranial structures is transmitted by the trigeminal sensory neurons, which function in the same manner as the dorsal root ganglion neurons. The cell body of the dorsal root ganglion neuron, its peripheral branch (which innervates a small area of periphery), and its central axon (which projects to the CNS) communicate with the thalamus, which in turn communicates with the cerebral cortex using third order neurons. Page 855
A 30 year-old female has suffered a third-degree burn to her hand after spilling hot oil on it in a kitchen accident. Which of the following teaching points by a member of her care team is most appropriate?
"Opioids aren't without side effects, but we will take action to manage these side effects so you can continue getting these drugs." Explanation: While opioids carry side effect such as constipation, these can be managed in order to continue treatment; constipation would not preclude the continued use of opioids, but would require management. Pain medication should precede the onset of pain, and tolerance is not grounds for discontinuing treatment. Page 867
A beta-adrenergic blocker has been prescribed for a client diagnosed with migraines. The most important information for the nurse to teach the client would be:
"Take the medication daily as you have been directed." Explanation: Preventative medications such as beta-adrenergic blockers should be taken consistently to prevent vascular changes from occurring. In most cases, preventative treatment must be taken daily for months to years. They should not be stopped abruptly and should be weaned or tapered off. Page 874
A client arrives in the clinic and informs the nurse that he is having pain in the left knee that has lasted for several weeks. The physician orders an x-ray of the left hip and knee. The client tells the nurse that the pain is in the knee, not the hip. What is the best response by the nurse?
"The pain you are having may be referred pain, which can cause the pain in the knee resulting from a hip problem." Explanation: Referred pain is pain that is perceived at a site different from its point of origin but innervated by the same spinal segment. It may be difficult for the brain to correctly identify the original source of pain. A and D are nontherapeutic responses. It is beyond the scope of practice for the nurse to change a physician's order. Page 864
A nurse who is testing a patient's response to passive movement of the fingers with the patient's eyes closed, notes that the patient cannot accurately identify on which side the movement occurred or in what position the finger was placed. Which of the following is an appropriate interpretation of this result?
Abnormal discrimination pathway function Explanation: The discriminative dorsal column-medial lemniscus pathway is able to sense fine touch and discriminate between two points as close as 5 mm. This pathway also mediates sense of position. Loss of this pathway means only that the anterolateral pathway is functioning and is unable to make fine distinctions in touch proprioception and points. The test does not test reflexes or temperature. Page 856
Chronic pain is difficult to treat. Cancer, a common cause of chronic pain, has been especially addressed by the World Health Organization (WHO). What has WHO created to assist clinicians in choosing appropriate analgesics?
An analgesic ladder for pain control Explanation: The World Health Organization has created an analgesic ladder for cancer pain that assists clinicians in choosing the appropriate analgesic. The other answers are incorrect. Page 867
When conducting a health assessment that focuses on the pain experienced by an older client diagnosed with early dementia, the nurse will pay particular attention to which of the following?
Behavioral signs of pain demonstrated by the client Explanation: The assessment of pain in older adults can range from relatively simple in a well-informed, alert, cognitively intact person with pain from a single source and no comorbidities to extraordinarily difficult in a confused person. When possible, a person's report of pain is the gold standard, but behavioral signs of pain should also be considered. This is especially true when the client's cognitive function is impaired. While the other options should be considered, the client's non verbal behaviors should be of particular interest to the nurse. Page 876
Which of the following types of pain is characterized by severe, brief, often repetitive pain?
Neuralgia Explanation: Neuralgia is characterized by severe, brief, often repetitive attacks of lightning-like or throbbing pain. Neuropathic pain is widespread and is not otherwise explainable, burning pain and attacks of pain that occur without seeming provocation. Tic douloureux is characterized by paroxysmal attacks of stabbing pain that usually are limited to the unilateral sensory distribution of one or more branches of the trigeminal nerve, most often the maxillary or mandibular divisions. Postherpetic neuralgia affects sensory ganglia, and the peripheral nerve to the skin of the corresponding dermatomes cause a unilateral localized vesicular eruption and abnormally exaggerated subjective response to pain. Page 870
A severe type of headache that occurs more frequently in men than women and is described as having unrelenting, unilateral pain located most frequently in the orbit is called what?
Cluster headache Explanation: Cluster headache is a type of primary neurovascular headache that typically includes severe, unrelenting, unilateral pain located, in order of decreasing frequency, in the orbital, retro-orbital, temporal, supraorbital, and infraorbital region. The other answers are incorrect. Page 874
The provider is testing the patient's ability to identify the specific location of skin touch in two different areas. This ability is communicated through which pathway?
Discriminative Explanation: The discriminative pathway relays precise information regarding spatial orientation. This is the only pathway taken by the sensations of muscle and joint movement, vibration and delicate discriminative touch, as is required to differentiate the location of touch on the skin at two neighboring points. The anterolateral pathway (anterion and lateral spinothalamic pathways) provide transmission of sensory information such as pain, thermal sensations, crude touch and pressure that does not require discrete localization or fine discrimination. The paleospinothalamic tract gives touch its affective or emotional aspects, such as heavy pressure. Page 855
A patient with diabetes mellitus has just undergone a right, below the knee amputation following gangrene infection. A few days post-op, the patient confides in the nurse that he still feels his right foot. Knowing the pathophysiologic principles behind this, the nurse can:
Explain that many amputees have this sensation and that one theory surmises the end of a regenerating nerve becomes trapped in the scar tissue of the amputation site. Explanation: Multiple theories exist related to the causes of phantom limb pain. One rationale is that the end of the regenerating nerve becomes trapped in the scar tissue that forms a barrier to regenerating outgrowth of the axon. The usual treatment includes: the use of sympathetic blocks; TENS of the large myelinated afferents innervating the area; hypnosis; and, relaxation training. Page 871
Which interventions are appropriate for a client with acute pain following abdominal surgery? Select all that apply.
Ibuprofen (Motrin) Cold therapy Hydrocodone (Vicodin) Guided imagery Explanation: Chronic pain interventions may include neural blockade, transcutaneous electrical nerve stimulation, physical therapy, cognitive-behavioral interventions, nonnarcotic medications such as tricyclic antidepressants, antiseizure medications and NSAIDs, and narcotic medications. Acute pain interventions include many of the interventions for chronic pain but with a stronger focus on narcotic analgesics but not on using tricyclic antidepressants or antiseizure medications. Page 867
With which of the following activities would a patient experiencing astereognosis need help?
Identifying an object by touch Explanation: Astereognosis is the inability to identify objects by touch. The patient would be able to describe the object's characteristics but not recognize it without visual cues. Page 857
When assessing neurologic response times, the nurse expects the fastest rate of transmission to be from fibers that have which characteristics?
Large diameter, myelinated Explanation: Signal transmission is fastest in large diameter, myelinated fibers such as type A. Type B fibers are smaller in diameter and myelinated. Unmyelinated, small- diameter Type C fibers have the slowest conduction. Page 858
The nurse instructs the certified nursing assistant (CNA) to be sure to turn the client every 2 hours in order to avoid pressure on the skin and avoid a pressure ulcer. What type of stimuli is the nurse encouraging the CNA to avoid?
Mechanical stimuli Explanation: Mechanical stimuli can arise from intense pressure applied to skin or from the violent contraction or extreme stretch of a muscle. Chemical stimuli arise from a number of sources, including tissue trauma, ischemia, and inflammation. Thermal stimuli can result from extremes of heat or cold. Pain stimuli is not a stimuli. Page 862
Which statement explains how nonsteroidal anti-inflammatory drugs (NSAIDs) control pain?
NSAIDs block the enzyme that synthesizes prostaglandins. Explanation: Nociceptors respond to three different types of stimuli: chemical, thermal, and mechanical. The chemical mediators such as bradykinin, histamine, serotonin, and potassium activate or sensitize nociceptors and continue the inflammatory response by releasing prostaglandins. Aspirin, ibuprofen, and other NSAIDs block inflammation by blocking the enzyme needed to synthesize prostaglandins. Page 861
Migraine headaches affect millions of people worldwide. What are first-line agents for the treatment of migraine headaches?
Naproxen sodium and metoclopramide Explanation: Based on clinical trials, first-line agents include acetylsalicylic acid, combinations of acetaminophen, acetylsalicylic acid, and caffeine and nonsteroidal anti-inflammatory drug analgesics (e.g., naproxen sodium, ibuprofen), serotonin (5-HT1) receptor agonists (e.g., sumatriptan, naratriptan, rizatriptan, zolmitriptan), ergotamine derivatives (e.g., dihydroergotamine), and antiemetic medications (e.g., ondansetron, metoclopramide). Morphine, tramadol, and syrup of ipecac are not first-line drugs in the treatment of migraine. Page 873
A client on an acute medicine unit with a diagnosis of small bowel obstruction is reporting intense, diffuse abdominal pain. Which physiologic phenomenon is most likely contributing to the client's pain?
Nociceptive afferents are conducting along the cranial and spinal nerve pathways of the ANS. Explanation: Visceral pain, as characterized by the client's description of her pain, is conducted by way of nociceptive afferents that use the cranial and spinal nerve pathways of the ANS. The problem is not likely rooted in the inappropriate firing of first order neurons or the substitution of conduction by C fibers. Pain that is attributable to a pathologic process apart from the neural pain network is not normally considered to be neuropathic. Page 864
A client on an acute medicine unit of a hospital with a diagnosis of small bowel obstruction is complaining of intense, diffuse pain in her abdomen. Which of the following physiological phenomena is most likely contributing to her complaint?
Nociceptive afferents are conducting the sensation of pain along the cranial and spinal nerve pathways of the ANS. Explanation: Visceral pain, as characterized by the client's description of her pain, is conducted by way of nociceptive afferents that use the cranial and spinal nerve pathways of the ANS. The problem is not likely rooted in the inappropriate firing of first order neurons or the substitution of conduction by C fibers. Pain that is attributable to a pathological process apart from the neural pain network is not normally considered to be neuropathic. Page 863
Which of the following will conduct injurious stimuli to alert the body of potential damage?
Nociceptors Explanation: Nociceptors are sensitive to painful and noxious stimuli and alert the system to injury. Thermoreceptors will perceive heat, proprioceptors will perceive body position, and odorant receptors will perceive the sensation of smell. Page 861
A patient reports feeling a tingling sensation in the last two fingers of one hand after hitting the inner surface of the elbow on a desk. Which of the following is the cause of this symptom?
Paresthesia from temporary nerve compression Explanation: Temporary mild compression of a peripheral nerve can lead to paresthesia. Hypersensitivity is an increased response to mild stimuli. Hyperpathia is a syndrome in which pain is explosive after the raised sensory threshold is reached. Hypoesthesia is reduced or lost sensation of touch or temperature and may be an inherited trait. Page 869
A nurse assesses a patient with a cerebral infarct for sensation. Which of the following results indicates that second-order neurons are intact?
Patellar reflex +2 Explanation: First-order neurons transmit sensory information from the periphery of the neurons to the central nervous system. Second-order neurons communicate directly with the thalamus and work with the reflex networks and sensory pathways in the spinal cord. Third-order neurons relay information from the thalamus to the cerebral cortex. Level of consciousness does not indicate sensation. Page 861
When testing nociceptive stimuli to elicit a withdrawal reflex in the body, what stimuli are commonly used?
Pressure from a sharp object Explanation: Stimuli used include pressure from a sharp object, strong electric current to the skin, or application of heat or cold of approximately 10°C above or below normal skin temperature. The other answers are incorrect. Page 875
A client is experiencing chest pain that radiates to the left arm and neck. The nurse would interpret this pain as:
Referred Explanation: Referred pain is pain that is perceived at a site different from its point of origin but innervated by the same spinal segment. Visceral pain originates in the visceral organs and is one of the most common pains produced by disease, cutaneous pain arises from superficial structures, and somatic pain originates in deep body structures. Page 864
A 7 year old child had an emergency appendectomy during the night. When trying to assess their pain, the nurse should:
Show them a scale with faces of actual children and have them point to the picture that best describes how they are feeling. Explanation: Children do feel pain and have been shown to reliably and accurately report pain...With children 3-8 years of age, scales with faces of actual children or cartoon faces can be used to obtain a report of pain. Physiologic measures, such as heart rate, are convenient to measure but they are nonspecific. They may be a sign of anxiety and not pain. Distraction methods are good but medications should be used on an individual basis to match the analgesic agent with the level of pain. Page 875
The nurse is providing nonpharmacologic pain relief for a client who has a pain level of 2 in the leg. What intervention provided by the nurse would be considered distraction?
Sitting with the client and having a conversation Explanation: Distraction does not eliminate pain, but it can make pain more tolerable. It may serve as a type of sensory shielding whereby attention to pain is sacrificed to pay attention to other stimuli that are easily perceived. Examples of distraction include counting, repeating phrases or poems, and engaging in activities that require concentration, such as projects, activities, work, conversation, or describing pictures. Television, adventure movies, music, and humor also can provide distraction. Page 867
A client who is being treated for chronic low back pain is using a TENS unit for relief of pain. The nurse is aware that the use of this device is considered what type of pain relief?
Stimulus-induced analgesia Explanation: Stimulus-induced analgesia is one of the oldest known methods of pain relief. Electrical stimulation methods of pain relief include TENS, electrical acupuncture, and neurostimulation. A physical agent would be the use of heat or cold. Distraction is a nonpharmacologic method of reduction of pain by distracting the patient from his pain. Biofeedback is used to provide feedback to a person concerning the current status of some body function, temperature, temporal artery pulsation, blood pressure, or muscle tension. Page 867
A student is feeling inside her backpack to find her mobile phone. There are a number of other items in the backpack. Which component of somatosensory conduction is most likely to provide the detailed sensory information that will help her distinguish her phone from other items?
The primary dorsal root ganglion neuron, dorsal column neuron, and the thalamic neuron Explanation: The discriminative pathway, which is associated with the fine touch of item discrimination, involves just three neurons: the primary dorsal root ganglion neuron, the dorsal column neuron, and the thalamic neuron. Slow-conduction and anterolateral pathways that involve the reticular activating system are associated with pain, thermal sensation, and indiscriminate touch. Page 856
Children feel pain just as much as adults do. What is the major principle in pain management in the pediatric population?
Treat on individual basis and match analgesic agent with cause and level of pain. Explanation: The overriding principle in all pediatric pain management is to treat each child's pain on an individual basis and to match the analgesic agent with the cause and the level of pain. The other answers are incorrect. Page 876
A patient reports chronic pain. Assessment indicates it is located at the T6 dermatome. How will this information assist the nurse to develop an effective plan of care?
Treatment can be tailored to the specific location. Explanation: A dermatome is the region of the body wall that is supplied by a single pair of dorsal root ganglia. Isolating the location of the pain allows for focused treatment. Pain commonly interferes with ADLs. Interventions are designed to minimize disruption of ADLs. Management may reduce referred pain but may not alleviate them because the visceral and somatic neurons share the same dorsal horn projections. Clients with chronic pain benefit most from interventions that include physical, emotional, financial, and spiritual components of care. Using biologic treatments alone is less effective than the combination of all modalities. Page 855
Nonopioids, such as acetaminophen (Tylenol), are the first line of therapy for managing mild to moderate pain in the elderly because they are safe.
True Explanation: Opiods are used for more severe pain and palliative care Page 867
The nurse is testing her cliient's tactile sensation. She knows that the pacinian corpusles are functioning when the patient reports which sensation?
Vibration Explanation: The pacinian corpusles detect tissue vibration. Hair follicle end organs detect movement on the surface of the body. Free nerve endings detect touch and pressure. Skin stretching is detected by the Ruffini end organs. Page 858
A client is admitted to the acute care facility with severe pain in the abdomen related to inflammatory bowel disease. What type of pain will the nurse be administering medication to relieve?
Visceral pain Visceral pain has its origin in the visceral organs and is one of the most common pains produced by disease. While similar to somatic pain in many ways, both the neurologic mechanisms and the perception of visceral pain differ from somatic pain. One of the most important differences between surface pain and visceral pain is the type of damage that causes pain. Strong contractions, distention, or ischemia affecting the walls of the viscera can induce severe pain. Page 864
A client with a history of migraine headaches tells the physician that he or she usually experiences an aura before the onset of the headache. The client is most likely experiencing:
Visual disturbances Explanation: Migraine aura is associated with visual symptoms, including flickering lights, spots, or loss of vision; sensory symptoms, including feeling of pins or needles, or numbness; and speech disturbances or other neurologic symptoms. Page 873
