Chapter 15: Pain Assessment and Basic Comfort Measures Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse is caring for a patient who is a devout Orthodox Jew. The patient is on a patient-controlled analgesia (PCA) pump. What accommodations might the nurse have to make to conform to the patients cultural needs?

a.

Ask the patient whether he will need alternative forms of medication for the Sabbath.

b.

Ask the patient specific questions because Jews tend to be stoic regarding pain.

c.

Medicate the patient around the clock instead of as needed (prn).

d.

Understand that Jews believe that suffering is a consequence of actions in a previous life.

ANS: A

Orthodox or Observant Jews may not use electrical equipment during the Sabbath and on Holy Days; therefore, the staff should program the PCA to achieve optimum pain relief. Alternative methods will be needed during these times. Cultures vary regarding when to recognize pain, what words to use in expressing pain, when to seek treatment, and what treatments are desirable. Russians, Asians, and Native Americans tend to be stoic, whereas Italians, Puerto Ricans, and Jews tend to be more expressive. The nurse should ask the patient about his preferences. Some Hindu patients believe that suffering is a consequence of actions in a previous life. For example, a belief in the concept of Karma motivates the patient to bear the pain, refuse pain medications, and suffer in silence. Some Jews view pain as a communal suffering that they should share with others to affirm their life experience.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 348

OBJ: Assess a patients level of pain. TOP: Cultural Considerations

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. The patient is admitted with chronic pain. She states that nothing takes the pain away totally, but that Dilaudid works best. The fact that the patient calls the medication by name should alert the nurse to:

a.

suspect that the patient is drug seeking.

b.

expect that the patient may need smaller doses than normal.

c.

assess the patients acceptable level of comfort.

d.

accept the fact that nothing will help this patients pain.

ANS: C

It is important to assess the patients acceptable level of comfort so that both you and the patient are striving for the same outcome. Some patients with prior pain conditions can alert the nurse to pain-relieving measures that were successful. Patients with chronic/persistent pain are often familiar with the names and actions of medications, including opioid medications. This should not cause you to view the patient negatively or with suspicion. Patients currently receiving opioids for chronic pain often require higher doses of analgesics to alleviate new pain. Do not accept that there is nothing that will help this patients pain. Learn the institutional policy for how to proceed in this situation.

DIF: Cognitive Level: Application REF: Text reference: pp. 348-349

OBJ: Assess a patients level of comfort.

TOP: Assessment of Comfort Level KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse frequently must assess a patient who is experiencing pain. When assessing the intensity of the pain, the nurse should:

a.

ask whether there are any precipitating factors.

b.

question the patient about the location of the pain.

c.

offer the patient a pain scale to objectify the information.

d.

use open-ended questions to find out about the sensation.

ANS: C

Descriptive scales are an objective means of measuring pain intensity. Use a pain intensity scale appropriate to the patients age, developmental level, and comprehension, and ask the patient to rate the pain. An appropriate pain rating scale is reliable, easily understood, and easy to use, and it reflects changes in pain intensity. Asking the patient what precipitates the pain does not assess intensity, but rather assesses the pain pattern. Asking the patient about the location of pain does not assess the intensity of the patients pain. To determine the quality of the patients pain, the nurse may ask open-ended questions to find out about the sensation experienced (e.g., Tell me what your pain feels like). This approach assists in identifying the underlying pain mechanism (e.g., somatic or neuropathic pain), but it may not reveal intensity or changes in intensity.

DIF: Cognitive Level: Application

REF: Text reference: pp. 347-348|Text reference: pp. 362-363

OBJ: Assess a patients level of comfort. TOP: Assessing Pain Intensity

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. The nurse who is caring for a patient postoperatively notes that he is expressing discomfort and is diaphoretic. Which of the following interventions is most appropriate?

a.

Straighten the bed linens.

b.

Change the saturated surgical dressing.

c.

Administer prescribed pain medications.

d.

Check for displaced equipment underneath the patient.

ANS: C

Administer pain-relieving medications as ordered. Analgesics are the cornerstone of pain management. Smoothing wrinkles in bed linens may reduce pressure and irritation to the skin; however, pain-relieving medication should be given first. Changing a wet surgical dressing might not be needed if the patient has received a wet-to-dry dressing as treatment, or if not changing the dressing will reduce irritation to the skin but will not address the discomfort. Reposition underlying tubes, wires, or equipment that may apply pressure directly to dependent skin surfaces. Removing these stimuli may maximize the response to pain-relieving interventions such as medication, but pain-relieving medication should be administered first.

DIF: Cognitive Level: Application REF: Text reference: p. 350

OBJ: Identify skills appropriate for relieving a patients reported pain.

TOP: Treatment of Pain KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. The patients family is concerned that the patient may get too much pain medication after surgery and become addicted to the medication if he is placed on a PCA pump. They also voice concern about the effectiveness of the PCA. The nurse should instruct the family and the patient that:

a.

pain relief with the PCA pump is not as good as when the nurse provides it, but it does save on nursing time.

b.

pain relief is good when the medication peaks, but less so when the levels drop, and that is when the patient will know that he needs more.

c.

because the device provides medication as soon as the patient needs it, he will probably use less of the medication.

d.

the patient will be kept in bed for several days after surgery to make sure it is safe to ambulate.

ANS: C

Because the device provides medication on demand as soon as the patient feels the need, the total amount of opioid use is reduced. Because the blood level stays within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased. The PCA has several advantages. It allows more constant serum levels of the opioid and, as a result, avoids the peaks and troughs of a large bolus. An advantage of PCA is that when used postoperatively, fewer complications arise because earlier and easier ambulation occurs as a result of effective pain relief.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 353

OBJ: Teach a patient to use a PCA device.

TOP: Patient-Controlled Analgesia (PCA)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. The nurse caring for a patient who has a PCA knows that it:

a.

allows the family to participate in pain management for the patient.

b.

prevents mistakes in medication administration.

c.

can be used by all hospitalized patients.

d.

provides a more constant level of medication.

ANS: D

PCA allows more constant serum levels of the opioid, and, as a result, it avoids the peaks and troughs of a large bolus. Because the blood level is maintained within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased. Potential concerns involving PCA use are pump failure, and operator errors. Patients may misunderstand how PCA therapy works, may mistake the PCA button for the nurse call button, or may have family members who operate the demand button. Instruct the family not to push the timing device for the patient unless the patient is unable to push the button himself, and the nurse has instructed the family to do so. Use of a PCA pump does not prevent mistakes. The pump may fail to deliver drug on demand, may have a faulty alarm or a low battery, or may lack free-flow protection. Operators may incorrectly program the dose, concentration, or rate. Not all patients are candidates for PCA. Assess the patients cognitive ability to determine the appropriateness of PCA pain management.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 353

OBJ: Teach a patient to use a PCA device.

TOP: Patient-Controlled Analgesia (PCA)

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

7. When evaluating the effects of PCA, the nurse notes that the patient is sedated and is difficult to arouse. What step should the nurse take next?

a.

Insert an airway.

b.

Turn patient to the side.

c.

Stop the PCA.

d.

Expect this as a patient outcome of the therapy.

ANS: C

If the patient is sedated and is not readily arousable, stop the PCA. As long as the patient has spontaneous respirations, instruct him or her to take deep breaths. Apply oxygen at 2 L via nasal cannula. Elevate the head of the bed 30 degrees, unless contraindicated, to facilitate respirations. Heavy sedation is not an expected outcome of PCA therapy. Evaluate for the presence of analgesic side effects. Maintain a slightly drowsy, easily aroused patient.

DIF: Cognitive Level: Application REF: Text reference: p. 357

OBJ: Evaluate the effectiveness of pain management techniques.

TOP: Patient-Controlled Analgesia (PCA)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. The patient is scheduled for surgery late in the afternoon. His postoperative orders include PCA therapy. Which of the following nursing interventions is appropriate to perform?

a.

Teach the patient about PCA after the patient comes out of recovery.

b.

Teach the patient about PCA before surgery and before preoperative medication administration.

c.

Tell the patient not to use PCA unless he can no longer tolerate the pain.

d.

Inform the patients family to watch him carefully and to depress the PCA administration button whenever they think he needs it.

ANS: B

Instruct surgical patients preoperatively. Encourage the patient to push the button on the timing unit whenever he feels pain. Tell the patient not to delay if he is experiencing pain. Pain is easier to prevent than to treat. Inform the patient and family that the patient cannot overdose with PCA if only the patient pushes the button. The family should not push the button unless instructed to do so by the nurse.

DIF: Cognitive Level: Application REF: Text reference: p. 357

OBJ: Teach a patient to use a PCA device.

TOP: Patient-Controlled Analgesia (PCA) Teaching Consideration

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. The nurse knows that an advantage of intraspinal analgesia is the:

a.

smaller doses of epidural than intrathecal medication.

b.

lack of significant patient complications.

c.

systemic distribution of morphine faster than fentanyl.

d.

ability to achieve appropriate analgesia with smaller dosages.

ANS: D

Because opioids are delivered close to their site of action, the central nervous system (CNS), they have greater bioavailability and thus require much smaller doses to achieve adequate pain relief. Epidural and intrathecal doses are not equivalent. Intrathecal doses are much smaller than epidural doses. As an example, the epidural dose of morphine is 10 to 20 times greater than that required for an intrathecal dose. The catheter poses a threat to patient safety because of its anatomical location, its potential for migration through the dura, and its proximity to spinal nerves and vessels. Migration of an epidural catheter into the subarachnoid space can produce medication levels too high for intrathecal use. Fentanyl and sufentanil are hydrolipid, which causes them to have a quicker onset and a shorter duration of action (2 hours). Morphine and hydromorphone are hydrophilic, resulting in a longer onset and a longer duration of action (up to 24 hours with a single bolus dose).

DIF: Cognitive Level: Comprehension REF: Text reference: p. 358

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Intraspinal Analgesia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

10. The patient is in the hospital undergoing major abdominal surgery. When the patient returns from the recovery room, the nurse expects that he most likely will be receiving pain medication:

a.

by mouth.

b.

intramuscularly.

c.

via the epidural route.

d.

intravenously.

ANS: C

Research shows the epidural route to be most effective in managing postoperative pain from thoracic and abdominal surgeries.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 358

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Intraspinal Analgesia KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

11. While reviewing a patients medication history, the nurse determines that intraspinal analgesia is contraindicated as a result of:

a.

previous spinal anesthesia.

b.

recent administration of anticoagulants.

c.

a history of cardiac problems.

d.

a diagnosis of advanced cancer.

ANS: B

Recent anticoagulants sometimes contraindicate the placement of an epidural catheter because of the risk for epidural hematoma at the insertion site. Certain conditions may make epidural analgesia the method of choice for pain control: following surgery, for patients with trauma or advanced cancer that is not responsive to other pain management modalities, and those predisposed to cardiopulmonary complications because of a preexisting medical condition or surgery. Previous spinal anesthesia is not a contraindication for receiving subsequent spinal anesthesia.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 358-361

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Intraspinal Analgesia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

12. A nurse checks the continuous IV infusion for the intraspinal analgesia. The IV setup should be changed if:

a.

tubing with a Y-port is attached.

b.

an infusion pump is attached.

c.

the tubing connections are all taped.

d.

a diluted, preservative-free medication is used.

ANS: A

Use tubing without Y-ports for continuous infusions. Use of tubing without Y-ports prevents accidental injection or infusion of another medication meant for vascular space into epidural space. Normal equipment used for intraspinal infusion includes an infusion pump and compatible tubing without Y-ports. Catheter and injection cap or infusion pump tubing should be securely taped and labeled. Closed, intact systems prevent entry of pathogens and disruption of the flow of medication. Medication should be prediluted, preservative-free opioid or local anesthetic as prescribed by the physician and prepared for use in an IV infusion pump (usually prepared by pharmacy). Preservatives may be toxic to nerve tissue.

DIF: Cognitive Level: Application REF: Text reference: pp. 359-361

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Intraspinal Analgesia KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

13. Before administering an epidural medication, the nurse aspirates and suspects that the catheter has migrated into the subarachnoid space when:

a.

clear drainage is noted.

b.

no drainage is noted.

c.

purulent drainage is noted.

d.

redness, warmth, and edema are noted.

ANS: A

Aspiration of more than 1 mL of clear fluid or bloody return means that the catheter may have migrated into the subarachnoid space or into a vessel. Do not inject the drug. Notify the physician. Purulent drainage is a sign of infection, indicating that local inflammation and superficial skin infection at the insertion site have occurred.

DIF: Cognitive Level: Analysis REF: Text reference: p. 362

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Catheter Migration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

14. The nurse is preparing to administer a bolus of epidural medication. The nurse must remember to:

a.

clean the injection cap of the epidural catheter with an anti-infective according to agency policy.

b.

clean the injection cap of the epidural catheter with alcohol.

c.

inject opioids quickly and smoothly.

d.

flush with saline after the injection.

ANS: A

Clean the injection cap of the epidural catheter with povidone-iodine, or substitute anti-infective according to agency policy. Alcohol causes pain and is toxic to neural tissue. Inject opioid at a rate of 1 mL over 30 seconds. Slow injection prevents discomfort by lowering the pressure exerted by fluid as it enters the epidural space. The catheter is in a space, not a blood vessel; thus flushing with saline is not required.

DIF: Cognitive Level: Application REF: Text reference: p. 361

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Injecting a Bolus of Epidural Medication

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. A nurse is evaluating the epidural catheter insertion site and suspects that the intraspinal catheter has punctured the dura when _____ noted.

a.

clear drainage is

b.

bloody drainage is

c.

purulent drainage is

d.

redness, warmth, and swelling are

ANS: A

Clear drainage may indicate puncture of the dura. Bloody drainage may indicate that the catheter has entered the blood vessel. Purulent drainage is a sign of infection. Redness, warmth, and swelling are signs of inflammation. Local inflammation and superficial skin infection can occur at the insertion site.

DIF: Cognitive Level: Analysis REF: Text reference: p. 360

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Evaluating Epidural Site KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

16. When assessing a local infusion pump site, the nurse notes that which of the following requires an intervention?

a.

The device is labeled, indicating that an anesthetic is being used.

b.

The catheter connections are loose.

c.

Surgical dressings are dry and intact.

d.

No blood backup is present in the tubing.

ANS: B

Assess the catheter connections; all should be firmly attached. If connections become detached, do not reattach because infection could occur. Notify the physician. The label on the device provides information regarding type of anesthetic, concentration, volume, flow rate, date and time prepared, and the name of the person who prepared it. The nurse should read this label. The dressing should be dry and intact. If not, stop the infusion and notify the physician. The catheter may not be placed properly. Assess for blood backing up in the tubing. If blood is present, stop the infusion and notify the physician. This indicates possible displacement of the catheter into a blood vessel.

DIF: Cognitive Level: Analysis REF: Text reference: p. 364

OBJ: Monitor and manage the patient who is receiving a local anesthetic infusion pump.

TOP: Assessment of Local Anesthetic Infusion Pump

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

17. The patient had knee replacement surgery and has a local infusion pump to provide a local anesthetic to the surgical site. The patient puts on the call light and complains that pain at the site is more intense than it has ever been and is getting worse. The nurse checks the site and finds that the dressing is damp but intact. The infusion pump is pumping, and there is medication in the bag. The most probable cause of the problem might be the:

a.

catheter may be clogged.

b.

pump may be releasing too much drug into the site.

c.

catheter may be displaced.

d.

patient may be exaggerating the pain.

ANS: C

Assess the surgical dressing and the site of catheter insertion. The dressing should be dry and intact. Determine whether the catheter is properly placed. If the catheter is clogged, infusion of medication will stop. Pain levels will increase but the dressing will be dry, and the pump should alarm. If the pump is releasing too much medication, the nurse should expect to see symptoms of local anesthetic adverse reaction. It is not the patients responsibility to convince the nurse that he has pain; it is the nurses responsibility to believe the patient.

DIF: Cognitive Level: Analysis REF: Text reference: p. 365

OBJ: Monitor and manage the patient who is receiving a local anesthetic infusion pump.

TOP: Unexpected Outcomes KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

18. A nonpharmacological approach that the nurse may implement for patients who are experiencing pain that focuses on diverting the patients attention away from the pain sensation by promoting pleasurable and meaningful stimuli is:

a.

massage.

b.

heat/cold.

c.

guided imagery.

d.

distraction.

ANS: D

Distraction is a technique that diverts an individuals attention away from the pain sensation. By introducing meaningful stimuli, the nurse helps the patient refocus attention. Distraction directs a patients attention to something else and thus can reduce awareness of pain and even increase tolerance. A proper massage not only blocks the perception of pain impulses but also helps relax muscle tension and spasm that otherwise might increase pain. Massage hastens the elimination of wastes stored in muscles, improves oxygenation of tissues, and stimulates the relaxation response in the nervous system. Heat produces vasodilation, reduced blood viscosity, reduced muscle tension, and increased tissue metabolism. Heat helps relieve muscle spasms and joint stiffness. Cold produces vasoconstriction, reduced cell metabolism, and increased blood viscosity. Cold is effective for inflamed joints and muscles. The goal of imagery is to have the patient use one or several of the senses to create an image of the desired result. This image creates a positive psychophysiological response. Guided imagery can be used as a distraction technique.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 367

OBJ: Monitor and manage the patient who is receiving nonpharmacological measures to relieve pain.

TOP: Distraction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19. The patient is unable to rest even after pain medication has been administered. The nurse decides to give the patient a backrub. Which of the following strokes should the nurse use when finishing the backrub?

a.

Long firm stroking movements down the back

b.

Light strokes while moving up the back in a circular motion

c.

Kneading movements toward the sacrum

d.

Circular motion upward from buttocks to shoulders

ANS: A

The nurse should end the backrub with long firm strokes down the back. This is the most soothing of massage movements. The backrub is not finished with light strokes while moving up the back in a circular motion. Kneading movements toward the sacrum are done before the backrub is ended with long firm strokes down the back. The nurse should begin a backrub by massaging in a circular motion upward from buttocks to shoulders.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 369-370

OBJ: Identify and discuss various nonpharmacological pain-relief measures.

TOP: Ending Massage KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20. The patient is admitted for chronic pain. He states that morphine sulfate (Morphine) has been used to relieve his pain, but recently he has been needing to use more of the medication to relieve pain. This patients plan of care will have to incorporate interventions to deal with which of the following?

a.

Addiction

b.

Pseudoaddiction

c.

Drug tolerance

d.

Physical dependence

ANS: C

Drug tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drugs effects over time. Addiction is defined as a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors that influence its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Pseudoaddiction is a term that describes patient behavior that may occur when pain is undertreated. Patients with unrelieved pain may focus on obtaining medications, may clock watch, or otherwise may seem inappropriately drug seeking. Even such behaviors as illicit drug use and deception can occur in the patients efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that behaviors resolve when pain is effectively treated. Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug classspecific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug, and/or administration of an antagonist.

DIF: Cognitive Level: Analysis REF: Text reference: p. 346

OBJ: Plan care on the basis of a patients history, including pain history, and physical assessment findings. TOP: Terminology Related to Drug Dependency

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

21. Which of the following patient conditions is categorized as a neurobiological disease?

a.

Physical dependence

b.

Addiction

c.

Pseudoaddiction

d.

Drug tolerance

ANS: B

Addiction is defined as a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors that influence its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug classspecific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug, and/or administration of an antagonist. Pseudoaddiction is a term that describes patient behavior that may occur when pain is undertreated. Patients with unrelieved pain may focus on obtaining medications, may clock watch, or otherwise may seem inappropriately drug seeking. Even such behaviors as illicit drug use and deception can occur in the patients efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that behaviors resolve when pain is effectively treated. Drug tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drugs effects over time.

DIF: Cognitive Level: Analysis REF: Text reference: p. 346|Text reference: p. 348

OBJ: Plan care on the basis of a patients history, including pain history, and physical assessment findings. TOP: Terminology Related to Drug Dependency

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

22. Which of the following statements about evaluating patients in pain is true?

a.

The best judge of the existence of pain is the nurse.

b.

Visible signs always accompany pain.

c.

Patients often are hesitant to report pain.

d.

Nonpharmacological interventions are better than pain medications.

ANS: C

Patients often are hesitant to report pain for fear of being labeled as complainers, hypochondriacs, or addicts. The patients self-report is the most reliable indicator of the existence and intensity of pain. Even with severe pain, periods of physiological and behavioral adaptation occur, leading to periods of minimal or no observable signs of pain. Lack of pain expression does not necessarily mean lack of pain. Nonpharmacological interventions are synergistic with medications, but are not a substitute for pharmacological management of pain.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 347

OBJ: Assess a patients level of comfort. TOP: Misconceptions of Pain

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. Which of the following are characteristics of cancer pain? (Select all that apply.)

a.

It may be acute.

b.

It may be chronic.

c.

It usually is related to tumor recurrence or treatment.

d.

It often is of less intensity than the patient reports.

ANS: A, B, C

Cancer pain may be acute, chronic, or intermittent, and it usually is related to tumor recurrence or treatment. The patient is the only one who knows whether pain is present and what the experience is like. It is not the patients responsibility to convince the nurse that he has pain; it is the nurses responsibility to believe the patient.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 346

OBJ: Assess a patients level of pain. TOP: Cancer Pain

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. The patient has morphine sulfate ordered for pain every 4 hours prn. The patient complains of severe pain and usually requests more morphine an hour before it is due. The nurse should: (Select all that apply.)

a.

Request a placebo order from the physician.

b.

Offer the patient medication around the clock instead of prn.

c.

Offer the patient massage between medication doses.

d.

Offer the patient a nonopioid medication between morphine doses if ordered.

ANS: B, C, D

Some patients exhibit drug-seeking behaviors when in fact they are seeking pain relief. Occasionally, a physician will order a placebo to discredit a patients report of pain. This is unethical and should be avoided. Timely administration before a patients pain becomes severe is crucial to ensure optimal relief. Pain is easier to prevent than to treat. In most circumstances, administration of pharmacological agents around-the-clock rather than on an as-needed (prn) basis is preferable. Often a combination of nonopioids and opioids is effective in managing pain. Using an integrated approach that considers both pharmacological and nonpharmacological therapies in managing pain is recommended.

DIF: Cognitive Level: Application REF: Text reference: pp. 346-347

OBJ: Assess a patients level of pain. TOP: Pain Treatment Strategies

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. The patient voices concern to the nurse regarding his PCA pump. He states that he is afraid of getting an overdose if he pushes the button too many times. The nurse reassures the patient that: (Select all that apply.)

a.

there is a time delay (lockout) between patient doses.

b.

there is a maximum dose the patient can receive.

c.

the patient has a right to be concerned and needs to be careful.

d.

the patient could be put on a continuous infusion instead, because it is safer.

ANS: A, B

PCA prevents overdosing by interposing a preprogrammed delay time or lockout (usually 6 to 16 minutes) between patient-initiated doses. In addition, the prescriber may limit the total amount of opioid that the patient may receive in 1 to 4 hours (Pasero, 1999). Use basal (continuous) infusions cautiously because studies have not shown superior analgesic benefit. Continuous infusion increases the risk for opioid overdose.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 353-355

OBJ: Teach a patient to use a PCA device.

TOP: Patient-Controlled Analgesia (PCA)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. The patient states that the PCA is not controlling his pain. The nurse checks the infusion setup and IV site and then evaluates the patients ability to use the system. All looks in order. The nurse should notify the physician to:(Select all that apply.)

a.

report suspected drug-seeking behavior.

b.

possibly change the drug being used.

c.

adjust the dosage of the drug being used.

d.

request placebo medication to evaluate true pain.

ANS: B, C

Instruct the patient to check with the nurse or physician with questions and concerns, or if medication is not controlling the pain. The drug may have to be changed, or the dosage may need to be adjusted.

DIF: Cognitive Level: Application REF: Text reference: p. 348

OBJ: Teach a patient to use a PCA device.

TOP: Patient-Controlled Analgesia (PCA)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. Drugs administered in the epidural space spread by: (Select all that apply.)

a.

diffusion through the dura mater.

b.

transport through blood vessels.

c.

absorption by fat.

d.

absorption through muscle.

ANS: A, B, C

A drug administered in the epidural space spreads (1) by diffusion through the dura mater into the cerebrospinal fluid (CSF), where it acts directly on receptors in the dorsal horn of the spinal cord; (2) via blood vessels in the epidural space for systemic delivery; and/or (3) by means of absorption by fat in the epidural space, creating a depot where the drug is released slowly into the systemic circulation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 358

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Epidural Space KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. Pain is experienced differently by different people, because pain perception is based on which of the following? (Select all that apply.)

a.

Past pain experiences

b.

Personal values

c.

Cultural expectations

d.

Emotions

ANS: A, B, C, D

Because higher centers in the brain influence perception greatly, the pain experience is a product of a persons past pain experiences, values, cultural expectations, and emotions.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 347

OBJ: Monitor and manage the patient who is receiving nonpharmacological measures to relieve pain.

TOP: Pain Perception KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

COMPLETION

1. ___________ has an identifiable cause and rapid onset and generally disappears with healing.

ANS:

Acute pain

Acute pain or transient pain has an identifiable cause, has a rapid onset, varies in intensity, is of short duration, and generally disappears with healing.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 346

OBJ: Assess a patients level of pain. TOP: Acute Pain

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. Pain that extends beyond the period of healing and often lacks an identified pathology is known as _______________.

ANS:

chronic pain

Chronic pain or persistent pain extends beyond the period of healing, often lacks identified pathology, rarely has autonomic signs, does not provide a protective function, disrupts sleep and activities of daily living, degrades the health and function of an individual, and may be cancer or noncancer/nonmalignant in origin.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 346

OBJ: Assess a patients level of pain. TOP: Chronic Pain

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. ________________ is a method of preventing pain while reducing overall opioid use.

ANS:

Preemptive analgesia

Preemptive analgesia is a method of preventing pain while reducing overall opioid use.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 347

OBJ: Assess a patients level of pain. TOP: Preemptive Analgesia

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. __________________ is an interactive method of pain management that permits patient control over pain through self-administration of analgesics.

ANS:

Patient-controlled analgesia (PCA)

Patient-controlled analgesia (PCA) is an interactive method of pain management that permits patient control over pain through self-administration of analgesics.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 353

OBJ: Describe delivery of medication through a patient-controlled analgesia (PCA) device.

TOP: Patient-Controlled Analgesia (PCA)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. The _______________ is a potential space between the vertebral bones and the dura mater, the outermost meninges covering the brain and spinal cord.

ANS:

epidural space

The epidural space is a potential space between the vertebral bones and the dura mater, the outermost meninges covering the brain and spinal cord.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 358

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Epidural Space KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. Catheter migration into the______________ can produce dangerously high medication levels. Only physicians and nurse anesthetists administer drugs in this space.

ANS:

subarachnoid space

Only physicians and nurse anesthetists administer spinal drugs due to the increased risk associated with them.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 358

OBJ: Monitor and manage the patient who is receiving epidural analgesia.

TOP: Epidural Space KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

7. The application of touch and movement to muscles, tendons, and ligaments without manipulation of the joints is called _________________.

ANS:

massage

A gentle massage, a form of cutaneous stimulation, is the application of touch and movement to muscles, tendons, and ligaments without manipulation of the joints.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 366

OBJ: Monitor and manage the patient who is receiving nonpharmacological measures to relieve pain.

TOP: Massage KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

8. ________________ draws on internal experiences of memories, dreams, fantasies, and visions; explores the inner world of experience; protects the privacy of the patient; and fosters the imagination.

ANS:

Guided imagery

Guided imagery is a creative sensory experience that effectively reduces pain perception and minimizes reaction to pain. It draws on internal experiences of memories, dreams, fantasies, and visions; explores the inner world of experience; protects the privacy of the patient; and fosters the imagination. The goal of imagery is to have the patient use one or several of the senses to create an image of a desired result.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 367

OBJ: Monitor and manage the patient who is receiving nonpharmacological measures to relieve pain.

TOP: Guided Imagery KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

9. Massaging upward and outward from the vertebral column and back again is known as __________________.

ANS:

effleurage

Effleurage is massaging upward and outward from the vertebral column and back again. Gliding strokes, used without manipulation of deep muscles, smooth and extend muscles, increase nutrient absorption, and improve lymphatic and venous circulation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 368|Text reference: p. 370

OBJ: Identify and discuss various nonpharmacological pain-relief measures.

TOP: Effleurage KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. _______________________ is a massage technique used on tense muscles to knead muscles, promote relaxation, and stimulate local circulation.

ANS:

Ptrissage

Ptrissage is used on tense muscle groups to knead muscles, promote relaxation, and stimulate local circulation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 369

OBJ: Identify and discuss various nonpharmacological pain-relief measures.

TOP: Ptrissage KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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