Chapter 20: Clients with Pain Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 20: Clients with Pain

MULTIPLE CHOICE

1. To provide the best care to a client having pain, the nurse must assess which information in addition to using a pain measuring scale?

a.

A record of any healing taking place in damaged tissue

b.

Objective measurements of the tissue damage

c.

The clients perception of the pain

d.

The type of pain fibers conducting the pain

ANS: C

Because clinical pain is subjective and no objective measures of it exist, the only persons who can accurately define their own pain are those experiencing the pain.

DIF: Application/Applying REF: p. 351 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

2. An elderly client has mild dementia and the nurse feels the client may be in pain. The best way for the nurse to assess this client for pain is by

a.

asking direct questions about pain.

b.

changing the way the nurse phrases the questions.

c.

having the client rate pain with a 1-10 scale.

d.

using the FACES pain scale.

ANS: D

Assessing older clients, especially those with dementia, requires special considerations. A client with dementia may not be able to answer questions about pain even if phrased in different ways. Typical assessment tools are hard to use in this population, but the FACES scale can be used even in older adults with some dementia.

DIF: Application/Applying REF: p. 377 OBJ: Assessment

MSC: Health Promotion and Maintenance Aging Process

3. A clients leg was pinned under a piece of heavy equipment in the workplace for several hours, during which he was in severe pain. The physiologic response that the occupational health nurse could have assessed in this situation is

a.

a wide pulse pressure.

b.

constricted pupils.

c.

dry, cold skin.

d.

tachycardia.

ANS: D

The physiologic response to acute pain is caused by stimulation of the sympathetic nervous system. The client will probably exhibit the manifestations of (a) increased or decreased blood pressure, (b) tachycardia, (c) diaphoresis, (d) tachypnea, (e) focusing on the pain, and (f) guarding the painful part.

DIF: Application/Applying REF: p. 352 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Vital Signs

4. The nurse caring for a client with suspected appendicitis knows that the pain associated with appendicitis is

a.

cutaneous pain.

b.

somatic pain.

c.

superficial pain.

d.

visceral pain.

ANS: D

Visceral pain originates from body organs, or viscera, and often includes pain caused by acute appendicitis, cholecystitis, inflammation of the biliary and hepatic tract, gastroduodenal disease, cardiovascular disease, pleurisy, and renal and ureteral colic. Somatic pain is from ligaments, tendons, bones, blood vessels, and nerves. It is often poorly localized, may produce nausea, and may be associated with sweating and blood pressure changes. Cutaneous pain would arise from the skin structures. Superficial pain is not a defining designation.

DIF: Comprehension/Understanding REF: p. 354 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

5. A client with end-stage cancer is on a continuous IV of morphine to control intractable pain. The family is concerned that the client has a decreasing level of consciousness and has shallow respirations. Which action by the nurse is most appropriate?

a.

Call the physician and report the familys concerns.

b.

Prepare to administer naloxone (Narcan).

c.

Review the goals of end-of-life care with the family.

d.

Slow the rate of the IV infusion.

ANS: C

Respiratory depression is a side effect of opioid medications and is treated with naloxone. However, in a case where the client is receiving end-of-life care, the goals are a peaceful and pain-free death. All terminally ill clients experience some degree of altered mentation and respiratory changes. The nurse should review this information with the family and not plan on slowing the IV rate or giving naloxone. The nurse can call the physician to relay the familys concerns, but the primary nursing action would be to discuss the situation with the family.

DIF: Analysis/Analyzing REF: p. 365 OBJ: Intervention

MSC: Psychosocial Integrity End of Life Care

6. A client is in the hospital with an exacerbation of a chronic pain condition. Orders are for prn morphine IV push. When the primary nurse left for the weekend, the clients pain was under control. When the nurse returns to work, the client is reporting wild swings in pain control, being oversedated at some times and having extreme pain at other times. Which action by the primary nurse would best get this clients pain under control?

a.

Ask the physician to order the pain medication on a round-the-clock schedule.

b.

Observe the client for behaviors that might indicate possible addiction.

c.

Plan to administer the maximum amount of pain medication the next time it is due.

d.

Question the client about the pain to determine if he/she is exaggerating.

ANS: A

Intermittent dosing, such as seen with prn orders, causes wild swings in the blood levels of the pain medication, leaving the client overly sedated or undertreated. Nurses are typically uncomfortable with clients who demonstrate pain behavior or who request pain medication and often give the smallest doses possible while waiting the longest amount of time between doses that is possible. The client would respond best to scheduled pain medication given around the clock without having to ask for it and wait for the nurse to prepare and administer it. Another option would be a PCA pump.

DIF: Analysis/Analyzing REF: pp. 374-375 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Pain Management

7. The most effective way for the nurse to administer pain medication to a client who is experiencing severe pain related to metastatic liver cancer is to

a.

administer medication only when other methods of pain relief are ineffective.

b.

dispense pain medications on a regular basis.

c.

give only intravenous pain medications.

d.

respond promptly to as-needed (prn) pain requests.

ANS: B

Patients experiencing pain caused by widespread cancer require routine pain-relieving medication in order to function, often at higher doses.

DIF: Application/Applying REF: p. 372 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Pain Management

8. A client who has been dealing with chronic pain for the past 2 years would like to try biofeedback as a method of pain relief. The statement that indicates that the client understands this method of treatment is

a.

I want to give my attention to something other than my pain.

b.

I work really well with groups. I think that support will be just what I need.

c.

Im willing to try to control how blood flows to different parts of my body.

d.

It will be nice to try something that wont cost me anything.

ANS: C

The purpose of biofeedback in pain management is to teach the client self-control over physiologic variables that relate to the pain, such as muscle contraction and blood flow. Biofeedback takes a great deal of concentration. The equipment is very expensive. It is not used in a support group setting.

DIF: Evaluation/Evaluating REF: pp. 380-381 OBJ: Evaluation

MSC: Physiological Integrity Physiological Adaptation-Illness Management

9. A client who has been in chronic pain after an automobile accident successfully reduces his pain through a combination of biofeedback and meditation. The conclusion the nurse may draw from his success is that the

a.

pain was acute in nature.

b.

pain was psychological in nature.

c.

placebo effect occurred.

d.

therapy caused physiologic changes.

ANS: D

Many nonpharmaceutical interventions have been used clinically with positive results. The therapies are thought to cause physiologic changes.

DIF: Evaluation/Evaluating REF: pp. 378-379 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Illness Management

10. A client has chronic back pain from an injury several years ago. The client is in the doctors office, complaining of insomnia with fatigue and dissatisfaction with the previous physician who did nothing to help the pain. The client has a blunt affect and relates no longer being able to do many things that once were enjoyable. The nurse working with an interdisciplinary team to manage this clients pain understands the client

a.

has adapted a sick role out of frustration with the situation and health care.

b.

is probably malingering to get workers compensation.

c.

might be addicted to drugs and should have a urine drug screen.

d.

would not be so irritable after getting some sleep.

ANS: A

Clients with chronic pain are challenging. They may present with symptoms of depression, insomnia, and limited functioning, and may voice frustration with the health care system as they search for the specific cause of their pain and one definitive treatment. They may adapt what are known as pain behaviors and the sick role in order to gain more compassion, thus treatment, from health care providers.

DIF: Comprehension/Understanding REF: p. 352 OBJ: Assessment

MSC: Psychosocial Integrity Situational Role Changes, Coping Mechanisms

11. The nurse reminds a group of student nurses that the most significant problem associated with the use of demand or nurse-administered analgesia is

a.

determination of the difference between pain control and addiction.

b.

inability of heavily assigned nurses to respond in a timely manner.

c.

pain medications being administered too close to one another.

d.

the nurses underestimation of the need for medication.

ANS: A

The traditional method of treating pain is by nurse-administered pain medication. It is unfortunate that with this system pain is often significantly undertreated because nurses underestimate the clients need for pain medication.

DIF: Comprehension/Understanding REF: pp. 374-375 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Pain Management

12. A client is receiving an opioid analgesic through an epidural catheter. The nurse places the highest priority on

a.

assessing for respiratory depression.

b.

assisting the client with frequent position changes.

c.

establishing a baseline laboratory profile.

d.

performing hourly inspection of the catheter insertion site.

ANS: A

Possible side effects of epidural opioids are pruritus, urinary retention, and delayed respiratory depression, occurring 4 to 12 hours after a dose.

DIF: Application/Applying REF: p. 376 OBJ: Assessment

MSC: Safe, Effective Care Environment Establishing Priorities

13. A client is having a small wart removed from his index finger. The nurse assisting with this procedure would question the use of

a.

lidocaine.

b.

Novocain with epinephrine.

c.

procaine.

d.

Xylocaine.

ANS: B

Epinephrine-containing solutions are not used for nerve blocks of the penis, fingers, or toes, where vasoconstriction could cause inadequate blood flow and necrosis of the distal extremity. Lidocaine, procaine, and Xylocaine are all acceptable local anesthetics.

DIF: Application/Applying REF: p. 360 OBJ: Intervention

MSC: Safe, Effective Care Environment Injury Prevention

14. The nurse practitioner (NP) infiltrates with lidocaine the area around a lesion to be incised. For optimal anesthesia, the NP should anticipate a waiting period of

a.

5 to 10 minutes.

b.

to hour.

c.

no significant time.

d.

optimally, 1 hour.

ANS: A

Lidocaine produces its effect in 5 to 10 minutes and usually lasts about 2 hours.

DIF: Comprehension/Understanding REF: p. 360 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Pain Management

15. A client is receiving intravenous morphine every hour for severe pain. The nurse assesses the client and notes a blood pressure of mm Hg, pulse rate of 90 beats/min, and respirations of 6 breaths/min. Which action by the nurse takes priority? The nurse should

a.

administer the next dose of morphine when it is due.

b.

notify the physician about the patients hypotension.

c.

prepare to administer naloxone (Narcan).

d.

return in 1 hour so the client can get some uninterrupted sleep.

ANS: C

This client has respiratory depression, which is a known side effect of narcotic administration. Treatment of respiratory depression includes arousing the client, establishing a patent airway, administering an opiate antagonist such as naloxone, and providing artificial ventilation as necessary.

DIF: Analysis/Analyzing REF: p. 364 OBJ: Intervention

MSC: Safe, Effective Care Environment Establishing Priorities

16. The teaching plan for an individual receiving transcutaneous electrical nerve stimulation (TENS) should include the information that

a.

one electrode only is used over the painful site.

b.

the client can adjust both voltage and pulsation.

c.

the electrode wires should be visible to detect early problems.

d.

this therapy is useful for very few clients.

ANS: B

Voltage and pulsation are controlled by the person wearing the device. Positive and negative poles (electrodes) are placed within several inches of each other. TENS has been shown to relieve pain effectively in many people.

DIF: Application/Applying REF: p. 379 OBJ: Intervention

MSC: Health Promotion and Maintenance Self Care

17. A client with metastatic cancer is being dismissed to home health care. The clients orders include both a long-acting opioid analgesic and a short-acting analgesic for breakthrough pain. In addition, the client will be taking an NSAID every 8 hours. The clients spouse is very upset with these directions and voices concern to the nurse that the client will become an addict. Which information will best help the spouse and client maintain the medication schedule? The nurse should

a.

call the physician and ask him/her to come speak to the family.

b.

help them understand the need for such strong medications.

c.

inform them that in time, the medications can be decreased.

d.

initiate a referral to a pain specialist.

ANS: B

Clients with painful conditions, including metastatic cancers, are often treated at home and are responsible for self-care measures, including pain control. Many people worry about the possibility of addiction and as a result do not ask for or take adequate pain medications. Helping the clients spouse understand the rationale behind using such powerful medications may help the spouse overcome irrational fears and may promote self-care in the client. If the spouse is judgmental and the client wants to please him or her, the client may not take enough pain medication. Having the physician or pain specialist speak to the family is not incorrect, but it avoids the nurses primary responsibility to the client and family. With metastatic cancer, the need for pain medications will likely increase, not decrease, as the disease progresses.

DIF: Application/Applying REF: p. 373 OBJ: Intervention

MSC: Health Promotion Self Care

18. The client who had a right below-the-knee amputation 2 days ago is requesting pain medication for pain in his right foot. The nurse should

a.

administer the prescribed analgesic.

b.

elevate the stump on pillows and apply ice.

c.

offer an alternative therapy such as a massage.

d.

tell the client that he cannot be medicated for pain in the absent foot.

ANS: A

Phantom pain occurs with amputation of a body part. The person may continue to experience sensations in the missing part as if it were still there. When phantom pain does occur, throbbing, burning, stabbing, boring, or vise-like sensations are experienced in the amputated area. Pain medication for this complaint is appropriate.

DIF: Application/Applying REF: p. 355 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Pain Management

19. The nurse instructs the client taking ibuprofen that the drug is effective for pain relief because it acts to

a.

interfere with the relay of pain information through the dorsal horn.

b.

interrupt the transmission of pain impulses.

c.

reduce inflammation and block prostaglandins.

d.

slow painful stimuli through type A-delta pain fibers.

ANS: C

The site of action of nonsteroidal anti-inflammatory drugs (NSAIDs) is primarily the periphery at the receptor site, where NSAIDs serve an anti-inflammatory function and prevent the production of prostaglandins.

DIF: Comprehension/Understanding REF: p. 362 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Pain Management

20. The client with neuropathic pain develops allodynia, which

a.

can be relieved by daily doses of opioids.

b.

is a vague pain that is difficult for the client to describe.

c.

is pain due to a stimulus that does not normally cause pain.

d.

responds to NSAIDs taken several times a day.

ANS: C

Allodynia is pain that is evoked by stimuli that do not normally cause pain. Neuropathic pain responds poorly to typical pain medications and is treated with gabapentin and antidepressants. It is usually described as numbness, burning, stabbing, needles, and electric shock

DIF: Knowledge/Remembering REF: p. 354 OBJ: Assessment

MSC: Physiological Adaptation Physiological Adaptation-Pathophysiology

21. Two days after a cholecystectomy the client is kept comfortable with oral NSAIDs. The clients spouse asks the nurse why the client is not receiving something stronger, saying, I know the procedure causes a lot of pain because I also had my gallbladder removed. The nurses answer is based on the fact that

a.

oral medications are always the preferred route for pain medication.

b.

strong analgesics interfere with client assessment.

c.

the client should be switched to mild pain medication as quickly as possible.

d.

the clients perception of the relief of pain is the best standard of pain relief.

ANS: D

Because people perceive and interpret pain based on their own individual experience, pain is different for each person. Each client should be considered the expert on his or her pain.

DIF: Application/Applying REF: p. 351 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

22. A client is being discharged with scheduled doses of morphine every 8 hours. The goals for discharge teaching have been met when the client says I will

a.

eat high fiber foods and drink lots of fluids to avoid constipation.

b.

monitor my blood pressure carefully, and report any elevations over .

c.

take the morphine with food to avoid GI upset and possible stomach ulceration.

d.

notice a decrease in pain in about a week.

ANS: A

Constipation is the most common side effect seen with opioid use. A diet high in fiber with plenty of fluids and a stool-softening medication are common prophylactic treatment.

DIF: Evaluation/Evaluating REF: p. 364 OBJ: Evaluation

MSC: Health Promotion and Maintenance Self Care

23. When the client complains of nausea after receiving his first dose of morphine for pain, the nurse should

a.

encourage the client to wait as long as possible for the next dose.

b.

give only half of the prescribed dose of morphine the next time.

c.

instruct the client that with continued use the nausea will lessen.

d.

withhold the next dose of morphine until re-evaluation by the physician.

ANS: C

Opioids may cause nausea and vomiting because of action on the brain stem centers. It is important to remember that this side effect decreases with analgesic use.

DIF: Application/Applying REF: p. 364 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects

24. The nurse is caring for a client from the Mexican culture who is moaning and groaning in response to pain. The nurse plans care understanding that this response is viewed in the clients culture as

a.

a means to eliminate the pain.

b.

a method of expressing unmet needs.

c.

a woman-like and weak response to pain.

d.

an expression of acceptance of pain.

ANS: A

In the Mexican culture, moaning and groaning is seen as a method to reduce or eliminate pain rather than as an indication or expression of pain.

DIF: Analysis/Analyzing REF: p. 356 OBJ: Intervention

MSC: Psychosocial Integrity Cultural Diversity

25. A postoperative client that recently returned from surgery has a morphine PCA pump. The basal rate is ordered to be 1 mg/hour and the patient can have a 1-mg bolus every 15 minutes. When the nurse assesses the client, the nurse finds the client stuporous, hard to arouse, with a respiratory rate of 6 breaths/minute. After successfully treating the client, which action by the nurse takes priority? The nurse should

a.

ask the physician to discontinue the PCA pump and revert to prn opioids for pain.

b.

check the IV pump to ensure the basal rate is set correctly.

c.

question the client about how he/she has been using the button on the pump.

d.

request the physician order different basal and bolus rates.

ANS: B

The patient exhibited manifestations of opioid toxicity. The ordered dose was well within a safe range for a postoperative client. On a PCA pump, the demand feature has a lock-out device limiting the amount of opioid the client can administer. This could have been set incorrectly, allowing the client to overdose him/herself; however, a sleepy postoperative client often cannot use the demand feature without reminders. This leaves the basal rate as the most likely source of error and the nurse should check to see that it was set correctly. Giving prn pain medications often results in undertreatment of pain and should not be used on a postoperative client. If the pump was set incorrectly, there is no need to adjust the rates. Questioning the client and re-educating him/her if needed are always appropriate, but it is not the priority since the pump most likely was set incorrectly.

DIF: Analysis/Analyzing REF: pp. 375, 364 OBJ: Intervention

MSC: Safe, Effective Care Environment Safe Use of Equipment

26. A nurse is describing a client to a nursing student as watching the clock for the next dose of pain medication, liking pain medication too much, and being overly dramatic when expressing pain. This nurse described the client as addicted. The nursing instructor conferences with the student later, describing the clients behavior as

a.

addicted, because the instructor agrees with the staff nurses opinion.

b.

consistent with increasing tolerance to the ordered pain medication.

c.

displaying behaviors consistent with pseudoaddiction.

d.

requiring the assistance of a psychiatric social worker.

ANS: C

In pseudoaddiction, the client displays behaviors consistent with addiction, but does so because his/her pain in inadequately treated and the client believes that by displaying such behaviors, the nurse will recognize the need to manage the clients pain better. True addiction is rare. Whether the client is becoming more tolerant to the medication or whether the staff is undermedicating the client can be decided later upon further investigation. The priority is un-labeling the client so that he/she gets adequate pain control. Then the nurse should investigate the reasons behind the lack of good control.

DIF: Analysis/Analyzing REF: p. 367 OBJ: Intervention

MSC: Psychosocial Integrity Chemical and Other Dependencies

27. A postoperative client has liberal orders for pain medication and the nurse is delivering them on a strict schedule. The client denies pain when assessed but appears worried, is fidgeting in bed, cries occasionally, and uses the call light frequently for minor requests. When analyzing this situation, which component of the pain medication plan might the nurse discover needs revision?

a.

The doses of medications are too low.

b.

The interval between doses is too long.

c.

The nurse needs a better therapeutic relationship with the client.

d.

The route of administration should be changed to a faster acting route.

ANS: C

Pain management includes more than giving medication. This client is displaying behaviors consistent with anxiety, which is contributing to the intensity of the pain and the effectiveness of the pain medication. In a therapeutic relationship, the client feels cared for, supported, and understood. The client will in turn develop confidence in the nurse to keep the pain under control. The nurse should assess his or her actions towards the client to ensure he/she has established a professional, therapeutic relationship.

DIF: Analysis/Analyzing REF: pp. 371-372 OBJ: Assessment

MSC: Psychosocial Integrity Therapeutic Environment, Therapeutic

MULTIPLE RESPONSE

1. A client with a known opioid addiction is scheduled for surgery tomorrow. The nurse can best meet this clients needs for pain control by incorporating which interventions into the plan of care? (Select all that apply.)

a.

Be prepared to use higher than normal doses of pain medications.

b.

Involve the client and significant others in planning pain management techniques.

c.

Offer a referral to an addictions specialist.

d.

Plan to taper opioids slowly to avoid withdrawal symptoms.

e.

Request a patient-controlled analgesia (PCA) pump for the immediate postoperative phase.

ANS: A, B, D, E

Clients with addictions deserve pain control. Addicted clients will probably need higher than normal doses of opioid analgesics. Involve the client and significant others (if the client agrees) in planning pain control. Tapering opioids should be done slowly to avoid withdrawal symptoms. A PCA pump works well for acute pain relief. Ideally the client should be offered a referral to an addictions specialist, but the evening before surgery is not the time to plan for addictions counseling.

DIF: Application/Applying REF: p. 371 OBJ: Intervention

MSC: Psychosocial Integrity Chemical and Other Dependencies

2. A client who had surgery refuses pain medication. The nurse assessing this client would first ask questions regarding the clients (select all that apply)

a.

beliefs about the benefits of placebos.

b.

cultural expectations regarding pain behaviors and pain treatment.

c.

interpretation or meaning the client gives to the pain.

d.

prior experiences with pain and pain relief.

e.

understanding how different pain medications work.

ANS: B, C, D

Culture, the meaning a client ascribes to pain, and prior experiences with pain and pain relief all can have dramatic effects on the way a client manages a painful situation. Placebos are unethical and should not be used. Understanding the mechanism of action of different pain medications would not be a priority area to assess when trying to find the reason a client in pain refuses medication. Once the client has agreed to pain medication, the nurse should instruct the client on how the particular medication the client takes works.

DIF: Analysis/Analyzing REF: pp. 356, 357, 358

OBJ: Assessment MSC: Psychosocial Integrity Coping Mechanisms

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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