Chapter 30: Pain Assessment and Management in Children Nursing School Test Banks

Chapter 30: Pain Assessment and Management in Children

MULTIPLE CHOICE

1. Kyle, age 6 months, is brought to the clinic. His parent says, I think he hurts. He cries and rolls his head from side to side a lot. This most likely suggests which feature of pain?

a.

Type

c.

Duration

b.

Severity

d.

Location

ANS: D

The child is displaying a local sign of pain. Rolling the head from side to side and pulling at ears indicate pain in the ear. The childs behavior indicates the location of the pain. The behavior does not provide information about the type, severity, or duration.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 835

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

2. Physiologic measurements in childrens pain assessment are:

a.

The best indicator of pain in children of all ages.

b.

Essential to determine whether a child is telling the truth about pain.

c.

Of most value when children also report having pain.

d.

Of limited value as sole indicator of pain.

ANS: D

Physiologic manifestations of pain may vary considerably and may not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain the body adapts, and these signs decrease or stabilize. These signs are of limited value and must be viewed in the context of a pain-rating scale, behavioral assessment, and parental report. When the child states that pain exists, it does. That is the truth.

PTS: 1 DIF: Cognitive Level: Application REF: 828-829

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. The pediatric nurse understands that nonpharmacologic strategies for pain management:

a.

May reduce pain perception.

b.

Make pharmacologic strategies unnecessary.

c.

Usually take too long to implement.

d.

Trick children into believing they do not have pain.

ANS: A

Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. Nonpharmacologic techniques should be learned before the pain occurs. With severe pain it is best to use both pharmacologic and nonpharmacologic measures for pain control. The nonpharmacologic strategy should be matched with the childs pain severity and taught to the child before the onset of the painful experience. Some of the techniques may facilitate the childs experience with mild pain, but the child will still know that discomfort is present.

PTS: 1 DIF: Cognitive Level: Analysis REF: 840

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

4. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?

a.

Codeine

c.

Methadone

b.

Morphine

d.

Meperidine

ANS: B

The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in parenteral form in the United States. Meperidine is not used for continuous and extended pain relief.

PTS: 1 DIF: Cognitive Level: Analysis REF: 843

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

5. A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply:

a.

4% Liposomal Lidocaine (LMX) 15 minutes before the procedure.

b.

A transdermal fentanyl (Duragesic) patch immediately before the procedure.

c.

Eutectic mixture of local anesthetics (EMLA) 1 hour before the procedure.

d.

EMLA 30 minutes before the procedure.

ANS: C

EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. LMX must be applied 30 minutes before the procedure. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control. For maximal effectiveness, EMLA must be applied approximately 60 minutes in advance.

PTS: 1 DIF: Cognitive Level: Analysis REF: 844

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

6. The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to:

a.

Administer naloxone (Narcan).

b.

Discontinue the IV infusion.

c.

Discontinue morphine until the child is fully awake.

d.

Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.

ANS: A

The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive.

PTS: 1 DIF: Cognitive Level: Analysis REF: 850

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

7. When pain is assessed in an infant, it is inappropriate for the nurse to assess for:

a.

Facial expressions of pain.

c.

Crying.

b.

Localization of pain.

d.

Thrashing of extremities.

ANS: B

Infants are unable to localize pain. Frowning, grimacing, and facial flinching in an infant may indicate pain. Infants often exhibit high-pitched, tense, harsh crying to express pain. Infants may exhibit thrashing of extremities in response to a painful stimulus.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 829

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

8. Which myth may interfere with the treatment of pain in infants and children?

a.

Infants may have sleep difficulties after a painful event.

b.

Children and infants are more susceptible to respiratory depression from narcotics.

c.

Pain in children is multidimensional and subjective.

d.

A childs cognitive level does not influence the pain experience.

ANS: B

No data are available to support the belief that infants and children are at higher risk of respiratory depression when they are given narcotic analgesics. This is a myth. It is true that infants may have sleep difficulties after a painful event. Pain in children is multidimensional and subjective. The childs cognitive level, along with emotional factors and past experiences, does influence the perception of pain.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 850

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

9. The nurse caring for the child in pain understands that distraction:

a.

Can give total pain relief to the child.

b.

Is effective when the child is in severe pain.

c.

Is the best method for pain relief.

d.

Must be developmentally appropriate to refocus attention.

ANS: D

Distraction can be very effective in helping to control pain; however, it must be appropriate to the childs developmental level. Distraction can help control pain, but it is rarely able to provide total pain relief. Children in severe pain are not distractible. Children may use distraction to help control pain, although it is not the best method for pain relief.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 840

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

10. What medication is the most effective choice for treating pain associated with sickle cell crisis in a newly admitted 5-year-old child?

a.

Morphine

c.

Ibuprofen

b.

Acetaminophen

d.

Midazolam

ANS: A

Opioids, such as morphine, are the preferred drugs for the management of acute, severe pain, including postoperative pain, post-traumatic pain, pain from vaso-occlusive crisis, and chronic cancer pain. Acetaminophen provides only mild analgesic relief and is not appropriate for a newly admitted child with sickle cell crisis. Ibuprofen is a type of nonsteroidal antiinflammatory drug (NSAID) that is used primarily for pain associated with inflammation. It is appropriate for mild to moderate pain, but it is not adequate for this patient. Midazolam (Versed) is a short-acting drug used for conscious sedation, for preoperative sedation, and as an induction agent for general anesthesia.

PTS: 1 DIF: Cognitive Level: Application REF: 858

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

11. In which developmental stage is the child first able to localize pain and describe both the amount and the intensity of the pain felt?

a.

Toddler stage

c.

School-age stage

b.

Preschool stage

d.

Adolescent stage

ANS: B

The preschool stage is the period when the child is first able to describe the location and intensity of pain, by stating, for example, Ear hurts bad, when feeling pain. The toddler expresses pain by guarding or touching the painful area, verbalizes words that indicate discomfort such as ouch and hurt, and demonstrates generalized restlessness when feeling pain. The school-age child describes both the location of the pain and its intensity. The adolescent also describes the location and intensity of pain.

PTS: 1 DIF: Cognitive Level: Application REF: 833

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

12. Which assessment indicates to a nurse that a 2-year-old child is in need of pain medication?

a.

The child is lying rigidly in bed and not moving.

b.

The childs current vital signs are consistent with vital signs over the past 4 hours.

c.

The child becomes quiet when held and cuddled.

d.

The child has just returned from the recovery room.

ANS: A

Behaviors such as crying, distressed facial expressions, certain motor responses such as lying rigidly in bed and not moving, and interrupted sleep patterns are indicative of pain in children. Current vital signs that are consistent with earlier vital signs do not indicate that the child is feeling pain. Response to comforting behaviors does not suggest that the child is feeling pain. A child who is returning from the recovery room may or may not be in pain. Most times the childs pain is under adequate control at this time. The child may be fearful or having anxiety because of the strange surroundings and having just completed surgery.

PTS: 1 DIF: Cognitive Level: Application REF: 833

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

13. When assessing pain in any child, the nurse should consider that:

a.

Any pain assessment tool can be used to assess pain in children.

b.

Children as young as 1 year old use words to express pain.

c.

The childs behavioral, physiologic, and verbal responses are valuable when assessing pain.

d.

Pain assessment tools are minimally effective for communicating about pain.

ANS: C

Childrens behavioral, physiologic, and verbal responses are indicative when assessing pain. The use of pain measurement tools greatly assists in communicating about pain. The childs age is important in determining the appropriate pain assessment tool to use. Developmentally appropriate assessment tools need to be used to effectively identify and determine the level of pain felt by a child. Toddlers may use words such as ouch or hurt to identify pain, but infants and young children may not have the language or cognitive abilities to express pain. Pain assessment tools when used appropriately are successful and efficient in identifying and quantifying pain with children. Behavioral and physiologic signs and symptoms in combination with pain assessment tools are most effective in diagnosing pain levels in children.

PTS: 1 DIF: Cognitive Level: Application REF: 840

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

14. A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which pain assessment tool should the nurse use to assess this child for the presence of pain?

a.

FACES pain rating tool

c.

Oucher scale

b.

Numeric scale

d.

FLACC tool

ANS: D

A behavioral pain tool should be used when the child is preverbal or does not have the language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all self-report pain rating tools. Self-report measures are not sufficiently valid for children younger than 3 years of age because many children are not able to self-report their pain accurately.

PTS: 1 DIF: Cognitive Level: Application REF: 830

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

15. A nurse is gathering a history on a school-age child admitted for a migraine headache. The child states, I have been getting a migraine every 2 or 3 months for the last year. The nurse documents this as which type of pain?

a.

Acute

c.

Recurrent

b.

Chronic

d.

Subacute

ANS: C

Pain that is episodic and that recurs is defined as recurrent pain. The time frame within which episodes of pain recur is at least 3 months. Recurrent pain in children includes migraine headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain. Acute pain is pain that lasts for less than 3 months. Chronic pain is pain that lasts, on a daily basis, for more than 3 months. Subacute is not a term for documenting type of pain.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 834

OBJ: Nursing Process: Communication, Documentation

MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

16. Which medications are the most effective choices for treating pain associated with inflammation in children (Select all that apply)?

a.

Morphine

b.

Acetaminophen (Tylenol)

c.

Ibuprofen (Advil)

d.

Ketorolac (Toradol)

e.

Aspirin

ANS: C, D

Ibuprofen, naproxen/naproxen sodium, and ketorolac are all types of NSAIDs, which are used primarily for pain associated with inflammation. Opioids, such as morphine, are the preferred drugs for the management of acute, severe pain, including postoperative pain, post-traumatic pain, pain from vaso-occlusive crisis, and chronic cancer pain. Acetaminophen lacks the antiinflammatory effects of NSAIDs and provides only minimal antiinflammatory relief. Although aspirin is an antiinflammatory medication, because of its association with Reyes syndrome, its use is not recommended in children.

PTS: 1 DIF: Cognitive Level: Analysis REF: 844

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

17. An appropriate tool to assess pain in a 3-year-old child is the (Select all that apply):

a.

Visual Analog Scale (VAS)

b.

Adolescent and pediatric pain tool

c.

Oucher tool

d.

Poker Chip Tool

e.

FACES pain rating scale

ANS: C, D, E

The Oucher Tool can be used to assess pain in children 3 to 12 years of age. The Poker Chip Tool can be used to assess pain in children 4 to 12 years of age. The FACES pain rating scale can be used to assess pain for children 3 years of age and older. The VAS is indicated for use with older school-age children and adolescents. It can be used with younger school-age children, although less abstract tools are more appropriate. The adolescent and pediatric pain tool is indicated for use with children 8 to 17 years of age.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 831-832

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

18. The nurse is monitoring a patient for side effects associated with opioid analgesics. Which side effects should the nurse expect to monitor for (Select all that apply)?

a.

Diarrhea

b.

Respiratory depression

c.

Hypertension

d.

Pruritus

e.

Sweating

ANS: B, D, E

Side effects of opioids include respiratory depression, pruritus, and sweating. Constipation may occur, not diarrhea, and orthostatic hypotension may occur but not hypertension.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 850

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

19. Which dietary recommendations should a nurse make to an adolescent patient to manage constipation related to opioid analgesic administration (Select all that apply)?

a.

Bran cereal

b.

Decrease fluid intake

c.

Prune juice

d.

Cheese

e.

Vegetables

ANS: A, C, E

To manage the side effect of constipation caused by opioids, fluids should be increased, and bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause constipation so it should not be recommended.

PTS: 1 DIF: Cognitive Level: Application REF: 846

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

COMPLETION

20. A dose of oxycodone (OxyContin) 2 mg/kg has been ordered for a child weighing 33 lb. The nurse should administer ______ milligrams of OxyContin. (Record your answer as a whole number.)

ANS:

30

The childs weight is divided by 2.2 to obtain the weight in kilograms.

Kilograms in weight are then multiplied by the prescribed 2 mg.

33 lb/2.2 = 15 kg.

15 kg 2 mg = 30 mg.

PTS: 1 DIF: Cognitive Level: Application REF: 845

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

21. The nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the following assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense; Cry: no cry; Consolability: content, relaxed. The nurse records the FLACC assessment as ________. (Record your answer as a whole number.)

ANS:

2

The FLACC scale is recorded per the following table:

0

1

2

Face

No particular expression or smile

Occasional grimace or frown, withdrawn, disinterested

Frequent to constant frown, clenched jaw, quivering chin

Legs

Normal position or relaxed

Uneasy, restless, tense

Kicking or legs drawn up

Activity

Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid, or jerking

Cry

No cry (awake or asleep)

Moans or whimpers, occasional complaint

Crying steadily, screams or sobs, frequent complaints

Consolability

Content, relaxed

Reassured by occasional touching, hugging, or talking to; distractible

Difficult to console or comfort

PTS: 1 DIF: Cognitive Level: Application REF: 830

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MATCHING

A patient receiving an intravenous opioid analgesic has become apneic. Match the nursing interventions with the step numbers in order from the highest priority (first intervention) to the lowest priority (last intervention).

a.

Place the patient on continuous pulse oximetry to assess SaO2.

b.

Administer the prescribed naloxone (Narcan) dose by slow IV push.

c.

Ensure oxygen is available.

d.

Prepare to calm the child as analgesia is reversed.

22. Step 1

23. Step 2

24. Step 3

25. Step 4

22. ANS: B PTS: 1 DIF: Cognitive Level: Application

REF: 850 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The Narcan prescribed dose should be given first by slow IV push every 2 minutes until the effect is obtained. The second intervention should be assessment of the patients SaO2 status. Oxygen should be made available and administered if the SaO2 status indicates hypoxemia. Finally, the child should be calmed as the analgesia is reversed.

23. ANS: A PTS: 1 DIF: Cognitive Level: Application

REF: 850 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The Narcan prescribed dose should be given first by slow IV push every 2 minutes until the effect is obtained. The second intervention should be assessment of the patients SaO2 status. Oxygen should be made available and administered if the SaO2 status indicates hypoxemia. Finally, the child should be calmed as the analgesia is reversed.

24. ANS: C PTS: 1 DIF: Cognitive Level: Application

REF: 850 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The Narcan prescribed dose should be given first by slow IV push every 2 minutes until the effect is obtained. The second intervention should be assessment of the patients SaO2 status. Oxygen should be made available and administered if the SaO2 status indicates hypoxemia. Finally, the child should be calmed as the analgesia is reversed.

25. ANS: D PTS: 1 DIF: Cognitive Level: Application

REF: 850 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The Narcan prescribed dose should be given first by slow IV push every 2 minutes until the effect is obtained. The second intervention should be assessment of the patients SaO2 status. Oxygen should be made available and administered if the SaO2 status indicates hypoxemia. Finally, the child should be calmed as the analgesia is reversed.

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