Medical Surgical Nursing Patient Centered Collaborative Care, 7th Edition by Donna D. – Test Bank

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Chapter 5: Pain: The Fifth Vital Sign

Test Bank

MULTIPLE CHOICE

1.The nurse is caring for a client who was medicated for pain 1 hour ago. The client states that the medication is not working and the pain is still present. What is the first action that the nurse will take?

a.	Assess the client to determine a pain score.
b.	Believe the client’s report of pain.
c.	Wait until it is time for the next pain medication dose.
d.	Teach the client how to use guided imagery.

ANS: B

Health care providers often do not believe the client’s report of pain. The nurse’s primary role in pain management is to advocate for the client by believing reports of pain. It is important to remember that self-reporting is always the most reliable indication of pain. After the clinician believes that the client is in pain, the client can be assessed to obtain a pain score and can be taught nonpharmacologic methods of relieving pain. The nurse needs to take action to alleviate the pain and should not wait until the next medication dosage is due.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advocacy) MSC: Integrated Process: Nursing Process (Analysis)

2.When is the nurse correct in decreasing the dose of pain medication in a client with end-stage cancer?

a.	The spouse is worried that the client may become addicted.
b.	The client wants to remain alert during the visit of a long-time friend.
c.	The client has lost considerable weight and does not want to eat.
d.	The client is becoming combative at night.

ANS: B

The client has the right to choose whether to take the pain medication. The analgesic regimen should not interfere with the client’s sleep, rest, appetite, level of physical mobility, or driving ability. Close relationships are important in providing ongoing support for effective pain management intervention.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advocacy) MSC: Integrated Process: Nursing Process (Implementation)

3.A client with chronic pain is being discharged from the hospital. When planning the client’s pain relief regimen for home, it is most important for the nurse to communicate with which member of the health care team?

a.	Advanced practice nurse
b.	Home health care nurse
c.	Primary physician
d.	Psychologist

ANS: B

All members of the listed health care team are important. However, the home health care nurse will provide immediate home supervision and assistance to the client and family. The home health care nurse can refer to other health care team members as necessary. For the home health care nurse to carry out the role, it is essential that the acute care nurse communicate the client’s physical condition and support network, and any issues with pain management.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 62

TOP:Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team)

MSC: Integrated Process: Communication and Documentation

4.A client with arthritic pain is considering taking an herbal supplement to relieve arthritic pain. What teaching is most important for the nurse to carry out with this client?

a.	Inform any health care providers about the use of this supplement.
b.	Practice imagery along with taking the herbal supplement.
c.	Take only herbal supplements that are prescribed.
d.	Take herbal supplement at the onset of pain.

ANS: A

Always ask the client about the use of herbal supplements, because some can cause serious interactions with other pharmacologic agents. The other responses are not considered the most important.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications of Diagnostic Tests/Treatments/Procedures)

MSC:Integrated Process: Teaching/Learning

5.What instruction should the nurse include in the discharge teaching plan of a client who has a transcutaneous electrical nerve stimulation (TENS) unit?

a.	“Pain relief is sustained when stimulation is stopped.”
b.	“The current is adjusted by the physician.”
c.	“The electrodes are placed away from the painful site.”
d.	“You can perceive a pins and needles sensation.”

ANS: D

The TENS unit works through electrodes that are placed near the painful area site. These electrodes are connected to a small box that contains the current needed for pain relief. The current can be adjusted by any health care provider. Adjustment of this current can cause a pins and needles sensation. Pain relief with cutaneous therapy generally is sustained only as long as the stimulation continues.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 59

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:Integrated Process: Teaching/Learning

6.Why does the nurse always ask the client his or her pain level after taking routine vital signs?

a.	To determine whether pain is influencing blood pressure and heart rate
b.	To determine the need for more frequent vital sign measurement
c.	To ensure that pain assessment occurs on a regular basis
d.	To follow McCaffery’s guidelines on pain management

ANS: C

Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 46

TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment)

7.A client with cholecystitis has pain in the right shoulder area and asks, “What is happening to me? What did I do to my shoulder?” What is the nurse’s best response?

a.	“You are weak from staying in bed.”
b.	“Does your other arm hurt too?”
c.	“Sometimes pain from a certain organ is referred elsewhere in the body.”
d.	“I am going to hold your medication until we can determine what is happening.”

ANS: C

Many types of visceral pain can be felt in body areas other than the originating site. This is known as referred pain. Pain originating in the gallbladder can be referred to the right posterior shoulder. The client should be reassured that this is normal and should be medicated appropriately.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

8.The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem?

a.	Middle-aged woman with a fractured arm
b.	Client with expressive aphasia
c.	Younger adult with metastatic cancer
d.	Client who has undergone an appendectomy

ANS: B

Populations at highest risk for inadequate pain treatment include older adults, minorities, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advocacy) MSC: Integrated Process: Nursing Process (Assessment)

9.The physician orders a dose of medication that does not resolve the client’s chronic pain. When the nurse questions the order, the physician explains that he or she fears the client will develop an addiction with higher drug dosages. What is the nurse’s best response?

a.	Administer the medication as ordered.
b.	Assist the client to use guided imagery.
c.	Consult with the pain control specialist.
d.	Explain to the client that lower doses are better.

ANS: C

A health care provider may underprescribe medications for clients in pain for many reasons, such as regulatory scrutiny and cultural and societal attitudes. Undertreatment of pain is a serious problem in the United States and in the rest of the world. The nurse can act as an advocate for the client in pain by consulting with a pain care specialist.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Pharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Implementation)

10.A client who has been taking oxycodone (OxyContin) for an extended period of time comes to the clinic reporting that the drug is no longer relieving his pain. Which category would be given to the client’s complaint?

a.	Addiction
b.	Physical dependence
c.	Pseudoaddiction
d.	Tolerance

ANS: D

Tolerance is a state of the body’s adaptation to a drug so that it takes an increase in dosage to produce similar effects. This differs from addiction, which is characterized by compulsive craving for a medication, or physical dependence that manifests as the appearance of withdrawal symptoms when a drug is abruptly stopped or an antagonist is administered. Pseudoaddiction is the strong desire for a medication related to undertreatment of pain.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 44

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)

11.A home care client who is taking morphine for pain management abruptly stops taking the medication. Which symptom would indicate physical dependence?

a.	Abdominal cramping
b.	Craving for morphine
c.	Decreased heart rate
d.	Elevated temperature

ANS: A

Physiologic dependence on opioids such as morphine allows tissues to adapt to their presence. When opioids are suddenly removed, the dependent tissues stimulate an autonomic nervous system response that includes nausea and vomiting, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions.

DIF: Cognitive Level: Comprehension/Understanding REF: pp. 44-45

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

12.A home care client who is currently on hydromorphone (Dilaudid) for pain management presents to the hospital reporting abdominal cramping, nausea, and sweating. When taking the client’s history, the nurse asks which question first?

a.	“Are you currently in severe pain?”
b.	“Did you take more Dilaudid than prescribed?”
c.	“When did you take your last dose of Dilaudid?”
d.	“When was your last bowel movement?”

ANS: C

Physical dependence occurs in everyone who takes opioids over a period of time. Withdrawal syndrome occurs when the client abruptly stops taking the medication. Symptoms include abdominal cramping, nausea, sweating, delirium, and convulsions. Although the other distractors may be asked about as part of the admission assessment, they are not of priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

13.The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first?

a.	Administer blood pressure medication.
b.	Administer a drug to lower the heart rate.
c.	Assess whether the client needs anti-arthritis medication.
d.	Continue to assess for possible causes of elevated vital signs.

ANS: D

Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client’s high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation)

14.The nurse is caring for four clients who are reporting pain. Based on the following assessments and histories, which client’s pain is most likely chronic in nature?

a.	Foley catheter inserted 30 minutes ago with a heart rate of 100 beats/min
b.	History of heart disease with a heart rate of 120 beats/min
c.	History of fibromyalgia with a blood pressure of 110/70 mm Hg
d.	Hip replacement surgery with a blood pressure of 170/90 mm Hg

ANS: C

The definition of chronic pain involves the length of time the pain is experienced and/or the progressive nature of the problem causing the pain. Both heart disease and fibromyalgia could fit into this category. However, pain of a chronic nature does not call the sympathetic nervous system into play. Therefore, a rise in heart rate and blood pressure is not seen in a client who has chronic pain. The client with fibromyalgia who is having pain is not experiencing the increased blood pressure that would be seen with acute pain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

15.When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain?

a.	Anger and hostility
b.	Expressed hopelessness
c.	Inability to concentrate
d.	Psychosocial withdrawal

ANS: C

The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 41

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

16.The nurse anticipates that the client who rates pain as 10 on a scale of 1 to 10 has undergone which surgical procedure?

a.	Cranial surgery
b.	Leg surgery
c.	Neck surgery
d.	Upper abdominal surgery

ANS: D

In general, intrathoracic and upper intra-abdominal surgical approaches are associated with more severe pain. Muscle-splitting procedures generally are far more painful than muscle-stretching procedures.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 41

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

17.Which assessment finding is cause for concern in a client who has taken 4 grams of acetaminophen (Tylenol) to relieve back pain?

a.	Difficulty with urination
b.	Decreased respiratory rate
c.	Gastrointestinal bleeding
d.	Increased liver function tests

ANS: D

Tylenol has few anti-inflammatory properties. Therefore, it will not cause bleeding. Unlike nerve blocks and opioid drugs, it does not affect the respiratory rate or cause difficulty with urination. It can cause liver toxicity, especially in higher doses and taken more frequently than every 4 hours for long-term use.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Analysis)

18.During preoperative assessment, the client tells the nurse about taking NSAIDs for years. What question is most important for the nurse to ask?

a.	“Did you ever have a problem with bleeding?”
b.	“Do you bruise easily?”
c.	“How many tablets do you take every day?”
d.	“When was the last time you took your NSAID?

ANS: D

NSAIDs can prevent platelet aggregation; this results in a tendency toward bleeding. Before notifying the surgeon, the nurse should find out the last time the client took the medication and should check the chart to see whether there is a note that clarifies the surgeon’s awareness of the client’s use of this medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Assessment)

19.The client is taking an oxycodone-acetaminophen combination (Tylox) at home daily for chronic pain management. What instruction does the nurse give this client?

a.	“Avoid taking aspirin while you are on this medication.”
b.	“Drink plenty of water and eat foods high in fiber.”
c.	“Stop this medication after 3 days if the pain persists.”
d.	“Weigh yourself daily to determine whether you are retaining sodium or water.”

ANS: B

Opioid agonists, like oxycodone, act on systemic and neural opioid receptors and decrease gastrointestinal motility. Constipation is common and can be an aggravating problem. Fluids and foods high in fiber can prevent constipation. The other instructions would not be appropriate for this medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:Integrated Process: Teaching/Learning

20.The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse’s first action?

a.	Administering naloxone (Narcan) IV push
b.	Administering oxygen by nasal cannula
c.	Arousing the client by calling his or her name
d.	Documenting the findings and continuing to monitor

ANS: C

Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and the rate of respiration is increased spontaneously, no further intervention is required.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

21.The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take?

a.	Administer naloxone (Narcan).
b.	Administer oxygen.
c.	Assist with intubation.
d.	Monitor pain level.

ANS: A

A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client’s oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Planning)

22.A client is admitted to the hospital with a history of oxycodone (Percodan) abuse. For which clinical manifestations does the nurse observe the client?

a.	Anorexia and weight loss
b.	Decreased heart rate and respirations
c.	Muscle twitching and profuse perspiration
d.	Sedation and constipation

ANS: C

Physiologic dependence on opioids allows tissues to adapt to their presence. When opioids are suddenly removed, the dependent tissues stimulate an autonomic nervous system response that includes nausea and vomiting, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Chemical and Other Dependencies)

MSC: Integrated Process: Nursing Process (Assessment)

23.Which client would the nurse suggest should try subcutaneous opioid analgesia for pain management?

a.	Client who has had a surgical procedure
b.	Client with back pain who likes to walk
c.	Client with cancer who is nauseous
d.	Client experiencing acute chest pain

ANS: C

Subcutaneous opioid analgesia is recommended for cancer clients who cannot take anything by mouth. It is not recommended for acute pain, such as pain from a surgical procedure, because subcutaneous boluses have slower onset and a lower peak effect than IV boluses. It also requires the use of an ambulatory infusion pump, which may not always be acceptable to someone who is physically active.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Pharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Analysis)

24.A client with colon cancer is discharged to home with morphine for pain management. He is having episodes of nausea and vomiting. Which route of morphine administration would be most advantageous to use?

a.	Oral
b.	Rectal
c.	Intravenous
d.	Intramuscular

ANS: B

Rectal administration of opioids is recommended for clients who are NPO, nauseated, or at home. Oral agents are the preferred route of analgesia in many cases. However, because of his nausea and vomiting, this client does not have the functional GI system needed for good absorption of oral agents. Intramuscular agents are not recommended for cancer pain. Intravenous agents are recommended when oral and rectal routes fail to provide pain control.

DIF: Cognitive Level: Comprehension/Understanding REF: Table 5-7, p. 55

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Pharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Assessment)

25.The nurse is caring for four clients. Which client assessment is the most indicative of having pain?

a.	Blood pressure 150/70 mm Hg and sleeping
b.	Client stating that he is “anxious”
c.	Heart rate of 105 beats/min and restlessness
d.	Postoperative client with a neck incision

ANS: C

At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

26.A client has a history of alcohol abuse. Which pain relief regimen does the nurse anticipate if morphine (MS Contin) is given for pain?

a.	A higher dose of opioids will be needed to provide effective pain relief.
b.	A lower dose of opioids will be needed to provide effective pain relief.
c.	The appropriate drug selection is an opioid agonist-antagonist combination.
d.	The client will receive no pain relief from the morphine.

ANS: A

People who drink significant amounts of alcohol daily have elevated liver enzyme activity that degrades morphine and morphine agonists. As a result, these clients frequently have tolerance for opioid analgesics and require higher doses of agonists to achieve an acceptable level of pain relief during acute pain episodes.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Analysis)

27.Which instruction is the most accurate for the nurse to give a client who has a patient-controlled analgesia device (PCA) after abdominal surgery?

a.	“Instruct your visitors to press the button for you when you are sleeping.”
b.	“Push the button every 15 minutes whether you feel pain at that time or not.”
c.	“Push the button when you first feel pain instead of waiting until pain is severe.”
d.	“Try to go as long as you possibly can before you press the button.”

ANS: C

Clients should be instructed to push the button to release medication when the pain begins rather than waiting until the pain becomes so great that the dose given by the pump cannot control the pain. No one should push the button for the client. Clients should not be instructed to bear the pain as long as possible before using PCA.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 54

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Pharmacological Pain Management)

MSC:Integrated Process: Teaching/Learning

28.The nurse assesses several postoperative clients receiving patient-controlled epidural analgesia (PCEA). Which client does the nurse prioritize to assess first?

a.	Client receiving bupivacaine (Marcaine) describing “inability to move legs”
b.	Client receiving fentanyl (Sublimaze) describing “itchy arms”
c.	Client receiving hydromorphone (Dilaudid) describing “full feeling”
d.	Client receiving morphine describing “difficulty staying awake”

ANS: A

Epidural analgesia can cause sensory and motor deficits. The inability to move the legs could mean that the client is receiving too high a dose of the drug or that damage has been done to the spinal cord. This requires immediate intervention. Itchy arms, a full feeling, and difficulty staying awake could be side effects of the medications, but they are not matters of priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Pharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Planning)

29.A client has epidural analgesia with bupivacaine (Marcaine) for pain relief. For which condition should the nurse assess this client?

a.	Extremity itching
b.	Inability to raise legs off the bed
c.	Nausea and vomiting
d.	Respiratory rate of 8 breaths/min

ANS: B

Lower motor weakness is more common when an epidural local anesthetic (such as bupivacaine) is used. The other three problems are seen more often when opioids are used.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Pharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Planning)

30.When assessing a client who is taking long-term ibuprofen (Motrin) for pain, the nurse finds numerous areas of bruising. What is the nurse’s first action?

a.	Assess for gastric discomfort.
b.	Assess for the presence of pain.
c.	Continue to monitor bruising.
d.	Place client on falls precaution.

ANS: A

NSAIDs can cause gastrointestinal disturbances and can prevent platelet aggregation, which results in GI bleeding. Therefore, clients should be observed for gastric discomfort or vomiting and bleeding.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Reactions/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Evaluation)

31.Which statement made by a nurse represents the need for further education regarding pain management in older adult clients?

a.	“Older adults are at greatest risk for undertreated pain.”
b.	“Older adults tend to report pain less often than younger adults.”
c.	“Older clients usually have more experience with pain than younger clients.”
d.	“Older clients have a different pain mechanism and do not feel it as much.”

ANS: D

There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients. The other statements are accurate regarding older clients and pain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Adaptation (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Teaching/Learning

32.Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting?

a.	Cutaneous skin stimulation
b.	Hypnosis
c.	Imagery
d.	Radiofrequency ablation

ANS: C

Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client’s capacity for imagery include being able to listen to music or other auditory stimuli.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP:Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC: Integrated Process: Nursing Process (Assessment)

33.A client who is at the end of life is being given morphine for pain management. The family expresses concern that the morphine may cause the client to stop breathing and die. What is the nurse’s best response?

a.	“He needs the morphine to prevent pain.”
b.	“His respirations are not affected by the morphine.”
c.	“We will decrease the dose if his breathing slows.”
d.	“We will give him oxygen to help with his breathing.”

ANS: B

Because clients become tolerant to the respiratory effects of an opioid, it does not hasten death unless the dose was not properly and gradually titrated. Decreasing the drug would cause pain to occur, and oxygen will not help with his rate of respirations.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Reactions/Contraindications/Interactions/Side Effects)

MSC:Integrated Process: Teaching/Learning

34.A client is stating that he has the sensation of burning, aching, and dullness. Which afferent nerve fibers should be transmitting the pain?

a.	A delta fibers
b.	C fibers
c.	A alpha fibers
d.	A beta fibers

ANS: B

The sensation of burning, aching, and dullness is transmitted by the C fibers in contrast to the A delta fibers, which carry rapid, sharp, pricking, or piercing sensations. A alpha and A beta fibers are large-diameter fibers that may close the gate and decrease pain.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 43

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

35.A client is postoperative day one and has a patient-controlled analgesia (PCA) pump with a continuous basal dose for pain control. Currently, the client is stating that the operative pain is escalating. What is the first action of the nurse?

a.	Try diversion to take the client’s mind off the pain.
b.	Ask the client to ambulate around the unit.
c.	Assess the client’s pain according to PQRST.
d.	Call the physician to request an order to increase the basal dose.

ANS: C

Assessment is the first step in the nursing process. The nurse will need the information gleaned from the assessment using PQRST (factors precipitating the pain, quality of the pain, region and radiation of the pain, severity of the pain, and timing of the pain) to request a change in medication order. Diversion and ambulation can be used in client care but will not control escalating pain in the postoperative client.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Assessment)

36.Which client does the nurse assess first for pain control?

a.	Older client with chronic rheumatoid arthritis
b.	Client postoperative day three walking in the hallway
c.	Sleeping client with an epidural pump
d.	Quiet client with pancreatic cancer curled up in bed

ANS: D

The pain of pancreatic cancer is usually severe. This client should be assessed first because the client’s present behavior may indicate suffering and pain. The client with arthritis has had this condition for a while and may not be experiencing severe pain. The client who is walking in the hallway and the client who is sleeping do not demonstrate nonverbal pain behaviors.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1.Which is most indicative of pain in an older client who is confused? (Select all that apply.)

a.	Decreased blood pressure
b.	Screaming
c.	Facial grimace
d.	Restlessness
e.	Crying
f.	Decreased respirations

ANS: B, C, D, E

No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 49

TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC: Integrated Process: Nursing Process (Assessment)

2.An older client just returned from surgery and is rating pain as “8” on a 0 to 10 scale. Which medications are unsafe choices for treatment of severe pain in this older adult?

a.	Meperidine (Demerol)
b.	Methadone (Dolophine)
c.	Propoxyphene (Darvocet)
d.	Morphine (Durmorph)
e.	Codeine

ANS: A, B, C, E

Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the gold standard and may be used in the older adult while monitoring for sedation and respiratory depression is conducted.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 5-1, p. 45

TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Pharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Planning)