Chapter 04: Assessment and Care of Patients with Pain

Question 1

A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?

Answer 1

Clients self-report

Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations

Question 2

A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best?

Answer 2

Being able to sleep doesnt mean pain doesnt exist.

A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the clients descriptions, especially if the pain is chronic in nature.

Question 3

The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the clients long-term outcome?

Answer 3

Discuss acceptable pain control after your operation with the surgeon.

The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself and discuss acceptable pain control with the surgeon.

Question 4

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment?

Answer 4

FACES Pain Scale-Revised

All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.

Question 5

The nurse is assessing a clients pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment?

Answer 5

What pain rating would be acceptable to you?

A comprehensive pain assessment includes the items listed in the question plus the clients opinion on a functional goal, such as what pain rating would be acceptable to him or her.

Question 6

A nurse is assessing pain in an older adult. What action by the nurse is best?

Answer 6

Sit down, ask one question at a time, and allow the client to answer.

Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability.

Question 7

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is on the light constantly asking for more pain medication. When assessing this clients pain, what statement or question by the nurse is most appropriate?

Answer 7

Help me understand how pain is affecting you right now.

. Help me understand how pain is affecting you right now.

Question 8

A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?

Answer 8

Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale

Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first.

Question 9

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?

Answer 9

Assess physiologic indicators and vital signs.

Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this
population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the
presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be
holding very still to prevent more pain.

Question 10

A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best?

Answer 10

Pain is so complex it takes different approaches to control it.

Question 11

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the clients care plan?

Answer 11

Round-the-clock analgesia with PRN analgesics

Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication.

Question 12

A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?

Answer 12

Client with a respiratory rate of 8 breaths/min

Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client.

Question 13

A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?

Answer 13

Presses the button when the client cannot reach it

The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client.

Question 14

A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the clients health history would lead the nurse to consult with the provider over the choice of medication?

Answer 14

Drinking 3 to 5 beers a day

The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen.
The nurse should relay this information to the provider.

Question 15

A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider?

Answer 15

Urine output of 20 mL/2 hr

Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug

Question 16

A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?

Answer 16

Remove the old patch when applying the new one.

The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur.

Question 17

A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed.

Answer 17

Hydromorphone (Dilaudid)

Hydromorphone is a good alternative to morphine for moderate to severe pain

Question 18

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The clients oxygen saturation is 87%. What action should the nurse perform first?

Answer 18

Attempt to arouse the client

The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation.

Question 19

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication
would the nurse plan to educate the client?

Answer 19

Duloxetine (Cymbalta)

Antidepressants and anticonvulsants often are used for neuropathic pain relief

Question 20

An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control methodologies as an adjunct to medication. Which strategy would be most successful with this client population?

Answer 20

Listening to music on a headset

Listening to music on a headset would be the most successful cognitive-behavioral pain control method for several reasons.

Question 21

An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important?

Answer 21

Request a home safety assessment.

All these activities are appropriate when discharging a client whose needs will continue after discharge.

Question 22

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should
the nurse see first?

Answer 22

Client with a Pasero Scale score of 4

The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency.

Question 23

A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?

Answer 23

Have another nurse double-check the pump settings.

PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be doublechecked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent

Question 24

A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?

Answer 24

Ask the client about pain goals and if they are being met.

A comprehensive pain management plan includes the clients goals for pain control. Adequate pain control is necessary to allow full participation in therapy. The first thing the nurse should do is to ask about the clients pain goals and if they are being met.

Question 25

A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client?

Answer 25

Check any over-the-counter medications for acetaminophen

All instructions are appropriate for this client. However, advising the client to check over-the-counter
medications for acetaminophen is an important safety measure. Acetaminophen is often found in common over-the-counter medications and should be limited to 3000 mg/day.

Question 26

A faculty member explains to students the process by which pain is perceived by the client. Which processes does the faculty member include in the discussion? (Select all that apply.)

Answer 26

Modulation
Sensory perception
Transduction
Transmission

The four processes involved in making pain a conscious experience are modulation, sensory perception,
transduction, and transmission

Question 27

A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which information is accurate? (Select all that apply.)

Answer 27

Addiction is a chronic physiologic disease process
Tolerance is a normal response to regular opioid use.
Tolerance is said to occur when opioid effects decrease
Physical dependence occurs after repeated doses of an opioid.

Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependencetherapeutic effect or side effects).

Question 28

A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Answer 28

Perform a bladder scan if the client is unable to void after 4 hours.
Remind the client to use the incentive spirometer every hour.
Take and record the clients vital signs per agency protocol.

The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and should ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.

Question 29

A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. What actions by the nurse are most appropriate? (Select all that apply.)

Answer 29

Educate the client on cold therapy.
Repeat the ice application.
Teach the client relaxation techniques.

Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse should focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them.

Question 30

A student nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.)

Answer 30

Decreased immune response
Development of chronic pain
Possible immobility
Slower healing
Negative quality of life

There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart
rate, blood pressure, and oxygen demand.

Question 31

A nursing student is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.)

Answer 31

Neuropathic pain sometimes accompanies amputation.
Deep somatic pain is pain arising from bone and connective tissues.
Somatic pain originates from skin and subcutaneous tissues.
Visceral pain is often diffuse and poorly localized.

Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

Question 32

A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.)

Answer 32

Avoid using other medications that cause sedation.
Give the lowest dose that produces good control.
Identify clients at high risk for unwanted sedation.
Use an oximeter to monitor clients receiving analgesia

Question 33

A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. What actions by the nurse are most appropriate?
(Select all that apply.)

Answer 33

Consult with the prescriber and voice objections.
Notify the nurse manager of the physicians request.

Nurses should never give placebos to treat a clients pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse should voice concerns with the prescriber and, if needed, contact the nurse manager.