Chapter 1: Pain Flashcards
Which postoperative client is manifesting the most serious negative effect of inadequate pain management?
- Demonstrates continuous use of call bell related to unsatisfied needs and discomfort
- Develops venous thromboembolism related to immobility caused by pain and discomfort
- Refuses to participate in physical therapy because of fear of pain caused by exercises
- Feels depressed about loss of function and hopeless about getting relief from pain
Ans: 2
Inadequate pain management for postsurgical clients can affect quality of life, function, recovery, and postsurgical complication; thus, all the manifestations are examples of negative results. However, venous thromboembolism can lead to pulmonary embolism, and this is an immediate life-threatening concern. The nurse also needs to implement interventions to resolve unsatisfied needs, fear of pain, and hopelessness related to pain and function. Focus: Prioritization; Test Taking Tip: Use Maslow’s hierarchy to identify priorities in caring for clients. Physiologic needs are the first concern. In this case, venous thromboembolism is the most serious physiologic outcome secondary to inadequate pain management.
A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse’s initial action?
- Check the medication administration records for the past several days.
- Ask the nurse educator to provide in-service training about pain management.
- Perform a complete pain assessment on the client and take a pain history.
- Have a conference with the staff nurses to assess their care of this client.
Ans: 4
The charge nurse must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Focus: Supervision, Prioritization; Test Taking Tip: The first step of nursing process is assessment. In this case, the charge nurse applies nursing process to assess the nursing staff’s performance and attitudes.
According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical clients? Select all that apply.
- Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications
- Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures
- Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus
- Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies
- Long-acting oral opioids, especially in the immediate postoperative period, for continuous around-the-clock relief
- Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, or ketamine is recommended for postoperative pain
Ans: 1, 2, 3, 4
The American Pain Society in collaboration with the American Society of Anesthesiologists recommendations for postoperative clients include: acetaminophen and/or NSAIDs if there are no contraindications; surgical site-specific peripheral regional anesthetic for procedures; neuraxial analgesia (also known as epidural) for major thoracic and abdominal procedures, if client has risk for cardiac complications or prolonged ileus; and multimodal therapy, which includes use of different types of medications and other therapies. Long-acting oral opioids are not recommended in the postoperative period. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine is not recommended. Focus: Prioritization; Test Taking Tip: Passing a test and working as a competent nurse requires keeping up to date with current practice guidelines. Select all that apply questions are particularly challenging. Read each option carefully and try to exclude incorrect options.
The home health nurse is interviewing an older client with a history of mild heart failure and rheumatoid arthritis. The client reports “feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed.” Which member of the health care team would be the most appropriate to aid in the client’s report of pain?
- Health care provider to review the dosage and frequency of pain medication
- Physical therapist for evaluation of function and possible exercise therapy
- Social worker to locate community resources for complementary therapy
- Unlicensed assistive personnel to help client with a warm shower in the morning
Ans: 4
One of the common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A nonpharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions. Focus: Delegation.
Family members are encouraging the client to “tough out the pain” rather than risk drug addiction to opioids. The client is stoically abiding. The nurse recognizes that the sociocultural dimension of pain is the current priority for the client. Which question will the nurse ask?
- “Where is the pain located, and does it radiate to other parts of your body?”
- “How would you describe the pain, and how is it affecting you?”
- “What do you believe about pain medication and drug addiction?”
- “How is the pain affecting your activity level and your ability to function?”
Ans: 3
Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization.
A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will the nurse advocate for first?
- Gabapentin
- Corticosteroids
- Hydromorphone
- Lorazepam
Ans: 1
Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be prescribed as an adjuvant medication. Focus: Prioritization.
Which client is most likely to receive opioids for extended periods of time?
- A client with fibromyalgia
- A client with phantom limb pain in the leg
- A client with progressive pancreatic cancer
- A client with trigeminal neuralgia
Ans: 3
Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine. Phantom limb pain usually subsides after ambulation begins. Focus: Prioritization.
The nurse is caring for a postoperative client who reports pain. Based on recent evidence-based guidelines, which approach would be best?
- Multimodal strategies
- Standing orders by protocol
- Intravenous patient-controlled analgesia (PCA)
- Opioid dosage based on valid numerical scale
Ans: 1
Multimodal therapies for postoperative clients include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies. This approach is thought to be the most important strategy for pain management for most postoperative clients. Standing orders are less optimal because there is no consideration of individual needs or characteristics. PCA is one important element, but not all clients can manage PCA devices. Assessment tools are an important part of overall management, but basing opioid dose on a numerical scale does not consider individual client circumstances. Focus: Prioritization.
The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first?
1. Make a note in the nurse’s file and continue to observe clinical
performance.
- Refer the new nurse to the in-service education department.
- Quiz the nurse about knowledge of pain management and pharmacology.
- Give praise for documenting dose and time and discuss documentation deficits.
Ans: 4
In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists. Focus: Supervision.
Which clients must be assigned to an experienced RN? Select all that apply.
- Client who was in an automobile crash and sustained multiple injuries
- Client with chronic back pain related to a workplace injury
- Client who has returned from surgery and has a chest tube in place
- Client with abdominal cramps related to food poisoning
- Client with a severe headache of unknown origin
- Client with chest pain who has a history of arteriosclerosis
Ans: 1, 3, 5, 6
These clients should be assigned to an experienced RN because all have acute conditions that require close monitoring for any developing complications. Abdominal cramps secondary to food poisoning is an acute condition; however, the cramping, vomiting and diarrhea are usually self- limiting. The client with chronic back pain would be considered physically stable. Although all clients will benefit from care provided by an experienced RN, the client with abdominal cramps and the client with back pain could be assigned to a new RN, an LPN/LVN, or a float nurse. Focus: Assignment; Test Taking Tip: To determine acuity of clients, use nursing concepts, such as gas exchange and perfusion. Clients 1, 3, 5, and 6 could have potential problems related to perfusion. The client with the chest tube could also have a potential problem related to gas exchange.
In application of the principles of pain treatment, what is the first consideration?
- Treatment is based on client goals.
- A multidisciplinary approach is needed.
- Client’s perception of pain must be accepted.
- Drug side effects must be prevented and managed.
Ans: 3
The client must be believed, and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to the other options in developing the treatment plan. Focus:Prioritization.
The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern?
- A 35-year-old opioid-naïve adult will receive a basal dose of morphine via IV patient-controlled analgesia (PCA).
- A 65-year-old adult will be discharged with a prescription for nonsteroidal anti-inflammatory drugs (NSAIDS).
- A 25-year-old adult is prescribed as needed intramuscular (IM) analgesic for pain.
- A 45-year-old adult is taking oral fluids and foods has orders for IV morphine.
Ans: 1
The nurse would consider questioning all of the medication prescriptions, but the opioid-naïve adult has the greatest immediate risk, because use of a basal dose has been associated with an increased incidence of respiratory depression in opioid-naïve clients. Older adults are frequently prescribed NSAIDS; however, they are used with caution, and the client’s history should be reviewed for potential problems, such as a history of gastrointestinal bleeding, cardiac disease, or renal dysfunction. Many medications such as anticoagulants, oral hypoglycemics, diuretics, and antihypertensives can also cause adverse drug–drug interactions with NSAIDs. IM injections cause pain, absorption is unreliable, and there are no advantages over other routes of administration routes. If a client is able to tolerate oral foods and fluids, oral medications are preferred because the efficacy of the oral route is equal to the IV route. Focus: Prioritization; Test Taking Tip: It is worthwhile to study the purposes, pharmacologic actions, and side effects of commonly used medications. Morphine is considered the prototype of the opioid medications. For opioid-naïve clients, the priority concern is respiratory depression. For clients who need opioids for long-term pain management, the primary side effect is constipation.
Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration?
- Client who has sharp chest pain that increases with cough and shortness of breath
- Client who reports excruciating lower back pain with hematuria
- Client who is having an acute myocardial infarction with severe chest pain
- Client who is having a severe migraine with an elevated blood pressure
Ans: 3
The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain and increase venous capacitance. The other clients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent. Focus: Prioritization.
When an analgesic is titrated to manage pain, what is the priority goal?
1. Titrate to the smallest dose that provides relief with the fewest side effects.
- Titrate upward until the client is pain free or acceptable level is reached.
- Titrate downward to prevent toxicity, overdose, and adverse effects.
- Titrate to a dosage that is adequate to meet the client’s subjective needs.
Ans: 1
The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside. Focus:Prioritization.
The health care provider prescribes 7 mg morphine IV as needed (PRN). The nursing student prepares the medication and shows the syringe (see figures below) to the nursing instructor. What should the nursing instructor do first?
- Tell the student to review the provider’s prescription before administering medication.
- Waste the medication and tell the student that remediation is required for serious error.
- Ask the student to demonstrate the calculations and steps required to prepare the dose.
- Accompany the student to the client’s room and observe as the medication is administered.
Ans: 3 (10/7 = 0.7mL)
The student has made an error and the syringe, as shown, contains 70 mg. The syringe contains 7 mL of medication. The student should have obtained a tuberculin syringe and drawn up 0.7 mL. First, the nursing instructor would assess the student’s knowledge and understanding of the calculations and method of preparing the medication. The instructor would use this approach to help the student self-identify errors, which might include misinterpreting the original prescription, misreading the label, or misreading the syringe markings. Focus:Prioritization, Supervision.
A client received as needed (PRN) morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel (UAP) reports that the client has a respiratory rate of 10 breaths/min. What is the priority action?
- Call the health care provider to obtain an order for naloxone.
- Assess the client’s responsiveness and respiratory status.
- Obtain a bag-valve mask and deliver breaths at 20 breaths/min.
- Double-check the prescription to see which drugs were ordered.
Ans: 2
The UAP has correctly reported findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on assessment findings, the other options may also be appropriate. Focus:Prioritization.
The client is diagnosed by the emergency department health care provider (HCP) with an acute migraine. For which situation is it most important to have a discussion with the HCP before medication is prescribed?
- The HCP is considering dexamethasone to prevent reoccurrence, and the client has type 2 diabetes.
- The HCP is considering subcutaneous sumatriptan, and the client took ergotamine 3 hours ago.
- The HCP is considering metoclopramide, and this is a first-time migraine for the client.
- The HCP is considering prochlorperazine, and the client drove himself to the hospital.
Ans: 2
The American Headache Society developed recent guidelines for treatment of acute migraines. Intravenous metoclopramide and prochlorperazine and subcutaneous sumatriptan are recommended for adults who present with first-time onset of acute migraines. Sumatriptan should not be used if ergotamine, dihydroergotamine, or other triptan medication has been used in the past 24 hours because of the additive effect of narrowing of the blood vessels that could result in damage to major organs (e.g., stroke or myocardial infarction). Dexamethasone may cause increased glucose levels. Prochlorperazine can cause drowsiness. Focus: Prioritization.