Chapter 9: Pain Management

Question 1

1. The nurse, who is a member of the palliative care team, is assessing a client. The client
   reports saving client-controlled analgesics (PCA) until the pain is intense because pain
   control has been inadequate. What client education should the nurse give this client?
   A. Medication should be taken when pain levels are low so the pain is easier to
   reduce.
   B. Pain medication can be increased when the pain becomes intense.
   C. It is difficult to control chronic pain, so this is an inevitable part of the disease
   process.
   D. The client will likely benefit more from distraction than pharmacologic
   interventions.

Answer 1

ANS: A
Rationale: Better pain control can be achieved with a preventive approach, reducing the amount of time clients are in pain. Low levels of pain are easier to reduce or control than intense levels of pain. Pain medication is used to prevent pain so pain medication is not increased when pain becomes intense. Chronic pain is treatable. Giving the client alternative methods to control pain is good, but it will not work if the client is in so much pain that they cannot implement reliable alternative methods.

Question 2

2. Two clients have recently returned to the postsurgical unit after knee arthroplasty. One
   client is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other client is
   reporting a pain level of 3 to 4 on the same pain scale. What is the nurse’s most plausible
   rationale for understanding the clients’ different perceptions of pain?
   A. Awareness and emotions affect the perception of pain.
   B. One of the clients is exaggerating the sense of pain.
   C. The clients are likely experiencing a variance in vasoconstriction.
   D. One of the clients may be experiencing opioid tolerance.

Answer 2

ANS: A
Rationale: Different people feel different degrees of pain from similar stimuli due to the effects of awareness and emotions, which vary from person to person. The nurse should not assume the client is exaggerating the pain, because clients are the best authority on their pain, and definitions for pain state that pain is “whatever the person says it is, existing whenever the experiencing person says it does.” Variances in vasoconstriction do not affect pain perception. Opioid tolerance is associated with chronic pain treatment and would not likely apply to these clients.

Question 3

3. The nurse is caring for a 71-year-old client who experienced a humeral fracture in a
   fall. The client is receiving an opioid for pain control. Which principle of pain management
   for an older adult should the nurse apply?
   A. Monitor for signs of drug toxicity.
   B. Assess for an increase in absorption of the drug.
   C. Monitor for a paradoxical increase in pain.
   D. Administer higher doses of opioids to relieve pain.

Answer 3

ANS: A
Rationale: Because older adults have an increased sensitivity to co-analgesic agents and more comorbidities compared with younger people, the nurse should monitor for drug
toxicity. Absorption of drugs is not increased in older adults, nor is there a paradoxical increase in pain. Higher doses of opioids should not be administered to older adults; rather, the dose should be reduced because they are more likely to have adverse effects.

Question 4

4. The nurse is assessing a client’s pain while the client awaits a cholecystectomy. The
   client is tearful, hesitant to move, and grimacing, but reports feeling pain as a 2 at this
   time on a 0-to-10 pain scale. How should the nurse best respond to this assessment
   finding?
   A. Remind the client that they are indeed experiencing pain.
   B. Reinforce education about the pain scale number system.
   C. Reassess the client’s pain in 30 minutes.
   D. Administer an analgesic and then reassess.

Answer 4

ANS: B
Rationale: The client’s numerical pain rating (2) does not match the physical signs of pain they are exhibiting. The nurse may need to provide further client education so the client can correctly rate the pain. The nurse may also need to verify that the same scale is being used by the client and caregiver, to promote continuity. Although all answers are correct, the best initial approach would be to reinforce education about the pain scale.

Question 5

5. The nurse is creating a nursing care plan for a client with a primary diagnosis of
   cellulitis and a secondary diagnosis of chronic pain. What common trait of clients who live
   with chronic pain should be integrated into care planning?
   A. They are typically more comfortable with underlying pain than clients without
   chronic pain.
   B. They often have a lower pain threshold than clients without chronic pain.
   C. They often have an increased tolerance of pain.
   D. They can experience acute pain in addition to chronic pain.

Answer 5

ANS: D
Rationale: It is tempting to expect that people who have had multiple or prolonged experiences with pain will be less anxious and more tolerant of pain than those who have
had little experience with pain. However, this is not true for many people. The more experience a person has had with pain, the more frightened they may be about subsequent painful events. Chronic pain and acute pain are not mutually exclusive. These clients may not have a different pain threshold or tolerance to pain.

Question 6

6. A client with osteoarthritis of the hip for a number of years reports a dull, aching pain
   with ambulation and pain shooting down the leg at night while sleeping. The nurse
   recognizes that the client is experiencing which type of pain?
   A. Acute pain
   B. Breakthrough pain
   C. Chronic pain
   D. Neuropathic pain

Answer 6

ANS: C
Rationale: The pain from osteoarthritis is a chronic pain that persists over a period of time due to the degeneration of the hip joint. Acute pain has a shorter duration and resolves
with healing. Breakthrough pain is a temporary increase in controlled persistent pain. Neuropathic or pathophysiologic pain is caused by injury to a nerve with impaired
processing of sensory input.

Question 7

7. A client has just returned from the postanesthesia care unit (PACU) following left tibia
   open reduction internal fixation. The client is reporting pain, and the nurse is preparing to
   administer intravenous hydromorphone. Prior to administering the drug, the nurse
   should prioritize which assessment?
   A. Electrolyte levels
   B. Heart rate
   C. Respiratory status
   D. Hydration

Answer 7

ANS: C
Rationale: Before administering an opioid, the nurse should assess the client’s respiratory rate and depth of respirations because opioids can cause respiratory depression, especially coupled with the effects of anesthesia. The nurse should also monitor electrolyte levels, heart rate, and hydration, but respiratory rate and depth are the priority assessment.

Question 8

8. A client is receiving postoperative morphine through a client-controlled analgesia
   (PCA) pump and the client’s prescriptions specify an initial bolus dose. What is the nurse’s
   priority assessment?
   A. Assessment for decreased level of consciousness (LOC)
   B. Assessment for respiratory depression
   C. Assessment for fluid overload
   D. Assessment for paradoxical increase in pain

Answer 8

ANS: B
Rationale: A client who receives opioids by any route must be assessed frequently for changes in respiratory status. Sedation is an expected effect of a narcotic analgesic,
though severely decreased LOC is problematic. Fluid overload and paradoxical increase in pain are unlikely, though opioid-induced hyperalgesia (OIH) occurs in rare instances.

Question 9

9. A client is asking for a breakthrough dose of analgesia. The pain-medication
   prescriptions are written as a combination of an opioid analgesic and a nonsteroidal
   anti-inflammatory drug (NSAID) given together. What is the primary rationale for
   administering pain medication in this manner?
   A. To prevent respiratory depression
   B. To eliminate the need for additional medication during the night
   C. To achieve better pain control than with one medication alone
   D. To eliminate the potentially adverse effects of the opioid

Answer 9

ANS: C
Rationale: A multimodal regimen combines drugs with different underlying mechanisms, which allows better pain control than with one medication alone. This, in turn, allows for lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects. This method also reduces, but does not eliminate, adverse
effects of the opioid. This regimen is not motivated by the need to prevent respiratory depression or to eliminate nighttime dosing.

Question 10

10. The nurse is caring for a client with metastatic bone cancer. The client asks the nurse,
    “Why am I getting larger doses of this pain medication? It does not seem to be affecting
    me.” What is the nurse’s best response?
    A. “Over time you become more tolerant of the drug.”
    B. “You may have become immune to the effects of the drug.”
    C. “You may be developing a mild addiction to the drug.”
    D. “Your body absorbs less of the drug due to the cancer.”

Answer 10

ANS: A
Rationale: Over time, the client is likely to become more tolerant of the dosage. Little evidence indicates that clients with cancer become addicted to the opioid medications.
Clients do not become immune to the effects of the drug, and the body does not absorb less of the drug because of the cancer.

Question 11

11. A client is receiving care on the oncology unit for breast cancer that has metastasized
    to the lungs and liver. When addressing the client’s pain in the plan of nursing care, the
    nurse should consider which characteristic of cancer pain?
    A. Cancer pain is often related to the stress of the client knowing they have cancer
    and requires relatively low doses of pain medications along with a high dose of
    anti-anxiety medications.
    B. Cancer pain is always chronic and challenging to treat, so distraction is often the
    best intervention.
    C. Cancer pain can be acute or chronic and typically requires comparatively high
    doses of pain medications.
    D. Cancer pain is often misreported by clients because of confusion related to their
    disease process.

Answer 11

ANS: C
Rationale: Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that when cancer clients are asked about possible outcomes, pain is reported to be the most feared outcome. Higher doses of pain medication are usually needed with cancer clients, especially with metastasis. Cancer pain is not treated with anti-anxiety medications. Cancer pain can be chronic and difficult to treat so distraction may help, but higher doses of pain medications are usually the best intervention. No research indicates cancer clients misreport pain because of confusion related to their disease process.

Question 12

12. The nurse is admitting a client with an abdominal tumor who is experiencing
    increasing unrelieved pain over the last three days despite taking opioids, as prescribed.
    Which sign—a manifestation of unrelieved pain—should the nurse expect to assess in this
    client?
    A. Hyperglycemia
    B. Bradycardia
    C. Hyperactive bowel sounds
    D. Poor skin turgor

Answer 12

ANS: A
Rationale: Unrelieved pain produces harmful effects on many body systems. Reduced insulin secretion can cause elevated blood glucose levels. Tachycardia (not bradycardia)
may occur with the increased release of catecholamines. Decreased gastric and bowel motility would occur, resulting in hypoactive (not hyperactive) bowel sounds. With
increased secretion of antidiuretic hormone, fluid volume overload can occur. Poor skin turgor is a sign of fluid volume deficit, or dehydration.

Question 13

13. The nurse in a pain clinic is caring for a client who has long-term, intractable pain. The
    pain team feels that first-line pharmacologic methods of pain relief have been ineffective.
    Which recommendation should guide this client’s subsequent care?
    A. The client may benefit from new alternative pain management options that are
    available in other countries.
    B. The client may benefit from a multimodal approach to pain management.
    C. The client may need to increase exercise and activity levels significantly to
    create distractions.
    D. The client may need to relocate to long-term care to have activities of daily living
    needs met.

Answer 13

ANS: B
Rationale: In some situations, especially with long-term severe intractable pain, pharmacologic methods of pain relief alone are ineffective. In those situations, a
multimodal approach to pain management, including nonpharmacologic interventions, may be considered. Investigating new alternative pain-management options that are available abroad is unrealistic and may even be dangerous advice. Increasing exercise and activities to create distractions is unrealistic when a client is in intractable pain, and this recommendation conveys the attitude that the pain is not real. Moving to a long-term care facility so others may care for the client does not address the issue of pain.

Question 14

14. The home health nurse is caring for a homebound client who is terminally ill and is
    delivering a client-controlled analgesia (PCA) pump at today’s visit. The family members
    will be taking care of the client. What would the nurse’s priority interventions be for this
    visit?
    A. Teach the family the theory of pain management and the use of alternative
    therapies.
    B. Provide psychosocial family support during this emotional experience.
    C. Provide client and family teaching regarding the operation of the pump,
    monitoring the IV site, and knowing the side effects of the medication.
    D. Provide family teaching regarding use of morphine, recognizing morphine
    overdose, and offering spiritual guidance.

Answer 14

ANS: C
Rationale: If PCA is to be used in the client’s home, the client and family are taught about the operation of the pump as well as the side effects of the medication and strategies to
manage them. The family would also need to monitor the IV site and notify the nurse of any changes, such as infiltration, that could endanger the client. Teaching the family the
theory of pain management or the use of alternative therapies and the nurse providing emotional support are important, but the family must be able to operate the pump as well as know the side effects of the medication and strategies to manage them. Offering spiritual guidance would not be a priority at this point and morphine is not the only medication given by PCA.

Question 15

15. A client with cancer expresses concern to the nurse that increasingly higher doses of
    opioids are needed to control pain and the client is concerned about opioid overdose and
    addiction. Which concept of pain management should guide the nurse’s response to this
    client?
    A. Addiction occurs when higher doses are needed to control pain.
    B. The need for increasing doses of opioids to control pain is a sign of substance use
    disorder (SUD).
    C. Opioid-induced hyperalgesia results in the need for increasing doses of opioids.
    D. Tolerance develops when higher doses are needed to control pain.

Answer 15

ANS: D
Rationale: Clients requiring opioids for chronic pain, especially cancer clients, need increasing doses to relieve pain. The requirement for higher drug doses results in a
greater drug tolerance, which is a physical dependency as opposed to addiction, which is a psychological dependency. Although tolerance to the drug will increase, addiction (also
known as substance use disorder) is not dose related, but is a separate psychological dependency issue. Opioid-induced hyperalgesia causes an increased sensitivity (lowered
threshold) for pain and does not result in the need for higher doses of opioids.

Question 16

16. The nurse is caring for a client with back pain. The nurse reviews the medications and
    sees that an NSAID (ibuprofen) is prescribed every 6 hours as needed. How should the
    nurse best implement preventive pain measures?
    A. Let the client know ibuprofen is available every 6 hours, if needed.
    B. Administer ibuprofen if the client’s pain rating is 5 or higher, on a 0 to 10 scale.
    C. Use a pain scale to assess client’s pain and offer ibuprofen every 6 hours.
    D. Assume the client is not in pain if the client does not request pain medication.

Answer 16

ANS: C
Rationale: Offering pain medication every 6 hours, rather than as needed, provides better pain control since analgesic blood levels are maintained at a stable level. The nurse
should let the client know the analgesic is available every 6 hours, if needed, but the nurse should also offer the analgesic every 6 hours and encourage its use to maintain
better pain control. An analgesic should be administered when the client is uncomfortable, which is not the same level in all clients and not necessarily at a rating of
5 out of 10. Each client reacts to pain differently, and the nurse should not assume that a client is not in pain if the client does not request an analgesic.

Question 17

17. A client who had abdominal surgery reports extreme pain when the bed sheet
    touches the abdomen. Which concept does the nurse use to explain this phenomenon to
    the client?
    A. Hyperalgesia
    B. Nociceptive pain
    C. Phantom pain
    D. Allodynia

Answer 17

ANS: D
Rationale: This client is experiencing allodynia, pain which occurs due to a non-noxious stimulus (the bed sheet) that does not normally cause pain, caused by nerve injury
around the abdominal incision. Hyperalgesia (an increased intensity of pain) and nociceptive pain are caused by noxious stimuli. Phantom pain is a postsurgical pain syndrome due to peripheral nerve damage that may occur after amputation of a limb.

Question 18

18. The nurse is caring for a client with dementia who has a fractured femur secondary to
    a fall. Which approach should the nurse take in regard to pain management with this
    client?
    A. Assume that a client with dementia does not feel pain.
    B. Document that the client is not in pain if the client is sleeping.
    C. Assess vital signs to determine if the client is in pain.
    D. Assume that a fracture is painful and the client is in pain.

Answer 18

ANS: D
Rationale: When assessing a nonverbal or uncommunicative client for pain, such as the client with dementia, consider whether the client has a condition that is typically painful
and treat the client accordingly. A client with dementia can feel pain even if the client is unable to verbalize pain. Being asleep is not an indicator that the client does not have
pain. While vital signs may change with pain, they are the least sensitive indicators of pain.

Question 19

19. An unlicensed assistive personnel (UAP) reports to the nurse that a postsurgical client
    has pain rated as 8 on a 0-to-10-point scale. The UAP tells the nurse that the client is
    exaggerating and does not need pain medication. What is the nurse’s best response?
    A. “Since pain often comes and goes with postsurgical clients, reassess the client’s
    pain in 30 minutes.”
    B. “We need to provide pain medications because it is the law, and we must always
    follow the law.”
    C. “Unless there is strong evidence to the contrary, we should take the client’s
    report at face value.”
    D. “It’s not unusual for clients to misreport pain to get our attention when we are
    busy.”

Answer 19

ANS: C
Rationale: Self-report is considered the most reliable measure of the existence and intensity of the client’s pain and is recommended by the Joint Commission. A broad
definition of pain is “whatever the person says it is, existing whenever the experiencing person says it does.” Action should be taken unless there are demonstrable extenuating
circumstances. Rechecking without offering an intervention would be insufficient, and the law is not the sole reason for providing care. It would be wrong for the nurse to teach the
UAP that clients report pain to get the nurse’s attention.

Question 20

20. The home health nurse is developing a plan of care for a client who will be managing
    chronic pain at home with NSAID analgesics. Which pain management interventions
    should the nurse teach the client? Select all that apply.
    A. Use a pain assessment tool to monitor pain levels and response to interventions.
    B. Monitor for adverse analgesic effects and notify the health care provider if they
    occur.
    C. Take an analgesic when the pain reaches an intolerable level.
    D. Discuss signs and symptoms and risk of addiction.
    E. Discuss the use of nonpharmacologic measures of pain control.

Answer 20

ANS: A, B, E
Rationale: To promote self-management of pain at home, the nurse teaches the client to use a pain rating scale to monitor the level of pain in response to interventions. The client should also be taught adverse effects of medications that require medical attention. The client should be instructed to take an analgesic when pain is first felt, not when it reaches an intolerable level. Additionally, the nurse should also discuss nonpharmacologic measures to control pain, such as heat/cold, transcutaneous electrical nerve stimulation, and relaxation breathing. Since this client is not using opioid medications to control pain, there is no risk of addiction.

Question 21

21. The emergency department nurse is caring for an adult client who was in a motor
    vehicle accident. Radiography reveals an ulnar fracture. Which type of pain is the nurse
    addressing with this client?
    A. Chronic
    B. Acute
    C. Intermittent
    D. Osteopenic

Answer 21

ANS: B
Rationale: Acute pain is usually of recent onset and commonly associated with a specific injury. Acute pain indicates that damage or injury has occurred. Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Phantom pain occurs when the body experiences a loss, such as an amputation, and still feels pain in the missing part. “Osteopenic” pain is not a recognized category of pain.

Question 22

22. A client’s spouse is concerned because the client is requiring increasingly high doses
    of analgesia. The spouse reports that the client, “was in pain long before the cancer
    diagnosis because of a broken back about 20 years ago. For that problem, though, the
    pain medicine wasn’t just raised and raised.” What would be the nurse’s best response?
    A. “I did not know that. I will speak to the health care provider about your
    husband’s pain control.”
    B. “Much cancer pain is caused by tumor involvement and needs to be treated in a
    way that brings the client relief.”
    C. “Cancer is a chronic kind of pain, so the more it hurts the client, the more
    medicine we give the client until it no longer hurts.”
    D. “Does the increasing medication dosage concern you?”

Answer 22

ANS: B
Rationale: Much pain associated with cancer is a direct result of tumor involvement. Conveying client/family concerns to the health care provider is something a nurse does,
but is not the best response by the nurse. Cancer pain can be either acute or chronic, and you do not tell a family member that you are going to keep increasing the dosage of the medication until “it does not hurt anymore.” The family member is obviously concerned.

Question 23

23. A 75-year-old client has been admitted to the rehabilitation facility after falling and
    fracturing the left hip. The client has not regained functional ability and may have to be
    readmitted to an acute-care facility. When planning this client’s care, what should the
    nurse know about the negative effects of the stress associated with pain?
    A. Stress is less pronounced in older adults because they generally have more
    sophisticated coping skills than younger adults.
    B. Stress is particularly harmful in older adults who have been injured or who are
    ill.
    C. It affects only those clients who are already debilitated prior to experiencing
    pain.
    D. It has no inherent negative effects; it just alerts the person/health care team of
    an underlying disease process.

Answer 23

ANS: B
Rationale: The widespread endocrine, immunologic, and inflammatory changes that occur with the stress of pain can have significant negative effects. This is particularly
harmful in clients whose health is already compromised by age, illness, or injury. Older adults are not immune to the negative effects of stress. Prior debilitation does not have
to be present in order for stress to cause potential harm.

Question 24

24. The nurse is caring for a client with a fractured pelvis and a ruptured bladder resulting
    from a motor vehicle accident. The nurse’s aide (NA) reports concern to the nurse
    because the client’s resting heart rate is 110 beats per minute, respirations are 24
    breaths per minute, temperature is 37.3°C (99.1°F) axillary, and the blood pressure is
    125/85 mm Hg. What other information is most important as the nurse assesses this
    client’s physiologic status?
    A. The client’s understanding of pain physiology
    B. The client’s serum glucose level
    C. The client’s white blood cell count
    D. The client’s rating of their pain

Answer 24

ANS: D
Rationale: The nurse’s assessment of the client’s pain is a priority. There is no suggestion of diabetes, and leukocytosis would not occur at this early stage of recovery. The client
does not need to fully understand pain physiology to communicate the presence, absence, or severity of pain.

Question 25

25. The nurse on a rehabilitation unit receives a report about a new client who has
    fibromyalgia and has difficulty with ADLs. The off-going nurse also reports that the client
    is withdrawn, refusing visitors, and has been vacillating between tears and anger all
    afternoon. What aspect of chronic pain syndromes could account for this client’s
    behavior?
    A. Fibromyalgia is not a chronic pain syndrome, so further assessment is
    necessary.
    B. The client is likely frustrated about having to be in the hospital.
    C. The client likely has an underlying psychiatric disorder.
    D. Chronic pain can cause intense emotional responses.

Answer 25

ANS: D
Rationale: Regardless of how clients cope with chronic pain, pain that lasts for an extended period can result in depression, anger, or emotional withdrawal. Nowhere in the
scenario does it indicate the client is upset about the hospitalization or has a psychiatric disorder. Fibromyalgia is closely associated with chronic pain.

Question 26

26. The nurse is caring for a client admitted to the medical–surgical unit after an injury.
    The client states, “I hurt so bad. I suffer from chronic pain anyway, and now it is so much
    worse.” When planning the client’s care, which variables should the nurse consider?
    Select all that apply.
    A. How the presence of pain affects clients and families
    B. Resources that can assist the client with pain management
    C. The influence of the client’s cognition on their pain
    D. The advantages and disadvantages of available pain relief strategies
    E. The difference between acute and intermittent pain

Answer 26

ANS: A, B, D
Rationale: Nurses should understand the effects of chronic pain on clients and families and should be knowledgeable about pain relief strategies and appropriate resources to
assist effectively with pain management. There is no evidence of cognitive deficits in this client, and the difference between acute and intermittent pain has no immediate bearing on this client’s care.

Question 27

27. A client is experiencing severe pain after suffering an electrical burn in a workplace
    accident. The nurse is applying knowledge of the pathophysiology of pain when planning
    this client’s nursing care. What is the physiologic process by which noxious stimuli, such
    as burns, activate nociceptors?
    A. Transduction
    B. Transmission
    C. Perception
    D. Modulation

Answer 27

ANS: A
Rationale: Transduction refers to the processes by which noxious stimuli, such as a surgical incision or burn, activate primary afferent neurons called nociceptors. Transmission, perception, and modulation are subsequent to this process.

Question 28

28. A client was diagnosed with rheumatoid arthritis 1 year ago, but has achieved
    adequate symptom control with celecoxib, a COX-2 selective NSAID. The nurse should
    recognize that this drug, like other NSAIDs, influences what aspect of the
    pathophysiology of nociceptive pain?
    A. Distorting the action potential that is transmitted along the A-delta ( ) and C
    fibers
    B. Diverting noxious information from passing through the dorsal root ganglia and
    synapses in the dorsal horn of the spinal cord
    C. Blocking modulation by limiting the reuptake of serotonin and norepinephrine
    D. Inhibiting transduction by blocking the formation of prostaglandins in the
    periphery

Answer 28

ANS: D
Rationale: NSAIDs produce pain relief primarily by blocking the formation of prostaglandins in the periphery; this is a central component of the pathophysiology of transduction. NSAIDs do not act directly on the aspects of transmission, perception, or modulation of pain that are listed.

Question 29

29. The nurse is caring for a postsurgical client who minimally speaks the dominant
    language. How should the nurse most accurately assess this client’s pain?
    A. Use a chart with the dominant language on one side of the page and the client’s
    native language on the other so the client can rate their pain.
    B. Ask the client to write down a number according to the 0-to-10-point pain scale.
    C. Use the Visual Analog Scale (VAS).
    D. Use the services of a translator each time when assessing the client to document
    the client’s pain rating.

Answer 29

ANS: A
Rationale: Of the listed options, a language comparison chart is most plausible. The VAS requires dominant language skills, even though it is visual. Asking the client to write
similarly requires the use of the dominant language. It is impractical to obtain translator services for every pain assessment, since this is among the most frequently performed nursing assessments.

Question 30

30. A client’s intractable neuropathic pain is being treated using a multimodal approach
    to analgesia. After administering a recently increased dose of IV morphine to the client,
    the nurse has returned to assess the client and finds the client unresponsive to verbal and
    physical stimulation with a respiratory rate of five breaths per minute. The nurse has
    called a code blue and should anticipate the administration of what drug?
    A. Acetylcysteine
    B. Naloxone
    C. Celecoxib
    D. Acetylsalicylic acid

Answer 30

ANS: B
Rationale: Severe opioid-induced sedation necessitates the administration of naloxone, an opioid antagonist. Celecoxib, acetylcysteine, and acetylsalicylic acid are ineffective.

Question 31

31. The nurse is assessing an 86-year-old postoperative client who has an unexpressive,
    stoic demeanor. The client is curled into the fetal position and diaphoretic, and the vital
    signs are elevated. On a 10-point scale, the client indicates a pain level of “3 or so.” How
    should the nurse treat this client’s pain?
    A. Treat the client on the basis of objective signs of pain and reassess frequently.
    B. Call the health care provider for new prescriptions because it is apparent that the
    pain medicine is not working.
    C. Believe what the client says, reinforce education, and reassess often.
    D. Ask the family what they think and treat the client accordingly.

Answer 31

ANS: C
Rationale: As always, the best guide to pain management and administration of analgesic agents in all clients, regardless of age, is what the individual client says. However, further education and assessment are appropriate. The scenario does not indicate the present pain-management prescriptions are not working for this client. The family’s insights do not override the client’s self-report.

Question 32

32. The nurse caring for an older adult client with osteoarthritis is reviewing the client’s
    chart. This client is on a variety of medications prescribed by different care providers in
    the community. In light of the QSEN competency of safety, what is the nurse most
    concerned about with this client?
    A. Depression
    B. Chronic illness
    C. Inadequate pain control
    D. Drug interactions

Answer 32

ANS: D
Rationale: Drug interactions are more likely to occur in older adults because of the higher incidence of chronic illness and the increased use of prescription and OTC medications.
The other options are all good answers for this client because of the client’s age and disease process. However, they are not what the nurse would be most concerned about
in terms of ensuring safety.

Question 33

33. The nurse is caring for a client with sickle cell disease who lives in the community.
    Over the years, there has been joint damage, and the client is in chronic pain. The client
    has developed a tolerance to the usual pain medication. When does the tolerance to pain
    medication become the most significant problem?
    A. When it results in inadequate relief from pain
    B. When dealing with withdrawal symptoms resulting from the tolerance
    C. When having to report the client’s addiction to the client’s health care provider
    D. When the family becomes concerned about increasing dosage

Answer 33

ANS: A
Rationale: Tolerance to opioids is common and becomes a problem primarily in terms of maintaining adequate pain control. Symptoms of withdrawal may occur when opiates are discontinued, but there is no indication that the client’s medication will be discontinued. This client does not have an addiction, and the family’s concerns are secondary to those
of the client.

Question 34

34. The nurse is admitting a client to the rehabilitation unit who has a diagnosis of
    persistent, severe pain. According to the client’s history, the client’s pain has not
    responded to conventional approaches to pain management. What treatment should the
    nurse expect will be tried with this client?
    A. Intravenous analgesia
    B. Long-term intrathecal or epidural catheter
    C. Oral analgesia
    D. Intramuscular analgesia

Answer 34

ANS: B
Rationale: For clients who have persistent, severe pain that fails to respond to other treatments or who obtain pain relief only with the risk of serious side effects, medication
given by a long-term intrathecal or epidural catheter may be effective. The other listed means of pain control would already have been tried in a client with persistent severe
pain that has not responded to previous treatment.

Question 35

35. The nurse is caring for a young adult client with a diagnosis of cerebral palsy who has
    been admitted for the relief of painful contractures in the lower extremities. When
    creating a nursing care plan for this client, what variables should the nurse consider?
    Select all that apply.
    A. Client’s gender
    B. Client’s comorbid conditions
    C. Type of procedure to be performed
    D. Changes in neurologic function that may result from the procedure
    E. Prior effectiveness in relieving the pain

Answer 35

ANS: B, C, D, E
Rationale: The nursing care of clients who undergo procedures for the relief of chronic pain depends on the type of procedure performed, its effectiveness in relieving the pain, and the changes in neurologic function that accompany the procedure. The client’s comorbid conditions will also affect care, but gender is not a key consideration.

Question 36

36. The nurse is caring for a client whose diagnosis of bone cancer is causing severe and
    increasing pain. Before introducing nonpharmacologic pain control interventions into the
    client’s plan of care, the nurse should teach the client which of the following?
    A. Nonpharmacologic interventions must be provided by individuals other than
    members of the health care team.
    B. These interventions will not directly reduce pain, but will refocus the client on
    positive stimuli.
    C. These interventions carry similar risks of adverse effects as analgesics.
    D. Reducing the use of analgesics is not the purpose of these interventions.

Answer 36

ANS: D
Rationale: Clients who have been taking analgesic agents may mistakenly assume that clinicians suggest a nonpharmacologic method to reduce the use or dose of analgesic agents. Nonpharmacologic interventions indeed reduce pain and their use is not limited to practitioners outside the health care team. In general, adverse effects are minimal.

Question 37

37. A client receiving an intravenous (IV) opioid following surgery is being switched to an
    oral form of the drug. To provide safe care for the client, which concept of equianalgesia
    should the nurse follow? Select all that apply.
    A. There is a difference in potency between oral and IV doses of morphine.
    B. Equianalgesic conversion prevents giving the client an opioid overdose.
    C. Equianalgesic conversion is only for opioid-tolerant clients.
    D. Oral analgesics do not control pain as well as IV analgesic administration.
    E. The dose and frequency of the opioid conversion is guided by the client’s
    individual response to the drug.

Answer 37

ANS: A, B, E
Rationale: Equianalgesic conversion from an IV to an oral opioid is guided by the ratio representing the difference in potency between the two drugs. This conversion assures
that the client is not over- or under-dosed when switching routes of opioid administration. Using the equianalgesic conversion as a guide, doses and frequency of
administration are guided by the client’s individual response. Equianalgesic conversion is used for selecting doses for opioid-naive clients. It is not to be used for opioid-tolerant
clients. When the drug and dose are properly selected, oral opioids can be as effective as IV opioids.

Question 38

38. A medical nurse is appraising the effectiveness of a client’s current pain control
    regimen. The nurse is aware that if an intervention is deemed ineffective, goals need to
    be reassessed and other measures need to be considered. What is the role of the nurse in
    obtaining additional pain relief for the client?
    A. Primary caregiver
    B. Client advocate
    C. Team leader
    D. Case manager

Answer 38

ANS: B
Rationale: If the intervention was ineffective, the nurse should consider other measures. If these are ineffective, pain-relief goals need to be reassessed in collaboration with the health care provider. The nurse serves as the client’s advocate in obtaining additional pain relief. The primary caregiver, not the nurse, orders the medication. The nurse is not serving in the role of team leader or case manager in obtaining additional pain relief for
the client.

Question 39

39. A nurse has cited a research study that highlights the clinical effectiveness of using
    placebos in the management of postsurgical clients’ pain. What principle should guide the
    nurse’s use of placebos in pain management?
    A. Placebos require a higher level of informed consent than conventional care.
    B. Placebos are an acceptable, but unconventional, form of nonpharmacologic pain
    management.
    C. Placebos are never recommended in the treatment of pain.
    D. Placebos require the active participation of the client’s family.

Answer 39

ANS: C
Rationale: Broad agreement is that there are no individuals for whom and no condition for which placebos are the recommended treatment. This principle supersedes the other listed statements.

Question 40

40. The nurse is assuming the care of an adult client who has been experiencing severe
    and intractable pain. When reviewing the client’s medication administration record, the
    nurse notes the presence of gabapentin. The nurse is justified in suspecting which
    phenomenon in the etiology of the client’s pain?
    A. Neuroplasticity
    B. Misperception
    C. Psychosomatic processes
    D. Neuropathy

Answer 40

ANS: D
Rationale: The anticonvulsants gabapentin and pregabalin are first-line analgesic agents for neuropathic pain. Neuroplasticity is the ability of the peripheral and central nervous systems to change both structure and function as a result of noxious stimuli; this does not likely contribute to the client’s pain. Similarly, psychosomatic factors and
misperception of pain are highly unlikely.