Essential Pain Questions

Question 1

1. The “fifth vital sign” is
A. Hear rate
B. Oxygen saturation
C. Pain
D. Urine output

Answer 1

1. The answer is C.

Question 2

2. The concept of “four humors” was applied to medicine by
A. Aristotle
B. Hippocrates
C. Huang Di Nei Jing
D. Socrates

Answer 2

2. The answer is B. Hippocrates described the humors as related to one of the four constitutions,
   each of which was also correlated with the changing seasons and representative
   natural elements

Question 3

3. All of the following treatments are based on the gate control theory of pain EXCEPT
A. TENS
B. Spinal cord stimulation
C. Deep brain stimulation
D. Radio frequency ablation

Answer 3

3. The answer is D. Radiofrequency ablation destroys the nerve fiber by heating it and
   thereby producing analgesia.

Question 4

1. The following is true of chronic pain:
   A. Analgesics have no role in the multidisciplinary management of chronic pain
   B. Perpetuating factors may be remote from the originating cause
   C. It can be effectively managed in a primary care setting
   D. Immobilization of the affected part helps in the healing process

Answer 4

1. The answer is B. Pain persisting after the healing process is complete does not serve any
   meaningful purpose. On the other hand, acute pain serves to protect the affected body
   part and it actually helps the healing process. Multidisciplinary management, though it
   encourages the patient to reduce analgesics, has a role in during acute exacerbations.

Question 5

2. Ann is 35-year-old woman who has been suffering from a headache for the last 6
   months. She is on various medications and the side effects of these are affecting her
   work and daily activities. During assessment for the MPC (Multidisciplinary Pain
   Center) program she mentions that she recently has suffered two episodes of jerky
   movements of the right arm which made her wake up from sleep. Which of the
   following would be appropriate?
   A. Conduct a detailed psychological assessment to rule out a somatization disorder
   B. Advise her to reduce or stop her current medications
   C. Ask her to increase the dose of diazepam that she is taking at bedtime
   D. Refer to a physician for further clinical evaluation and investigations

Answer 5

2. The answer is D. One of the aims of assessment for MPC is to rule out those patients who
   have a medical or psychological contraindication to such a program. Ann could be having
   a focal seizure and this needs to be investigated.

Question 6

3. Which of the following is part of a multidisciplinary approach to pain management?
   A. Emphasize active patient participation and responsibility
   B. Provide education and training in the use of specific skills
   C. Help the patient re-conceptualize pain and associated problems from uncontrollable
   to manageable
   D. All of the above

Answer 6

3. The answer is D. In patients suffering from chronic pain, complete freedom from pain
   is often impossible to achieve. Programs usually emphasize physical conditioning, medication
   management, acquisition of coping and vocational skills, and gaining knowledge
   about pain so that the pain becomes manageable.

Question 7

4. Which of the following statements regarding the role of medications in pain management
   program is not true?
   A. Analgesics are given on a time-contingent basis
   B. Patients in an MPC program do not generally derive adequate pain relief from
   analgesic medication
   C. Pain cocktail technique involves mixing various opioids and NSAIDs in a masking
   vehicle
   D. Long-term use of other medications is discouraged both because of their potential
   side effects and the philosophy that the patient must learn to control his or her pain

Answer 7

4. The answer is C. The pain cocktail technique is a method of converting all opioids to an
   equivalent dose of sustained acting opioids or methadone and delivered with a masking
   vehicle. The dose is then tapered over the period of treatment. Most of the medications
   except antidepressants are finally stopped.

Question 8

5. Success of a pain management program can be measured by all EXCEPT
   A. Utilization of health care system following treatment
   B. Elimination or reduction of opioid medication
   C. Pain reduction
   D. Oswestry Disability Index (ODI)

Answer 8

5. The answer is D. ODI is used to assess disability due to pain.

Question 9

1. The following statement regarding nociceptors is true:
   A. visceral structures respond to pain induced by ischemia, spasm, inflammation, and
   mechanical stimulation
   B. Both cornea and tooth are innervated by A-β, A-δ, and C fibers
   C. Pain from ischemic bowel is well localized around the umbilicus
   D. Nociceptors are abundant in the brain

Answer 9

1. The answer is A. Cornea is devoid of C fibers. Visceral pain is poorly localized and brain
   is insensitive to pain.

Question 10

2. Regarding pain hypersensitivity,
   A. It is purely due to peripheral mechanisms
   B. Allodynia is persistent pain after the removal of the painful stimulus
   C. Hyperalgesia is when a noxious stimulus produces an exaggerated response
   D. Hyperpathia is pain produced by cold

Answer 10

2. The answer is C. Both central and peripheral mechanisms are implicated in pain hypersensitivity.
   Allodynia is when pain is produced by stimuli which are not normally painful
   (e.g., touch) and hyperpathia is when repetitive stimuli produces the sensation of pain.

Question 11

3. Which of the following regarding A-delta fibers is true?
   A. They are unmyelinated
   B. They are associated with sharp localized pain
   C. They do not respond to mechanical stimulus
   D. They are are fast conducting at a speed of 40 m/sec

Answer 11

3. The answer is B. A-delta fibers are myelinated and fast conducting at 20 m/sec. They do
   respond to mechanical stimulus which is above a specific threshold.

Question 12

4. Regarding spinal cord, which of the following statements is FALSE?
   A. A-δ and the C fibers give branches to innervate neurons in Rexed’s laminae
   I and II
   B. Axons of the second-order neurons in laminae IV–VI cross the midline and ascend
   into the brainstem
   C. Laminae are composed of white matter
   D. The spinal cord is divided into 10 laminae

Answer 12

4. The answer is C. The spinal gray matter is divided into 10 laminae depending on the
   histological appearance.

Question 13

5. The beneficial effects of cognitive-behavioral therapy in chronic pain are mediated by
   A. Augmenting descending inhibitory pathways
   B. Blocking transmission of pain in the spinothalamic tract
   C. By releasing acetylcholine from parasympathetic nerve endings
   D. None of the above

Answer 13

5. The answer is A. Outflow of descending inhibitory impulses from frontal cortex, cingulate
   gyrus and hypothalamus are influenced by the patient’s psychological and emotional state.
   Psychological support, including imagery, biofeedback, and music therapy can reduce
   pain intensity by either facilitating descending pathways or inhibiting cortical perception.

Question 14

1. Evan is a 45-year-old man who had undergone lumbar discectomy for back pain and
   leg pain about 3 weeks ago. He is now complaining of constant dull ache in his lower
   back along with sharp shooting pain down his right leg. He is also complaining of
   occasional burning sensation in the anterior aspect of his right thigh. Evan is likely
   suffering from
   A. Neuropathic pain
   B. Nociceptive pain
   C. Mixed pain
   D. Physiologic pain

Answer 14

1. The answer is C. This pain has feature of both neuropathic and nociceptive pain. It has
   radiation that is indicative of nerve damage either pre-existing or secondary to surgery.
   Assessing qualitative aspect of pain is important in diagnosis and management.

Question 15

2. Ionic basis of activation of nociceptors involves all EXCEPT
   A. An inward sodium current
   B. A depolarizing calcium current
   C. Activation of nerve endings by potassium and hydrogen ions
   D. Hyperpolarization of cell membrane

Answer 15

2. The answer is D. Transduction is the process by which the noxious stimulus at the
   nerve ending converted to electrical activity. Activation of nociceptor triggers a generator
   potential mediated by calcium ion which in turn activates an inward sodium current
   resulting in propagation of action potential along the axon. Potassium and hydrogen
   ions are involved in activation of the nerve endings. Hyperpolarization makes the cell
   membrane less excitable.

Question 16

3. Action potentials through the sensitized nociceptors release the following peptides in
and around the site of injury EXCEPT
A. Prostaglandin α
B. Calcitonin gene-related peptide
C. Cholecystokinin
D. Substance P

Answer 16

3. The answer is A. Prostaglandin α is not a peptide but an eicosanoid.

Question 17

4. The correct sequence of the noxious stimulus from the periphery to the sensory
   cortex is
   A. Aδ/C fibers→dorsal ganglia→spinothalamic
   tract→hypothalamus→thalamus→sensory cortex
   B. Aδ/C fibers→dorsal ganglia→spinothalamic
   tract→medulla→thalamus→sensory cortex
   C. Aδ/C fibers→spinothalamic tract→dorsal
   ganglia→medulla→thalamus→sensory cortex
   D. Aδ/C fibers→spinothalamic
   tract→dorsal ganglia→medulla→hypothalamus→sensory cortex

Answer 17

4. The answer is B.

Question 18

5. The correct statement regarding NMDA receptor is
   A. It is a 4-subunit, voltage-gated ligand-specific ion channel
   B. Glutamate binding to NMDA receptors sustains an outward Ca2+ flux
   C. Are responsible for producing analgesia
   D. Ketamine acts as an NMDA agonist

Answer 18

5. The answer is A. The effect of glutamate on NMDA receptor is sustained Ca2+ influx and
   it amplifies pain. Ketamine is NMDA receptor antagonist.

Question 19

1. Somatic and visceral pain could be distinguished by the following:
   A. Somatic pain is likely to be sharp, burning, and poorly localized
   B. Visceral pain is likely to be dull, diffuse, and well localized
   C. Referred pain is suggestive of its visceral origin
   D. Autonomic disturbances are characteristic of somatic pain

Answer 19

1. The answer is C. Somatic pain is well localized where as visceral pain is poorly localized
   with associated autonomic disturbances such as sweating bradycardia and hypotension

Question 20

2. A 48-year-old bus driver is complaining of acute left buttock pain moving down the
   back of thigh and leg to the heel. On examination, he has grade 4 flexion of the knee
   and 1+ ankle reflex on the left. He has reduced sensation to light touch over the same
   area. He is likely to have
   A. S2 radiculopathy
   B. Left sacro-iliac joint pain
   C. Fracture of the left femur
   D. Lumbar facet joint arthropathy

Answer 20

2. The answer is A. He is suffering from S2 nerve root pain. Nerve root pain follows this
   distribution. It could be a result of disc prolapse, infection, or tumor.

Question 21

3. Which of the following statement is FALSE regarding cranial nerve testing?
   A. Conjugate gaze testing assesses the functions of cranial nerves II, III, and VI
   B. Trigeminal nerve has both sensory and motor functions
   C. Gag reflex assesses the function of vagus nerve
   D. Facial nerve has only motor function

Answer 21

3. The answer is A. Conjugate gaze testing assesses cranial nerves III, IV, and VI. The tests
   for II nerve are visual acuity and visual field testing. Trigeminal nerve controls the muscles
   of mastication.

Question 22

4. Which of the following is true regarding psychological evaluation using Mini-Mental
   examination?
   A. Testing of orientation, registration, language, attention and calculation
   B. A maximum score is 30, and any score less than 23 is considered abnormal
   C. It provides information about the potential source of a patient’s mental deficit
   D. Level of education has no effect on the result

Answer 22

4. The answer is B. It involves testing five areas of mental status: orientation, registration,
   attention and calculation, recall, and language. In the case of the last two responses, the
   opposites are true.

Question 23

5. Choose the correctly matched pair:
   A. Fact G questionnaire – Cancer pain
   B. SF-36 – lower scores indicating better health
   C. Brief Pain Inventory – Single-dimension survey
   D. VAS and VRS – Multi dimension Survey

Answer 23

5. The answer is A. In SF-36, higher scores indicate better health. VAS and VRS are singledimension
   surveys, whereas BPI is a multi-dimensional survey.

Question 24

1. A patient has developed low back pain after straining from lifting a heavy piece of
   furniture. He has localized back pain for the first time, no radicular symptoms, and a
   normal neurologic exam. Next step in the evaluation should be
   A. Order an MRI of the spine with contrast
   B. Order an MRI of the spine without contrast
   C. Obtain X-rays of the spine
   D. Defer imaging for now and provide conservative therapy

Answer 24

1. The answer is D. Without radicular or neurologic signs, conservative management is the
   initial management of simple low back pain. With radicular signs or altered neurologic
   exam, an MRI is the test of choice.

Question 25

2. Intrathecal pumps are a contraindication to performing an MRI
   A. True
   B. False

Answer 25

2. The answer is B. A presence of an implanted intrathecal pumps used for pain, such as
   the Medtronic SynchroMedTM pump, is not an absolute contraindication to MRI. The
   pump itself may stop functioning during the MRI exposure, but will resume thereafter. It
   is recommended that the pump programming be checked immediately after the MRI to
   verify that it has not been altered.

Question 26

3. For the evaluation of which of the following conditions is the triple-phase bone scan is
   most useful?
   A. Complex Regional Pain Syndrome (CRPS)
   B. Prosthetic loosening without infection
   C. Osteomyelitis
   D. Cancer metastases

Answer 26

3. The answer is C. Although classically advocated for use in identifying Complex Regional
   Pain Syndrome, a regular single-phase bone scan is equally effective for the diagnosis of
   this condition. Triple-phase bone scan is an imaging modality that is more useful for
   osteomyelitis. A triple-phase bone scan, as its name implies, has three phases: a dynamic
   phase (performed immediately after radiotracer injection), a blood pool phase (performed
   3–5 min after injection), and a delayed bone phase (performed 2–6 h after injection). In
   this scan, both blood flow and bone turnover are also evaluated as opposed to evaluation
   of only bone turnover in a plain bone scan. In the dynamic phase, the general amount of
   blood flow to an area is determined; in the blood pool phase, the amount of extravasation
   of tracer into the surrounding tissue is detected. In the delayed phase, bone uptake
   is measured. Because infections lead to increased blood flow in the area of infection as
   well as leaky tissue (osteomyel-“itis”), the two initial phases of a three-phase bone scan are
   useful in their diagnosis. The final phase, the delayed bone scan phase, localizes this infection
   to the bone (“osteo”-myelitis) by demonstrating increased bone turnover. Fractures
   and metastases as well as infections may cause hyperperfusion and hyperemia resulting in
   positive three-phase bone scans. When diagnostic doubt exists and greater specificity is
   needed, a subsequent scan using indium-111-tagged leukocytes will be positive for infection
   but not the other conditions. In this scan, leukocytes are withdrawn from a patient,
   labeled with indium-111, and re-injected. Detection is performed 24 h later with the hope
   that these labeled leukocytes will concentrate at an area of infection

Question 27

4. The only imaging modality that provides real-time imaging is
A. MRI
B. CT Scan
C. Ultrasound
D. Plain Radiograph

Answer 27

4. The answer is C. Ultrasound uses high-intensity sound waves in the range of 2–
   20 MHz to generate images of internal structures. It is attractive in that it is
   portable, and images can be achieved in real time. Furthermore, this modality does not employ ionizing radiation or contrast agents, thus minimizing side effects and
   damage.

Question 28

5. Complications following myelography include:
A. Headache
B. Arachnoiditis
C. Meningitis
D. All of the above

Answer 28

5. The answer is D.

Question 29

1. The following statement regarding μ receptors is FALSE:
   A. Therapeutically useful receptor is μ1
   B. μ2 activation leads to side effects
   C. These receptors are proteins
   D. κ receptor mediates visceral and spinal analgesia

Answer 29

1. The answer is C. Opioid receptors are glycoproteins. μ1 and receptor activation produces
   analgesia, while that of μ2 leads to the observed side effects such as respiratory depression,
   nausea, vomiting, euphoria, decreased gastrointestinal motility, urinary retention,
   tolerance, dependence, histamine release, miosis, and/or anorexia.

Question 30

2. Biotransformation of opioids primarily occurs in the liver by
   A. Phase I reaction, mostly hydroxylation
   B. Cytochrome P450, which has a major role in opioid metabolism
   C. Phase II reaction involving conjugation with glucuronide
   D. All of the above

Answer 30

2. The answer is D. Phase I reaction produces more water-soluble and less active metabolite.
   Phase II reaction yields a large molecular weight compound which is usually inactive and
   is more easily excreted

Question 31

3. Administration of morphine by oral route is very effective in controlling pain.
Bioavailability by this route is
A. 75%
B. 25%
C. 50%
D. 90%

Answer 31

3. The answer is B. Despite significant first-pass metabolism, oral administration is made
   effective by proper scheduling and dosing adjustments.

Question 32

4. The advantages of the use transdermal opioids include the following EXCEPT
   A. Noninvasive
   B. Effective
   C. Uses a small electric charge to propel the drug across the skin
   D. Avoids gastrointestinal side effects

Answer 32

4. The answer is C. The medication is delivered through passive diffusion. Iontophoresis
   uses electric charge for drug delivery.

Question 33

5. The most concerning side effect of intrathecal opioid delivery is
A. Itching
B. Delayed respiratory depression
C. Urinary retention
D. Nausea and vomiting

Answer 33

5. The answer is B. Intrathecal opioids can spread rostrally producing delayed respiratory
   depression at a time when patient is least monitored. This is a real concern in the case of
   hydrophilic opioid like morphine

Question 34

1. The following is NOT a therapeutic indication for opioids:
A. Constipation
B. Diarrhea
C. Pain
D. Cough

Answer 34

1. The answer is A. Opioids can be used for symptomatic relief of diarrhea. Opioids also have
   antitussive properties.

Question 35

2. Patients on long-term therapy with opioids do NOT develop tolerance to
A. Pain
B. Nausea and vomiting
C. Constipation
D. Respiratory depression

Answer 35

2. The answer is C.

Question 36

3. A 65-year-old woman undergoes knee arthroscopy, and in recovery she complaints
   of severe postoperative pain despite have been given substantial dose of intravenous
   morphine. Review of her past medical records reveals that she has been taking
   dihydrocodeine for the past year for arthritis. She is likely suffering from
   A. Addiction
   B. Pseudo addiction
   C. Cross-tolerance
   D. Physical dependence

Answer 36

3. The answer is C. She has developed tolerance tomorphine secondary to the long-term use
   of dihydrocodeine

Question 37

4. Opioid rotation is indicated when
A. There is decreasing analgesic efficiency
B. There are persistent side effects
C. Patient requests it
D. All of the above

Answer 37

4. The answer is D. It also may be indicated when the patient cannot take oral medication

Question 38

5. Which of the following opioids can potentially cause convulsions secondary to a
metabolite?
A. Fentanyl
B. Diacetylmorphine
C. Meperidine
D. Sufentanil

Answer 38

5. The answer is C. Normeperidine is a metabolic byproduct of meperidine. Normeperidine
   has less analgesic potency than meperidine, but has the pharmacological property of
   decreasing seizure threshold and inducing central nervous system hyperexcitability and
   seizures.

Question 39

1. The following is an undesirable effect of combined administration of an NSAID and
   acetaminophen:
   A. Increased incidence of gastrointestinal bleeding
   B. Decreased analgesic effect
   C. Renal failure
   D. Reduced antipyretic activity

Answer 39

1. The answer is A. The combination can produce GI bleeding even in the presence of proton
pump inhibitors (PPIs).

Question 40

2. The analgesic potency of 30 mg of ketorolac is equivalent to
A. 30 mg of morphine
B. 5 mg of morphine
C. 3 mg of morphine
D. 10 mg of morphine

Answer 40

2. The answer is D. Ketorolac has been shown to have opioid-sparing action when used for
   postoperative pain relief. However, it is not potent enough to be used as a sole analgesic
   after major surgery.

Question 41

3. Methyl prednisolone acetate used for interventional pain procedures
   A. Has high mineralcorticoid and low glucocorticoid effect
   B. Has significant systemic effect due to rapid absorption
   C. Can produce chemical arachnoiditis
   D. Can be safely used for cervical transforaminal epidural steroid injections

Answer 41

3. The answer is C. Methyl prednisolone acetate has high glucocorticoid and low mineralcorticoid
   activity. It is slowly absorbed from the site of injection and can lead to vascular
   occlusion, which is blamed for neurological damage following nerve root injections.

Question 42

4. Which of the following is true regarding the treatment of neuropathic pain?
   A. Carbamazepine alleviates pain by decreasing conductance in Na+ channels
   B. Gabapentin acts by enhancing calcium entry into the cell
   C. Bioavailability of Gabapentin is more than pregabalin
   D. Convulsion is a side effect of Gabapentin

Answer 42

4. The answer is A. Gabapentin and pregabalin both have anticonvulsant properties and the
   latter has more bioavailability and hence the lower dose requirement. They block calcium
   entry into the cell, preventing the release of neurotransmitters.

Question 43

5. Which of the following benzodiazepines is used in the treatment of trigeminal neuralgia?
A. Temazepam
B. Diazepam
C. Clonazepam
D. Nitrazepam

Answer 43

5. The answer is C.

Question 44

1. Which of the following does NOT increase the risk of bleeding during interventional
pain procedures?
A. Garlic
B. Ephedra
C. Ginseng
D. Gingko biloba

Answer 44

1. The answer is B. Garlic, ginseng, and gingko biloba all may increase the risk of bleeding.
   Ephedra does not. Ephedra, however, may cause systemic and pulmonary hypertension,
   tachycardia, cardiomyopathy, cardiac dysrhythmias, myocardial infarction, stroke,
   seizures, psychosis, and death due to its inherent sympathomimetic properties

Question 45

2. The ASA recommends that herbal medications be discontinued how early before any
   interventional procedure?
   A. 1 week
   B. 2–3 weeks
   C. greater than 3 weeks
   D. They do not have to be discontinued if used in the recommended dose range

Answer 45

2. The answer is B. The ASA currently recommends discontinuing all herbal medications
   2–3 weeks prior to any perioperative or interventional procedure. These precautions were
   taken to protect patients from side effects of these herbals, since standardizations have not
   been formulated. There have not been many safety trials conducted to determine a safe
   dosage for patients to take during the perioperative period

Question 46

3. White willow bark exerts its anti-inflammatory response by inhibiting which enzyme?
A. COX-2
B. Lipoxygenase
C. Both
D. None of the above

Answer 46

3. The answer is C. White willow bark, from the family of salicylates, shares the same
   metabolic pathway as aspirin and affects both the COX-2 and lipoxygenase enzyme. It
   has been suggested that prostaglandin and cytokine modulation may also contribute to its
   effect.

Question 47

4. Currently what proportion of patients presenting to the pain physician for consultation
are taking herbal supplements?
A. 1 in 3
B. 1 in 8
C. 1 in 20
D. 1 in 100

Answer 47

4. The answer is A. According to the recent literature, approximately one in three patients
   are taking herbal medications. Moreover, 70% of these patients would not disclose this
   information during routine preoperative questioning.

Question 48

1. A 37-year-old man presents with a history persistent axial low back pain despite a previous
   lumbar spine fusion from L3–5. He has been complaining of constant, 6/10 pain
   even after the surgery, for which he now takes extended-release oxycodone, oxycodone
   immediate release, and gabapentin. He is otherwise healthy. He is in your office today
   to discuss enrollment in a trial testing a new type of pain medication that inhibits
   cytokines. The safety of this medication has been demonstrated, but efficacy has not
   been shown yet.Which of the following statements is correct?
   A. His enrollment in the study will breach ethics
   B. It is safe to include him in the study even if he has expressed suicidal thoughts
   C. Participation is acceptable provided it will not produce a high level of risk to the
   patient or cause irreversible harm
   D. He can be enrolled provided he is in the treatment group

Answer 48

1. The answer is C. In designing a proposed clinical trial, it is important to consider the ethics
   of the study. Several criteria should be fulfilled. First, there should be important scientific reasons to conduct the trial. Chronic pain is endemic in the community (estimates up
   to 50%), and the administration of placebo for chronic pain is associated with significant
   improvement in pain control. Studies have documented a 30–40% response rate
   to placebo administration alone. Moreover, several interventions for the treatment of
   chronic pain have been shown to be ineffective when subjected to the rigors of a randomized
   controlled trial. Therefore, it is important to scientifically test the investigational
   drug against a placebo. Second, participation in the trial should not produce a high level
   of risk to the patient and should not cause irreversible harm. This patient has suffered
   from chronic pain for several years, and there is no reason to think that he is at undue
   risk if his pain continues. However, patients should be screened to determine their level of
   risk. For example, a patient who has expressed suicidal thoughts after worsening of pain
   would not be appropriate for this trial. Third, the patient should be monitored closely
   with clinic visits or telephone interactions, as appropriate. If his clinical condition worsens
   beyond a predetermined threshold, he should withdraw from the trial. Finally, it is
   imperative that he understand the purpose and design of the trial, the consequences of
   his participation in the trial, and provide informed consent. In spite of fulfilling these recommendations,
   some would argue that the trial should compare the investigational drug
   to standard therapy. This philosophy is embedded in the Declaration of Helsinki, which
   states that, “The benefits, risks, burdens, and effectiveness of a new method should be
   tested against those of the best current prophylactic, diagnostic, and therapeutic methods.
   This does not exclude the use of the placebo, or no treatment, in studies where no proven
   prophylactic, diagnostic, or therapeutic method exists.”

Question 49

2. The mechanisms whereby expectancies might produce biological effects include all of
   the following EXCEPT
   A. Reduction in anxiety
   B. Changes in cognition or coping mechanisms
   C. Changes in behavior that would improve health outcomes
   D. A reduction in immunity

Answer 49

2. The answer is D. Cognitive theory of placebo effect states that patient expectations are
   critical in the placebo response. Anxiety and stress reduce immunity.

Question 50

3. Placebo effect can be reversed with
A. Flumazenil
B. Naloxone
C. Doxapram
D. Neostigmine

Answer 50

3. The answer is B.

Question 51

4. Specific therapeutic effect of an active drug is calculated by
   A. Adding efficacies of the drug to that of the placebo
   B. Subtracting efficacy of placebo from that of the drug
   C. None of the above
   D. All of the above

Answer 51

4. The answer is B.

Question 52

5. Perceived placebo effect could be due to:
   A. Natural history of the disease
   B. Biologic fluctuation
   C. Increase in the skills of the physician
   D. All of the above

Answer 52

5. The answer is D.

Question 53

1. Mechanisms underlying the reciprocal relationships between pain, affective distress
   and stress may include
   A. Enhancement of the response to pain by amygdala
   B. Increase in cytokine activity due to stress
   C. Up-regulation of BDNF (brain-derived neurotropic factor)
   D. Only A and B are true

Answer 53

1. The answer is D. Chronic negative affective states can increase the response of the amygdala
   to pain, leading to increased pain perception. Increased production of cytokines
   can lead to the “over shooting” of immune response. Heightened glucocorticoid activity,
   stress, and pain culminate in downregulation of BDNF.

Question 54

2. Regarding CBT (Cognitive-Behavioral Therapy), all are true EXCEPT
   A. It focuses on modification of the thoughts, beliefs, and expectations
   B. It involves skills training
   C. Neuromatrix theory refutes the effectiveness of CBT
   D. CBT treatment can modify limbic activity

Answer 54

2. The answer is C. With cognitive restructuring and coping skills training patients may
   experience less physiological arousal and less intense pain, which is consistent with the
   Neuromatrix Theory of pain

Question 55

3. Which of the following is true about the use of antidepressants and their analgesic
   effects?
   A. Analgesic effects are only seen in patients who suffer from depression
   B. Depressed patients require higher doses for analgesic effect
   C. Antidepressants do not relieve pain if the patient suffers from depression
   D. Depressed patients respond faster to analgesic effects of antidepressants

Answer 55

3. The answer is D. Antidepressants relieve pain in patients irrespective of the fact whether
   they suffer from endogenous depression or not. In both these situation the dose required
   to produce a reduction in pain is far less than the dose needed to produce the anti
   depressant effect.

Question 56

4. Fluoxetine may be contraindicated if the patient is suffering from
A. Fibromyalgia
B. Diabetic neuropathy
C. Restless leg syndrome
D. IBS (irritable bowel syndrome)

Answer 56

4. The answer is C. Exacerbation of restless legs syndrome is a possibility with fluoxetine.

Question 57

5. A 32-year-old man is in the emergency room with a fracture of his right forearm. He
   is in pain and anxious because he is worried about loosing his job. He tells you that he
   had undergone treatment for depression in the past. Your emergency room treatment
   should include
   A. Analgesics only
   B. Anlagesics and anxiolytics
   C. Analgesics and antidepressants
   D. Analgesics, axiolytics, and antidepressants

Answer 57

5. The answer is A. This is an acute pain phase of pain, and treatment is centered
   on pain relief, identification and, if possible, remediation of the underlying medical
   condition.

Question 58

1. Which is true of the trigeminal neurolysis procedure
   A. All three divisions of the trigeminal nerve (ophthalmic, mandibular, and maxillary
   can be individually blocked
   B. The Gasserian ganglion block will block all the three divisions of the fifth cranial
   nerve
   C. It can be used to treat chronic headache
   D. Facial numbness is not a complication of this procedure

Answer 58

1. The answer is D. Only mandibular and maxillary divisions are blocked individually.
   Trigeminal nerve sub serves facial sensation so the neurolysis is not useful for treating
   chronic headache and it can lead on to unpleasant facial numbness.

Question 59

2. Mary is a 35-year-old female who has been suffering from a headache following
   whiplash injury. She says that her pain starts from the back of her head and radiates
   to the forehead and into both of her eyes. On examination, she has tenderness over the
   posterior occiput. The following statement is not correct:
   A. She could be suffering from occipital neuralgia
   B. Occipital nerve block is one of the treatment options
   C. Depot steroid injection can prolong the duration of occipital nerve block
   D. Peripheral nerve stimulation is not a treatment option for Mary

Answer 59

2. The answer isD.Occipital nerve stimulation can be used to treat resistant cases of occipital
   neuralgia.

Question 60

3. A 75-year-old man is referred to you by the orthopedic surgeon. He has been suffering
   from low back pain radiating to lateral side of his right calf. MRI of lumbar spine
   shows a herniated disc impinging right L5 nerve root. The indicated pain intervention
   is
   A. Right L5 nerve root block
   B. A caudal epidural
   C. Interlaminar epidural injection
   D. All of the above

Answer 60

3. The answer is D. All these interventions can produce pain relief, though a right L5 nerve
   root injection has the advantage of targeting directly the affected nerve root with minimal
   volume of the injectate.

Question 61

4. When performing radiofrequency ablation the following does NOT occur
   A. Heating up of the tissues
   B. Nerves are stimulated first to avoid complication
   C. Temperature ranges from 42◦ to 80◦
   D. None of the above

Answer 61

4. The answer is D.

Question 62

5. Which of the following statements is not true regarding SCS (Spinal Cord
   Stimulator)?
   A. The electrodes are placed in the epidural space, stimulating the dorsal column of the
   spinal cord
   B. SCS is effective for pain due to ischemia
   C. Infection is a possible complication
   D. SCS uses radiofrequency waves for stimulation

Answer 62

5. The answer is D. SCS uses lower frequencies for producing pain relief. It has been used
   successfully for treating angina and ischemic limb pain.

Question 63

1. Which of the following is not one of the goals of physiotherapy in pain management?
   A. Reduce all activities that increase pain
   B. Reduce self-perceived pain frequency, intensity, duration, disability, and depression
   C. Increase self-perceived functional status, quality of life, and health status
   D. Return to work, recreational, and home activities

Answer 63

1. The answer is A. The aim of physiotherapy is to minimize functional limitation due to
   pain.

Question 64

2. Moist hot packs ease pain by
A. Vasodilatation
B. Relaxing muscles
C. Decreasing muscle spasm
D. All of the above

Answer 64

2. The answer is D. Vasodilatation increases blood flow leading onto B and C.

Question 65

3. Regarding the use of ultrasound in treating pain
   A. Its effect on tissue blood flow is similar to application of heat
   B. It increases tissue permeability to applied medications
   C. All of the above
   D. None of the above

Answer 65

3. The answer is C.

Question 66

4. TENS (transcutaneous electrical nerve stimulation) differs from NMES (neuromuscular
   electrical stimulation) in that TENS:
   A. Uses electric current to stimulate muscles
   B. Is used in treating chronic pain
   C. Is used to identify individual muscles
   D. All of the above

Answer 66

4. The answer is B. TENS and NMES both use electric current to stimulate muscle. The
   latter is used to identify individual muscles and enables the physical therapist to teach the
   patient how to contract specific muscles.

Question 67

1. All of the following indicate appropriate referrals to occupational therapy EXCEPT
A. Fibromyalgia
B. Diabetic peripheral neuropathy
C. Rotator cuff tear
D. All of the above

Answer 67

1. The answer is D. Occupational therapists are qualified to treat a wide variety of clients
   including those with autoimmune, orthopedic, and neurological disorders. Appropriate
   client referrals include those who are experiencing acute or chronic pain, especially if there
   is a limitation in functional ability.

Question 68

2. Occupational therapy incorporates a variety of pain management strategies to promote
   participation and quality of life for each client. Which strategy falls under the
   “environmental/contextual” category?
   A. Personal adaptive equipment usage (such as a bathtub bench)
   B. Nerve gliding exercises done twice daily
   C. Physical agent modality usage
   D. Splinting fabrication

Answer 68

2. The answer is A. The other answers pertain to the physical management of pain; all strategies
   can be effective for healing of soft tissues and fall under physical interventions used
   by occupational therapists. Personal adaptive equipment usage (whether for dressing,
   bathing, grooming, or toileting) falls under the category of “environmental/contextual”
   adaptations for pain management. Occupational therapists are adept at analyzing people
   engaging in occupations within various contexts, so they can be counted on to quickly
   evaluate and address any such patient needs.

Question 69

3. Because there is a strong psychological component to the pain experience, which OT
   strategy is least likely to be effective for this component?
   A. Stress management
   B. Home safety modification
   C. Relaxation training
   D. Cognitive-behavioral approaches

Answer 69

3. The answer is B. Stress management, relaxation training, and cognitive-behavioral
   approaches have all been demonstrated to promote positive psychological coping strategies
   for acute or chronic pain management. Thus, home safety modification, although
   helpful for environmental/contextual intervention, will be less likely to have an impact on
   a client’s immediate need for positive coping strategies to address managing or lessening
   the impact of pain on their daily living.

Question 70

4. Chris, a 48-year-old truck driver, has a history of ulnar neuropathy and generalized
   wrist pain. He is now presenting with Carpal Tunnel Syndrome symptoms. You
   determine the need for Occupational Therapy (OT) evaluation and intervention (see
   Occupational Therapy Referral form – Fig. 15.2). In addition to referring to OT for
   wrist cock-up splints bilaterally, iontophoresis, and therapeutic exercise, it would be
   appropriate to request
   A. Home safety evaluation
   B. Relaxation education
   C. An ergonomic evaluation
   D. Myofascial release

Answer 70

4. The answer is C. Due to the symptoms of ulnar neuropathy and now carpal tunnel syndrome,
   it is expected that splints, iontophoresis, and therapeutic exercise will be beneficial
   to the client. Beyond this, the benefits ofmyofascial release have not been demonstrated to
   be effective. Relaxation may be beneficial, but the intervention most likely to bring about
   the needed work and lifestyle modifications would be an ergonomic evaluation. Through
   an ergonomic evaluation, Chris’ sitting and reach in the semi-truck, along with his daily routine and tasks can be analyzed by the occupational therapist. Together with Chris, they can develop an adaptation plan for driving, rest, self-exercise, and sleep breaks that will promote the best positions of his upper extremity joints to decrease inflammation and allow healing of the soft tissues.

Question 71

1. Which one of the following is not included in the traditional Chinese acupuncture
theory?
A. The Taoism
B. Qi
C. Lymph systems
D. Yin-Yang

Answer 71

1. The answer is C.

Question 72

2. Which technique(s) is (are) used in acupuncture practice?
A. A medical technique using needle
B. A medical techniques using moxa
C. A medical technique using cupping
D. All of the above

Answer 72

2. The answer isD. Cupping is another traditional acupuncture technique.Newer techniques
   include electro acupuncture, laser, and hydro injection.

Question 73

3. Which one of the following has NOT been suggested as the mechanism of acupuncture
   analgesia?
   A. Trigger the release of β-endorphin
   B. Trigger the release of interferon
   C. Interference with the pain pathway
   D. Reorganization of the local connective tissue

Answer 73

3. The answer is B. All the other responses are true regarding acupuncture.

Question 74

4. Acupuncture can be used for which of the following pain disorders?
A. Dysmenorrhea
B. Headache
C. Neck and shoulder pain
D. All of the above

Answer 74

4. The answer is D.

Question 75

1. Unrelieved acute pain can result in
A. Enhanced wound healing
B. Shorter hospital stay
C. Serious systemic abnormalities
D. More accurate clinical diagnosis

Answer 75

1. The answer is C. Unrelieved acute pain can lead to increased levels of catecholamines,
   which in turn can cause tachycardia, hypertension, myocardial ischemia, hypercoagulable
   state, abnormal breathing, and delayed gastric emptying. It can delay wound healing and
   suppress immunity, predisposing to infections. The end result can be delayed recovery
   and discharge from the hospital. Choice D is unethical.

Question 76

2. Which of the following is true regarding the importance of having a care plan for each
   patient
   A. It is the responsibility of the nurse to assess pain and provide adequate pain relief
   B. It helps to avoid frequent reassessment of pain
   C. It helps patient assess his/her own pain and take appropriate medication
   D. There is no need for discussing care plans with patients

Answer 76

2. The answer is A. Care plans are essential in the management of pain on the ward as it is
   primarily the nurse who will be providing initial assessment of pain. It involves a detailed
   discussion with the patient and his/her family.

Question 77

3. In which of the following patient assessment of pain could prove difficult?
A. Severely psychotic patient
B. One-year-old child
C. Demented octogenarian
D. All of the above

Answer 77

3. The answer is D.

Question 78

4. Regarding pain assessment tools:
   A. Pain assessment tools are designed to be easy to use by the nurse, since nurses are
   supposed to conduct a basic assessment
   B. Tools must be appropriate for the patient’s developmental, physical, emotional, and
   cognitive status
   C. Self-assessment of pain is most reliable
   D. B and C are true

Answer 78

4. The answer is D. Pain assessment tools should be reliable, valid and easy for the patient,
   nurse, and physician to use.

Question 79

5. A one-year-old boy is under your care following hernia repair. He is frowning, tensing
   up his legs, yet lying quietly, not crying and is reassured by occasional hugging. His
   FLACC score is
   A. 5
   B. 3
   C. 2
   D. 1

Answer 79

5. The answer is B. Face, Legs, Activity, Cry, and Consolability (FLACC) score is 3 out of a
   maximum of 10.

Question 80

1. Which of the following non-pharmacological modes of postoperative pain relief are
NOT mediated by endorphins?
A. Relaxation techniques
B. Application of heat or cold
C. Acupuncture
D. Application of TENS

Answer 80

1. The answer is B. The application of heat reduces muscle spasms and cold reduces inflammation,
   both resulting in pain relief. In the case of the other modalities, endorphins are
   released providing pain relief.

Question 81

2. Acetaminophen is widely used to control postoperative pain because it has
A. Anti-inflammatory properties
B. Opioid-sparing effect
C. Peripheral and central actions
D. No known renal or hepatic toxicity

Answer 81

2. The answer is B. Acetaminophen neither has anti-inflammatory properties nor peripheral
   action. It can produce hepatic necrosis if an overdose occurs.

Question 82

3. When administering opioids for surgical pain, enteral route is preferred whenever
   possible because
   A. It is the easiest route and offers the most stable pharmacokinetics
   B. It avoids first-pass metabolism
   C. Enteral route has a higher bioavailability
   D. The dose requirement is less

Answer 82

3. The answer is A. When administered enterally, opioids undergo significant first-pass
   metabolism in liver and hence their bioavailability by this route is less in comparison with
   other routes. For the same reason, when given orally, the dose requirement is substantially
   higher than intravenous dose.

Question 83

4. Which of the following properties of methadone makes it unsuitable in acute pain?
   A. Increased bioavailability and rapid rise in plasma concentration
   B. Dose-independent action
   C. Short duration of action
   D. Patients need to be followed-up and monitored closely

Answer 83

4. The answer is D. Slow onset of action secondary to slow rise in plasma concentration and
   dose-dependant potency make methadone an unsuitable agent for acute surgical pain.
   Prolonged duration of action and the need for close follow-up are yet another reasons.

Question 84

5. A morbidly obese patient is on PCA morphine following a gastric bypass procedure.
   Choose the most appropriate action for the situation
   A. Supplemental oxygen should be administered
   B. Monitoring of ventilation is not mandatory if saturation is 98% on room air
   C. Give oxygen, monitor oxygen saturation, and ventilation
   D. Pulse oximetry is sufficient as it is a reliable indicator of respiratory function

Answer 84

5. The answer is C. Obese patients on PCA should be monitored for both oxygenation
   and ventilation. Pulse oximeter does not monitor ventilation and becomes even more
   unreliable when oxygen is supplemented.

Question 85

1. A 45-year-old woman is in the emergency department following a house fire. Her pain
   score is 9 out of 10. Her skin is white, leathery and with mostly absent capillary refill.
   Chose the most appropriate statement:
   A. She has sustained a deep second-degree burn
   B. No surgery is indicated as her wound will heal spontaneously
   C. The treatment for this type of burn is surgical excision and grafting
   D. The pain she experiences has no bearing on her age and gender

Answer 85

1. The answer is C. She has sustained a third-degree burn and the pain score can
   vary depending on age, gender, previous pain experience, and the degree of burn
   injury.
   Treatment involves resuscitation, adequate pain relief, and surgical excision along with
   grafting.

Question 86

2. Regarding the pain experienced by the above patient
   A. She could potentially suffer four different types of pain
   B. Background pain is mild to moderate and lasts until complete healing occurs
   C. Preemptive analgesia may have a role in her pain management
   D. All of the above are true

Answer 86

2. The answer is D. Burn victims can experience pain directly due to injury, breakthrough
   pain, procedural pain, and post-surgical pain. Preemptive analgesia should
   be administered sufficiently early before a planned procedure such as a dressing
   change.

Question 87

3. Which of the following agents are not used in the immediate acute phase of burn pain?
A. Anxiolytics
B. Tricyclic antidepressants
C. NSAIDs
D. High potency opioids

Answer 87

3. The answer is B. TCA (tricyclic antidepressants) have latent onset and generally are not
   very useful in an acute setting.

Question 88

4. The following is not a causative factor in breakthrough pain in burns:
   A. Opioid intolerance
   B. Changes in plasma protein concentration
   C. Healing process
   D. Psychosocial factors

Answer 88

4. The answer is A. Opioid tolerance can lead to breakthrough pain.

Question 89

5. In the acute setting following trauma, which of the following is a contraindication to
epidural analgesia?
A. Hypovolemia
B. Coagulopathy
C. A and B
D. Flail chest

Answer 89

5. The answer is C. Thoracic epidural can be used for effective analgesia in flail chest.

Question 90

1. For brachial plexus blockade at the axillary level, which technique yields the highest
   success rate?
   A. A 2-injection transarterial technique
   B. A single-injection paresthesia technique
   C. A single-injection neurostimulation technique
   D. A 3–4-injection neurostimulation technique

Answer 90

D

Question 91

2. Which of the following sentences is true regarding local anesthetic systemic toxicity?:
   A. Systemic toxicity is very common when used for lower extremity peripheral nerve
   blocks
   B. A forceful, rapid injection of local anesthetic carries a higher risk of systemic local
   anesthetic toxicity
   C. There are no case reports of toxicity following lumbar plexus and proximal sciatic
   blocks, while there are several cases reported after popliteal sciatic blockades
   D. The risk of severe toxicity can be decreased if epinephrine is not used as an
   intravascular marker

Answer 91

B

Question 92

3. All the following are branches of the lumbar plexus EXCEPT
A. Genitofemoralis nerve
B. Femoral nerve
C. Sural nerve
D. Iliohypogastric nerve

Answer 92

C

Question 93

4. At the level of the popliteal fossa, the sciatic nerve is located:
   A. Medial to the femur and anterior to the popliteal artery
   B. Between the biceps femoris and the semimembranous muscles, posterior to the
   popliteal artery
   C. Medial to the semimembranosus muscles and posterior to the popliteal artery
   D. Posterior to the femur and anterior to the popliteal artery

Answer 93

B

Question 94

5. Which of the following is themost common side effect following interscalene brachial
plexus block?
A. Horner’s syndrome
B. Hemidiaphragmatic paresis
C. Recurrent laryngeal nerve block
D. Pneumothorax

Answer 94

B

Question 95

1. The use of ultrasound during administration of a nerve block helps to visualize
   A. Target nerve and the collateral structures
   B. Block needle
   C. Real-time spread of the local anesthetic solution
   D. All of the above

Answer 95

1. The answer is D.

Question 96

2. An effective, precise regional anesthetic technique can make significant contribution
   to multimodal approach to pain management. Which of the following is FALSE
   regarding multimodal analgesia:
   A. It reduces dose-dependant side effects of individual agents
   B. The combined analgesic effects are simply additive
   C. Analgesic effect is exerted through multiple pathways
   D. Improvement of overall patient satisfaction

Answer 96

2. The answer is B. The combined effect is synergistic. The combined effect is more than the
   sum of the analgesic effects of individual agents.

Question 97

3. Regarding US imaging for peripheral nerve block
   A. Long-axis view is always used
   B. Short-axis view is always used
   C. A short-axis view becomes long-axis view when the probe is rotated 90◦
   D. A short-axis view becomes long-axis view when the probe is rotated 180◦

Answer 97

3. The answer is C. Both short- and long-axis views are used depending on the operator
   preferences.

Question 98

4. US-guided nerve block is specifically indicated when performing nerve blocks in:
A. The presence of a coagulopathy
B. Trauma
C. Abnormal anatomy
D. All of the above

Answer 98

4. The answer is D.

Question 99

5. All of the following statements regarding ultrasound waves are true EXCEPT
   A. Waves have a frequency >20 kHz
   B. Frequencies of 7–15 mHz are used for regional anesthesia
   C. Lower frequencies attenuate more than higher frequencies
   D. Higher frequencies will provide higher resolution

Answer 99

5. The answer is C. Lower frequencies attenuate less in comparison with higher frequencies.

Question 100

1. Which is a component of labor pain?
A. Cervical dilatation
B. Myometrical ischemia
C. Vaginal distention
D. All of the above

Answer 100

1. The answer is D

Question 101

2. Options for analgesia for the second stage of labor include all of the following
EXCEPT
A. Single-dose spinal
B. Lumbar sympathetic block
C. Pudendal nerve
D. Epidural block

Answer 101

2. The answer is B. Lumbar sympathetic block provides analgesia for the first stage of labor
   but will not provide relief for the discomfort associated with vaginal and perineal pain.

Question 102

3. Maternal changes associated with labor include all of the following EXCEPT
A. Increased minute ventilation
B. Increased cardiac output
C. Respiratory acidosis
D. Increased endogenous epinephrine

Answer 102

3. The answer is C.

Question 103

4. Labor analgesia can be administered
A. Not before 5 cm dilatation
B. Only when Lamaze techniques fail
C. At maternal request
D. Only by an anesthesiologist

Answer 103

4. The answer is C.

Question 104

1. The approximate incidence of neuropathic pain in the general population is closest to
A. 1%
B. 5%
C. 10%
D. 15%

Answer 104

1. The answer is B. The prevalence of neuropathic pain in the general population currently
   is estimated to be between 3.3 and 8.2%. The prevalence of neuropathic pain is markedly
   higher among patients with diseases known to cause neuropathic pain, such as diabetes
   (40–50%), HIV infections (38–62%), and multiple sclerosis (27.5%).

Question 105

2. Signs and symptoms most suggestive of neuropathic pain include which one of the
following:
A. Anosmia
B. Depression
C. Hyperalgesia
D. Hypothermia

Answer 105

2. The answer is C. Hyperalgesia is an increased pain response to a suprathreshold noxious
   stimulus and is the result of abnormal processing of nociceptive input. Patients with
   neuropathic pain may complain, for example, that a simple pinprick and venipuncture
   are exquisitely painful experiences and are common clinical findings in neuropathic pain
   states.

Question 106

3. Which of the following medications is LEAST effective in the treatment of neuropathic
pain?
A. Gabapentin
B. Duloxetine
C. Naproxen
D. Oxycodone

Answer 106

3. The answer is C. Simple analgesics such as acetaminophen and non-steroidal antiinflammatory
   medication are usually ineffective in pure neuropathic pain but may help
   with a coexisting nociceptive condition (e.g., sciatica with musculoskeletal low back pain).

Question 107

4. Which of the following anticonvulsants has been approved by the FDA in the treatment
of neuropathic pain?
A. Phenytoin
B. Topirmate
C. Valproate
D. Gabapentin

Answer 107

4. The answer is D. There are three anticonvulsants currently approved by the FDA for
   the treatment of various neuropathic pain syndrome, including: 1. gabapentin approved
   for postherpetic neuralgia, 2. pregabalin approved for both postherpetic neuralgia and
   diabetic peripheral neuropathy, and 3. carbamazepine which has been approved for the
   treatment of trigeminal neuralgia.

Question 108

1. Raynaud’s phenomenon occurs as result of vasospasm and it has all the following
   features EXCEPT
   A. Emotional stimulus is not a trigger
   B. It can affect ears and nose
   C. Signs include pain and pallor of affected part
   D. Heat can provide analgesia

Answer 108

1. The answer is A. Raynaud’s commonly affects fingers and toes. It is precipitated by cold
   and emotional stimuli and relieved by the application of heat.

Question 109

2. Which of the following is not true regarding treatment of visceral pain?
   A. Acute visceral pain often does not require any therapeutic intervention
   B. Sympathetic blockade is an option for chronic visceral pain
   C. Ketamine has the added benefit of counteracting “wind-up phenomenon”
   D. Vagolytic agents are contra indicated

Answer 109

2. The answer is D. Vagolytics such as atropine can be used to treat spasmodic visceral pain.

Question 110

3. In Sickle cell anemia, the following is true of a sickle cell crisis EXCEPT
   A. Present with acute chest pain, abdominal pain, or bone pain
   B. Dehydration can worsen the effects of sickling
   C. Oxygen therapy is mandatory
   D. Treating pain has no effect in shortening the duration of the acute phase.

Answer 110

3. The answer is D. Sickling of red cells occurs when the hemoglobin becomes desaturated.
   Dehydration worsens the effects of sickling. Sickle cell crisis occurs secondary to vascular
   occlusion by the sickled red cells, leading on to ischemia. This can affect lungs,
   bone marrow, and the abdomen, and present as a sickle crisis. Correction of hypoxia and
   dehydration is vital in reversing sickling and its effects.

Question 111

4. The following statement is true regarding electro therapy for ischemic pain
   A. Spinal cord stimulation is an option for relieving pain and salvaging the limb
   B. TENS has a role in rehabilitation
   C. Both A and B are true
   D. Both A and B are false

Answer 111

4. The answer is C.

Question 112

1. The following statements are true regarding fibromyalgia EXCEPT:
   A. It more commonly affects male population
   B. It is associated with unidentifiable structural and inflammatory causes
   C. It is associated with co-morbid conditions such as anxiety and depression
   D. It affects approximately 5 million people in the United States

Answer 112

1. The answer is A. Fibromyalgia has female preponderance with a ratio of 9:1.

Question 113

2. Which of the following is (are) seen in fibromyalgia?
   A. Decreased levels of excitatory amino acids in the CSF
   B. Hypothalamus–pituitary and adrenal axis suppression
   C. None of the above
   D. All of the above

Answer 113

2. The answer is C. In fibromyalgia, there is activation of hypothalamo–pituitary–adrenal
   axis and elevated levels of excitatory amino acids, neurotropins, and substance P have
   been noted in the CSF.

Question 114

3. Which of the following is a feature of myofascial pain syndrome?
   A. Presence of trigger points in the skeletal muscles
   B. Absence of referred pain from trigger points
   C. Taunt bands in the muscles are not a feature
   D. Botox injection is not an effective therapeutic option

Answer 114

3. The answer is A. Pressure on trigger points, which could be felt as taunt bands, often
   reproduces the typical pain experienced by the patient. Botox injection is a treatment
   option.

Question 115

4. A 70-year-old woman presents with pain and morning stiffness of her right knee. She
   has been suffering from this for the past 6 months. She mentions that the pain and
   stiffness improve with activity. What would be the most likely finding if an X-ray of
   the right knee was ordered?
   A. Narrowing of the joint space
   B. A hairline fracture of the patella
   C. Presence of osteophytes
   D. Both A and C

Answer 115

4. The answer is D. She is most likely to be suffering from osteoarthritis.

Question 116

5. In the above patient, you make a diagnosis of osteoarthritis. On routine blood testing
   you notice that she has elevated serum creatinine. Given this finding, the following
   medication can be used to control her pain:
   A. Ketorolac
   B. Celecoxib
   C. Acetaminophen
   D. Ibuprofen

Answer 116

5. The answer is C. It is desirable to avoid NSAIDs in view of the elevated serum creatinine.

Question 117

1. About 60% of patients suffer from back pain and majority of these cases have benign
   etiology. Which of the following symptoms/signs may indicate pathology related to a
   malignant/infectious disease process
   A. Fever and night sweats
   B. Loss of bladder or bowel control
   C. Weight loss
   D. All of the above

Answer 117

1. The answer is D. History of cancer and progressive neurological deficit are other red flags.

Question 118

2. A 40-year-old male is complaining of lower back pain radiating to the buttocks and
   thighs. On examination, there is localized tenderness over the paravertebral muscles
   and the neurological examination is normal. Which of the following could be
   true?
   A. He could be suffering from nerve root pain
   B. He could be suffering from facet joint pain
   C. Blocking the medial branch of the posterior rami at one level can be diagnostic
   D. B and C are true

Answer 118

2. The answer is B. For diagnosis, two medial branches need to be blocked at each level.
   Nerve root pain usually radiates below the knees.

Question 119

3. Risk factors for neck pain include
A. Psychological factors
B. Presence of degenerative disc disease and facet disease
C. Sitting for long periods at work
D. Stress at work

Answer 119

3. The answer is D.

Question 120

4. Which of the following statements regarding neck pain is FALSE?
   A. Pain in the upper neck is likely to originate from C1–2
   B. Pain in the lower neck is likely from C5–6 and C6–7
   C. Neck pain can be referred to the head
   D. Neck pain can result from a pathological lesion in the throat

Answer 120

4. The answer is A. The upper neck pain is likely to originate from C2–3

Question 121

5. Which of the following is the most effective treatment for acute neck pain?
   A. NSAIDs combined with muscle relaxants
   B. Opioids, which are effective as potent analgesics
   C. Simple neck exercises to keep the neck mobile and increase the range of motion
   D. Immobilization of the neck using cervical collar for 3 months

Answer 121

5. The answer is C.

Question 122

1. A 20-year-old woman with a BMI of 35 is complaining of a headache that she has had
   for the last 6 months. She feels it “all over the head” as a constant dull pain, associated
   with diplopia. CT scan of the head shows cerebral edema and small lateral ventricles
   without any midline shift. Possible diagnostic and therapeutic considerations are
   A. She is suffering from benign intracranial hypertension and lumbar puncture is
   contraindicated as the intracranial pressure is elevated
   B. The diagnosis is tension headache and it is likely to respond to NSAIDS, caffeine,
   tricyclic antidepressants, or TENS
   C. She has a space-occupying lesion and the treatment is surgery or chemotherapy
   D. None of the above

Answer 122

1. The answer is D. The diagnosis is pseudotumor cerebri and the treatment options include
   acetazolamide, mannitol, digoxin, steroids, and surgical procedures like lumbar puncture.
   Obesity is a risk factor for this condition.

Question 123

2. In the classic migraine
   A. There is absence of aura
   B. There is a stronger familial inheritance
   C. One of the diagnostic criteria is at least five headaches lasting 4–72 h each
   D. scintillating lights and visual scotomas are not presenting symptoms

Answer 123

2. The answer is B. Aura is a feature of classic migraine. C is a feature of common migraine.
   Aura can have visual and sensory components.

Question 124

3. Which of the following supports the diagnosis of a cluster headache?
   A. Unilateral ocular pain associated with lacrimation
   B. Diplopia
   C. Headache lasting less than 15 min
   D. The headache never occurs during sleep

Answer 124

3. The answer is A. Diplopia is not a feature of cluster headache. Attacks last from 15 min to
   hours and characterized by nightly occurrences.

Question 125

4. Cluster headache is managed by
   A. Oxygen therapy for an established headache
   B. Intranasal capsaicin to reduce the intensity of headache
   C. Ergotamine, which is useful during the acute phase
   D. Non-opioids to minimize the risk of addiction to opioids

Answer 125

4. The answer is B. Ergotamine has a preventive role while oxygen therapy is used in the
   early phase of the cluster headache. Opioids can be used if other agents fail to relieve pain.

Question 126

5. Blindness may be a presenting feature in
A. Retinal migraine
B. Temporal arteritis
C. Pseudo tumor cerebri
D. Tension headache

Answer 126

5. The answer is B.

Question 127

1. Regarding Cancer-related pain
   A. Radiotherapy is always curative
   B. 25% of patients with advanced cancer suffer from pain
   C. Medical treatment is effective in up to 90% of patients
   D. Interventions have a limited role in its management

Answer 127

1. The answer is C. Cancer patients experience visceral, somatic, and neuropathic pain or a
   combination of these. Pain can result from radiotherapy. Ninety percent of patients with
   advanced cancer suffer from pain. Interventions have a role in controlling cancer pain
   which is resistant to other forms of treatment.

Question 128

2. Which of the following statements is true regarding WHO analgesic ladder for cancer
   pain treatment?
   A. Strong opioids are always indicated
   B. Severe intractable pain is treated with interventional procedures along with opioids
   and adjuvant agents
   C. Anticonvulsants have no role
   D. Modified analgesic ladder has five steps

Answer 128

2. The answer is B. Opioids are not indicated if the pain is mild. Anticonvulsants can be used
   as adjuvants, and the modified analgesic ladder has four steps

Question 129

3. Combining long- and short-acting opioids to control moderate to severe cancer pain
   A. Is indicated when the patient is on long-acting opioids and the pain is poorly
   controlled
   B. Is ideal when the patient experiences moderate to severe pain around the clock
   C. Can be helpful is the PRN dose of the short-acting opioid is increased gradually until
   it is about 20% of the total opioid intake
   D. Can be useful to treat breakthrough pain with the addition of a long-acting agent

Answer 129

3. The answer is B. Short-acting opioids are introduced initially to treat moderate to
   severe cancer pain. Long-acting opioids are added when inadequate analgesia is suggested
   by the persisting pain. Small doses of long-acting opioids are added to PRN doses
   of short-acting opioids until the contribution from the latter is one-fifth of the total
   daily opioid requirement. Breakthrough pain is covered by PRN dose of a short-acting
   opioid.

Question 130

4. Radiotherapy for cancer pain management
   A. Can be used for pain relief if the tumor is invading bone or soft tissue
   B. Can be used to reduce mass effect due to tumor
   C. Can be utilized as hemi-body radiation in some cases
   D. All of the above

Answer 130

4. The answer is D. In case of widely disseminated bone metastases, hemi-body irradiation
   is an option for pain relief.

Question 131

5. An 80-year-old man undergoes a neurolytic injection for cancer pain relief. A few
   hours later he complaints of voice hoarseness, weakness of all four extremities, and
   inability to lift his eyelid. He is most likely suffering from complications of
   A. Celiac plexus block
   B. Subarachnoid block
   C. Stellate ganglion block
   D. Superior laryngeal nerve block

Answer 131

5. The answer is C.

Question 132

1. The purpose of the Guidelines for Pain Management, as defined by The American
   Society of Anesthesiology Task Force, is all of the following EXCEPT
   A. Optimize pain control
   B. Minimize adverse outcomes and costs
   C. Enhance functional abilities, physical and psychological well-being
   D. Achieve a pain-free state

Answer 132

1. The answer is B. CHEOPS can have a maximum score of 13.

Question 133

2. All of the following statements are true regarding intrathecal morphine EXCEPT
   A. Respiratory depression, if occurs, will happen in the first 2 h
   B. Its hydrophilic nature imparts prolonged analgesia
   C. Intrathecal morphine warrants monitoring for hypoxia
   D. Pruritus is a known side effect

Answer 133

2. The answer is A. Intrathecal morphine can produce biphasic respiratory depression, the
   delayed depression occurring after 12 h of administration.

Question 134

3. Which of the following is true regarding the use of PCA in pediatric pain management?
   A. It is the most common form of intravenous opioid delivery
   B. It is never used below the age of 2 years
   C. Short-acting opioids are preferred
   D. Basal infusion of opioids is never used

Answer 134

3. The answer is A. Though controversial, it can be used in younger children. Longer-acting
   opioids such as morphine and hydromorphone are commonly employed in PCA.

Question 135

4. A 6-month-old infant undergoes inguinal herniotomy. The following option is not an
   option for postoperative pain relief:
   A. Caudal analgesia
   B. Infiltration of wound with local anesthetic
   C. Rectal acetaminophen
   D. Intrathecal opioid

Answer 135

4. The answer is D. When combining A and B, care should be taken not to exceed the total
   maximum dose of local anesthetic agent used.

Question 136

5. The maximum recommended dose of bupivacaine in pediatric age group is
A. 2 mg/Kg
B. 3 mg/Kg
C. 4 mg/Kg
D. 5 mg/Kg

Answer 136

5. The answer is B.

Question 137

1. Which of the following statement is true about cocaine?
   A. It is a directly acting sympathomimetic
   B. Cardiomyopathy is a known complication of cocaine abuse
   C. Hypertension leads to increased bleeding when used as a topical anesthetic
   D. It does not produce mydriasis

Answer 137

1. The answer is B. It is an indirectly acting sympathomimetic. It produces beneficial
   vasoconstriction when used as a topical agent.

Question 138

2. Choose the matched pair from the following:
   A. Continued use of a given dose producing diminishing effects = tolerance
   B. Drug class-specific withdrawal syndrome that can be produced by abrupt cessation =
   addiction
   C. Need to increase medication as a result of a progression of the disease = pseudo
   addiction
   D. Behaviors that may mimic those commonly associated with opioid abuse in the
   presence of unrelieved pain = pseudo tolerance

Answer 138

2. The answer is A. B is suggestive of physical dependence, C is pseudo tolerance, and D is
   pseudo addiction.

Question 139

3. Management of acute pain in the patient with history of opioid abuse involves
   A. Defining the pain syndrome and treating the underlying disorder
   B. Relying only on opioid-based therapies as none of the other therapies might not work
   C. Allowing the patient to choose the drugs.
   D. Signing of opioid contract is mandatory

Answer 139

3. The answer is A.

Question 140

4. Guidelines for prescribing drugs with a potential for addiction to a patient with a
   history of drug abuse include
   A. Setting clear rules and expectations for you and the patient, and having both sign an
   agreement
   B. Obtaining random urine screens
   C. Monitoring for lost or stolen prescriptions
   D. All of the above

Answer 140

4. The answer is D.

Question 141

5. Important considerations in a pregnant patient with a history of opioid abuse
   include
   A. Prescribing of methadone is a standard practice
   B. The use of buprenorphine or naltrexone is not as safe as methadone
   C. Opioid detoxification is contraindicated during the second trimester
   D. Methadone metabolism decreases during pregnancy

Answer 141

5. The answer is A.

Question 142

1. All of the following statements regarding physiological changes in the elderly are true
   EXCEPT
   A. Diastolic dysfunction is increased in the elderly.
   B. Serum creatinine level does not decrease with aging.
   C. Elderly patients have a higher volume of distribution.
   D. The lean body mass increases with age.

Answer 142

1. The answer is D. Lean body mass decreases with aging.

Question 143

2. Which of the following statements about opioid use in the elderly is true?
   A. It is safe to use meperidine in an elderly patient with renal dysfunction.
   B. Opioid doses should not be adjusted for age.
   C. Healthy elderly patients are not more prone to respiratory depression by opioids.
   D. The opioid dose should be decreased by 10–25% in the elderly.

Answer 143

2. The answer is D.

Question 144

3. The following statements regarding intervention techniques are true EXCEPT
   A. Elderly patients may have a lower incidence of previously undiagnosed
   coagulopathy.
   B. Interventional techniques can be used in the treatment of moderate to severe acute or
   chronic pain.
   C. Interventional techniques are useful in the management of cancer pain.
   D. Interventional techniques may be contraindicated in patients with dementia,
   Alzheimer’s disease, or other cognitive dysfunction

Answer 144

3. The answer is A.

Question 145

4. A 75-year-old man is admitted with malena and jaundice. His renal function has
   started to deteriorate. He is complaining of abdominal pain. Which of the following
   analgesics is contraindicated?
   A. Acetaminophen
   B. Ketorolac
   C. Morphine
   D. Fentanyl citrate

Answer 145

4. The answer is B. Ketorolac can worsen GI bleeding and renal function. Opioids need to
   be administered with caution.

Question 146

5. Normal PaO2 in an otherwise healthy 80-year-old patient would be approximately
A. 100 mm of Hg
B. 90 mm of Hg
C. 80 mm of Hg
D. 70 mm of Hg

Answer 146

5. The answer is C.

Question 147

1. High-intensity pain experienced in the tooth is the result of
   A. High sensitivity of free nerve endings in the dental pulp
   B. Dense supply of free nerve endings in the dental pulp
   C. Reduced thickness of dentine
   D. Dental pulp being a vascular structure

Answer 147

1. The answer is B. The dental pulp has a rich supply of free nerve endings.

Question 148

2. Which of the following is true regarding the nerve innervation of the tooth?
A. Dentine has Aδ and C fibers
B. Pulp has Aβ and C fibers
C. C fibers are polymodal
D. Lingual nerve is a sensory nerve

Answer 148

2. The answer is C. Dentine has Aβ and Aδ fibers while dentine has Aδ and C fibers.

Question 149

3. A 25-year-old woman presents with throbbing pain in her tooth which is aggravated
   by both hot and cold foods. Which of the following statements is FALSE?
   A. She is suffering from acute pulpitis
   B. Pulp is undergoing degeneration and necrosis
   C. Pain is likely to BE relieved by lying down
   D. X-ray may help in diagnosis

Answer 149

3. The Answer is C. She is most likely suffering from acute pulpitis and the pain is likely to
   worsen in supine position.

Question 150

4. A 22-year-old woman presents with a dental abscess and she is in severe pain. Which
   of the following is the treatment of choice to control her pain?
   A. NSAIDs
   B. Topical application of local anesthetic agents
   C. Nerve blocks
   D. An early surgical drainage of abscess

Answer 150

4. The answer is D. Topical anesthetic might not be effective in presence of an abscess, and
   NSAIDs can provide temporary relief. Nerve block in presence of infection is probably not
   ideal. Definitive treatment is drainage of abscess under appropriate antibiotic coverage.

Question 151

5. Regarding TMJ dysfunction
   A. Application of ultrasound is a treatment option
   B. Tricyclic antidepressants are not useful in the management of pain
   C. Occlusal splints worsen the symptoms
   D. Surgical correction is the first line of treatment

Answer 151

5. The answer is A.