Pain

Question 1

With Pain which consideration comes first?

1. Treatment is based on patient goals
2. Multidisciplinary approach is needed
3. Patients perception of pain must be accepted
4. Drug side effects must be prevented and managed

Answer 1

3. Patients perception of pain must be accepted

Patient must be believed and acknowledged. Then apply this information to the rest of the answers

Question 2

Which are nurses responsibilities related to the current opiod crisis

1. Recognize that negative attitudes towards substance abusers is a barrier to patient compliance.
2. Access electronic prescriptions drug monitoring program whenever patient recieves an opiod
3. Learn to Recognize S/S of opiod overdose and how to admin Naloxone
4. Use tone of voice and facial expressions that convey acceptance & understanding to patients who are addicted
5. Report healthcare providers who fail to safely prescribe opiods according to the guidelines of CDC

Answer 2

Correct

1. Recognize that negative attitudes towards substance abusers is a barrier to patient compliance.
2. Learn to Recognize S/S of opiod overdose and how to admin Naloxone
3. Use tone of voice and facial expressions that convey acceptance & understanding to patients who are addicted

Incorrect

2. Access electronic prescriptions drug monitoring program whenever patient recieves an opiod - Time consuming & not currently available Nation Wide
3. Report healthcare providers who fail to prescribe opiods according to the guidelines - CDC guidelines are not law and cannot be reported

Question 3

1 day post op. Client in PCA pump complains of pain. Which action do you take first?

1. Deliver the bolus per standing order
2. Contact HCP to ask for increase dose
3. Try nonpharmacological comfort measures
4. Assess pain for location, quality, and intensity

Answer 3

4. Assess pain for location, quality, and intensity

Always assess first. Pain must be assessed post op because it could be related to a Hemorrhage, Infection, tissue swelling

Question 4

Best way to schedule medication for constant pain?

1. As needed at patients request
2. Before painful procedures
3. IV bolus after pain assessment
4. Around-the-clock

Answer 4

4. Around-the-clock

Question 5

Patient with RA states: I feel pretty good, except for pain & stiffness in the morning when I get outta bed.

Which member of the healthcare team would be notified to aid in the patient’s pain.

1. HCP review drug dosage and frequency of pain medication
2. PT for evaluation of function and possible exercise therapy
3. Social Worker locate community resources for complementary therapy
4. Home Health Aid to help with warm shower in the morning

Answer 5

4. Home Health Aid to help with warm shower in the morning

Joint pain & stiffness upon rising are common in RA - it usually resolves throughout the day.

Warm shower or warm compress on affected joints may help, if not involve other members of the health care team.

Always start at the lowest / least invasive & work up wards with therapy

Question 6

When an analgesic is titrated to manage pain, what is the priority goal?

1. Titrate to smallest dose that provides relief with the fewest side effects
2. Titrate upwards until the patient is pain free or an acceptable level is reached
3. Titrate down to prevent toxicity, overdose, and adverse effects
4. Titrate to a dosage that is adequate to meet patients subjective needs.

Answer 6

1. Titrate to smallest dose that provides relief with the fewest side effects

Goal is to control pain while minimize SE.

Sever pain medication is titrated upwards until it is controlled.

Downward titration occurs when pain begins to subside

Question 7

Can NSAIDs be used post op, if there are no Contradictions?

IV opiods are preferred in post op clients instead of oral?

Answer 7

NSAIDS can be given post op as long as no Contradictions

Oral opiods are preferred post op.

Question 8

Patient refuses opiods due to parents influence to “ tough the pain out” due to fear of opiod addiction. Nurse recognizes that Sociocultural dimension of pain is the Priority.

Which question will the nurse ask?

1. Location of pain, and does the pain radiate?
2. Describe the pain, how is the pain affecting you?
3. What do you believe about pain medication & drug addiction?
4. How is the pain affecting your activity level and ability to function?

Answer 8

3. What do you believe about pain medication & drug addiction?

Beliefs, attitudes, and family influences are part of the sociocultural dimension of pain.

Mark K. “One of these things ain’t like the others”

Question 9

Most likely to recieve opiod for an extended period of time?

1. Fibromyalgia
2. Phantom limb pain
3. Progressive pancreatitic cancer
4. Trigeminal neuralgia

Answer 9

3. Progressive pancreatitic cancer (Cancer pain usually gets worse)

Fibromyalgia = non-opids & conjunctive therapy

Trigeminal neuralgia = Antiseizure meds (Carbamazepine)

Phantom limb usually goes away after ambulation

Question 10

Which could be given to a new RN

1. MVA multiple fractures
2. Chronic back pain from work
3. 6 h post-op chest tube
4. Ab cramps from food poisoning
5. Severe headache unknown origin
6. Chest pain history of atherosclerosis

Answer 10

Chronic and Self-Limiting can be given to a new nurse
2. Chronic back pain from work
4. Ab cramps from food poisoning

Acute patients with gas exchange/ Perfusion problems need frequent monitoring
1. MVA multiple fractures
3. 6 h post-op chest tube
5. Severe headache unknown origin
6. Chest pain history of atherosclerosis

Question 11

Client recieves Cyclobenzaprine (muscle relaxant) and the AP reports their RR is 10 per/min. Which action is the priority

1. Prepare for gastric lavage and administeringactivated charcoal.
2. Assess the patients responsiveness and respiratory status
3. Obtain bag-in-valve mask and deliver 20 breaths/mi
4. Double check all prescriptions they are taking.

Answer 11

2. Assess the patients responsiveness and respiratory status.

The nurse is ultimately responsible for assessment

Question 12

Acute migraine
Which is most important to have a discussion with HCP before medication is prescribed

1. Dexamethasone patient has type 2 diabetes
2. Subcutaneous sumatriptan patient took ergotamine 3 hours ago.
3. Valproate sodium and client recently started birth control pills
4. Prochlorperazine and patient drove self to the hospital

Answer 12

3. Subcutaneous sumatriptan patient took ergotamine 3 hours ago.
   Sumatriptan (Migrane Med) should not be taken with ergotamine (Migrane Med) within 24 hrs due to constriction of vessels (Stroke/ MI)

Acute migraines can be treated with
NSAIDS, ACETAMINOPHEN
Migraine Specific Agents ( triptans,dihydroergotamine)
Corticosteroids, Antiemetics or Anticonvulsants ( Valproate sodium & topiramate - except women who may become pregnant)

Dexamethasone may cause increased BS

Prochlorperazine - antipsychotic- Drowsiness

Valproate sodium (treats seizures & bipolar & Migraines) - No for pregnant women

Question 13

Patient is crying and grimacing but denies pain and refuses opiod pain meds because her brother was a Junkie. Which intervention is the priority for this patient

1. Encourage expression and fears and past experiences
2. Respect patient’s wishes and use nonpharmacologic therapies.
3. Explain that addiction is unlikely when opiods are use for acute pain
4. Seek family assistance to support the prescribed therapy.

Answer 13

First, encourage expression. This validates their feelings.

Question 14

Patient cannot report pain. What action would the nurse take first.

1. Closely assess for nonverbal signs
2. Obtain baseline behavior from family
3. Note time of and patients response to last analgesic
4. Give max as-needed dose within the time frame for relief

Answer 14

Obtain baseline behavior from family

Question 15

Client reports to charge nurse that other nurses have been ignoring request for pain meds. What is the nurses initial action?

1. Check MAR for past several days
2. Ask nurse educator to provide in-service training about pain management
3. Perform a complete pain assessment and pain history on patient
4. Have conference with staff to assess care of this patient

Answer 15

4. Have conference with staff to assess care of this patient

Charge nurse must use ADPIE with their staff too.
No need for pain evaluation because they didn’t state were currently in pain. The complaint is about the past performance of the nursing staff

Question 16

Which would you question due to increase risk of opiod overdose

1. ER/LA transdermal fentanyl, fibromyalgia
2. ER/LA oxycode for chronic lower back pain
3. PRN morphine for arthritis in elderly with sleep apnea
4. 90 mg morphine/ daily for hip fracture
5. ER/LA methadone PRN headache pain
6. PCA morphine post-op ab pain

Answer 16

Correct 1 - 5 are questioned

Opioids are not first line choice for Fibromyalgia, Chronic Lower Back Pain, Arthritis, Headache

90 mg is a very high dose.
Usually between 15 - 30

Question 17

Early adverse sign to reaction of opiods.

1. SOB
2. More difficult to arouse
3. Anxious & nervous
4. Pain is worsening

Answer 17

2. More difficult to arouse

Question 18

Issues with giving morphine for head injuries. (2)

Answer 18

Morphine can affect LOC

Depress breathing, increase ICP

Question 19

Most urgent behavior correction for man wearing a fentanyl patch.

1. Enjoys sitting in hottub to relax muscles
2. Prefers patch only on upper chest
3. Saves and reuses old patches
4. Changes patch every 4 days instead of 72 hrs.

Answer 19

1. Hot tub will increase rate at which patch releases drugs

Question 20

Dad gives daughter his narcos. Who should the nurse talk with first.

1. HCP to renew script so client doesn’t run out.
2. Pharmacist to monitor frequency of script refills
3. Social worker to help familiy with health care
4. Home Health Aid to watch for inappropriate medication use by familiy

Answer 20

Social worker.

This will ensure father has his narcos

Question 21

A new nurse after comparing the MAR with the HCP prescription for a patient on a PCA pump, the nurse notices that both the MAR & prescription indicate that the patient will get larger doses at night than during the day.

This confuses the nurse. Who should the clarify this information with.

1. Ask patient if they have worse pain at night
2. Ask HCP to verify larger amount dose
3. Ask pharmacist to confirm dosage on original prescription
4. Ask charge nurse if this is a typical dosage for night time PCA

Answer 21

Ask charge nurse if this is a typical dosage for night time PCA

Comparing MAR & prescription is correct

New nurses should use charge nurses as a resource.

Larger PCA doses are given at night to increase the interval between doses & help patient rest

Question 22

Which direction would you give a AP for a client taking Ketamine

1. Keep environment calm & quiet
2. Watch for and report respiratory distress
3. Offer frequent sips of noncaffinated fluids
4. Keep bed flat & turn frequently

Answer 22

Keep environment calm & quiet

Reduces the psychomimetic effects (hallucinations, delusion, anxiety)

Other side effects of Ketamine include:

N/V
Headaches

(Therefore bed flat, fluids, and frequent turning not a good idea)

Respiratory depression not a SE of Ketamine

Question 23

Which ones should be questioned

1. MS.A 35 female acute Cholelithiasis. Prescribed Morphine 1 - 15 mg IV q2h PRN
2. Mr. B 75 Hip Surgery yesterday. COPD Morphine 2 or 3 mg IV q2h PRN
3. Mr. C 55 acute pancreatitis, history smoking & substance abuse. Prescribed Morphine 1 - 3 mg IV q4h PRN
4. Mrs. D 83 Ankle Fracture, dementia & unable to elevate ankle. Meperidine 25 - 50 mg PO PRN
5. Mr. E 46 bacterial meningitis, severe headaches. Prescribed Codine 15 mg PO 1 - 2 tabs q4h PRN
6. Mr. F 25 abrasions from motorcycle accident. No other trauma noted in ICU Prescribed: Oxycodone w acetaminophen 5/325 PO 1 to 2 tabs q4h PRN
7. Ms. G 57 hysterectomy yesterday fir uterine Prolapse. Opiod naive. Prescribed Fentanyl 50 - 100 mcg IV q2h PRN
8. Mr. H 68 postherpetic neuralgia. Prescribed Morphine 2 to 3 mg IV q4h PRN

Answer 23

PRN opioid ranges from 2 - 6 mg IV q2h

Contradicted

1. Broad ranges like 1 - 15 mg are Contradicted
2. 1 - 3 mg isn’t likely to be enough due to past substance abuse
3. Meperidine is not used in Elderly due to depression of respiration there are safe opiods
4. Mr. F too much acetaminophen >4000 mg daily
5. 100 mcg fentanyl = 10 mg morphine which is too much for a naive client
6. Mr. H postherpetic neuralgia (peripheral nerve caused by the reactivation of the varicella zoster virus) would be treated with Anti-Seizure meds not opiods.

Correct use of opioids

2. Mr. B 2 - 3 mg is appropriate in client woth COPD
3. Mr. E codeine 15 mg PO 1-2 tabs every 4 - 6 hours is appropriate (nurse will check on effectiveness)

Question 24

Early/ late signs of compartment syndrome

Why should urine be checked in suspected compartment syndrome

How to test to compartment syndrome

Answer 24

Early: Pain / paresthesia
Late: Pulselessness / paralysis/ Pallor

Urine maybe dark due to creatinine kinase and myoglobins to enter blood circulation (rhabdomyolysis) leading to kidney failure.

Pressure test