PrepU Comfort & Rest Flashcards
The nurse is caring for a cl. who report N/V for 1 week. How will the nurse document (SATA)
A. neuropathic
B. referred
C. chronic
D. acute
E. visceral
D, E
Visceral pain associated with disease or injury.
Acute pain lasts for a few seconds to less than 5 months.
A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse explains the functioning of PCA to the client. What is the MAIN advantage of PCA?
A. Pain is relieved steadily and slowly
B. Reduced visits to HCP
C. The client is actively involved in pain management
C. = self-administers medication
-pain relief is rapid due to IV admin.
A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?
A. Acute
B. Chronic
C. referred
D. limited
C: pain from abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage.
Acute pain = more sharp and severe and lasts from 3 to 5 months
Chronic pain= lasting more than 12 weeks
Which is considered to be the most potent neuromodulators?
A. afferent
B. efferent
C. endorphins
D. enkephalins
C: endorphins and enkephalins are opioid neuromodulators, endorphins are more powerful and have prolonged analgesic effects.
While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant?
A. Braden scale
B. FACES scale
C. FLACC scale
D. Apgar score
C: (face, legs, activity, cry, and consolability) measures pain for children between ages 2 months and 7 years.
Braden scale is used to predict pressure sore risk
FACES assesses pain in older children using a series of faces, ranging from happy to crying.
Apgar score assesses how well infant tolerated birthing process (done at birth).
A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse’s BEST intervention in this situation?
A. ignore the boy’s pain, as he is not complaining
B. Ask the boy to draw a cartoon about the color or shape of his pain
C. Medicate the boy with analgesics to reduce anxiety of experiencing pain
D. Distract the boy so he does not notice his pain.
B. Addressing anxiety does not take care of pain
What type of process is involved in pain relief measures done by performing acupressure?
Cutaneous stimulation. E.G. Massage, application of heat and cold, and transcutaneous electrical nerve stimulations (TENS)
Also called “Gate-control theory”
Mechanism of action of endogenous opioids:
Binds to opioid receptor sites throughout the CNS = blocks release or production of pain-transmitting substances.
Most common side effects associated with opioid use:
sedation, nausea, and constipation
The nurse is caring for a client who reports having kidney pain from a urinary tract infection for 3 days. How will the nurse describe this pain when reporting off via SBAR? (SATA)
A. cutaneous
B. somatic
C. visceral
D. referred
E. neuropathic
F. acute
G. chronic
C, F
Visceral pain: discomfort arising from internal organs; associated with disease or injury: appendicitis (inflammation and vermiform appendix)
You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so?
A. First question I ask
B. When obtaining client vital signs
C. At discharge
D. At several points throughout your history-taking
B
A client has been experiencing persistent back pain despite the regular use of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). The nurse should encourage the client to speak with the care provider about the use of what adjuvant medication for pain control?
A. antiplatelet aggregator
B. antidepressant
C. cardiotonic
D. potassium-sparing diuretic
B: Antidepressants have been shown to be effective in treating and managing nerve pain. Mechanism of action unkown.
A client prescribed pain medication around the clock experiences pain 1 hours before the next dose of pain medication is due. Which is the most appropriate action by the nurse?
A. Assess for medication prescription for breakthrough pain
B. Tell the pt. they will have to wait for 1 hour
C. Administer the next pain medication dose
D. Assess the pt. for opioid addiction
A. Breakthrough pain is temporary flare-up of moderate to severe pain that occurs even when the client is taking pain medication around the clock.
When can breakthrough pain occur?
Before the next dose of analgesic is due (end of dose pain)
What is breakthrough pain treated with most effectively?
Supplemental doses of a short-acting opioid taken on an “as needed bases”
Which types of pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves?
Somatic pain
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After administration of an opioid anesthesia, the nurse observes the client’s resp. rate decreases to 8 breaths per minute. What is the priority action of the nurse?
A. Place cl. in supine position
B. Administer a smaller dose when the next dose is to be given.
C. Administer 0.4 mg of naloxone
D. Perform CPR
C. The client is experiencing impending respiratory arrest due to effect of medication - should be reversed immediately. CPR is only performed if cl. is in full arrest.
Supine position may further decrease respirations.
The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is MOST appropriate:
a. if a client is experiencing adverse effects, a peripheral IV line should be inserted to allow immediate administration of emergency drugs, if warranted.
b. the anesthesiologist/pain management team should be notified immediately if the client’s resp. rate is below 10 breath/min.
c. if the client gets a headache administer a low dose of OxyContin
d. the nurse should anticipate resistance when removing the epidural cathetor
b. breath rate below 10 breaths/min should be notified to the anesthesiologist/pain management team as should unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache.
-no other meds. should be administered
-peripheral IV line should already be in place
-resistance should not be felt when removing an epidural cath.
A client has just been started on opioid analgesia for pain control. The nurse assesses the client’s level of sedation using a sedation scale and notes that the client is somewhat drowsy but is easily aroused by voice. The nurse would assign which rating?
2: using sedation scale:
1 = client alert and awake
2 = client slightly drowsy but easy to arouse
3 = client is frequently drowsy, arousable but drifts of to sleep during conversation
A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client’s pain?
A. Wong-Baker
B. CRIES Pain Scale
C. FLACC Scale
D. PAINAD Scale
B : (0-6 m.o.)
Wong-Bake Faces Pain Rating = 3 y.o.
FLACC = infants and children 2 m.o. - 7 y.o.) unable to validate presence of or quantify pain severity
-PAINAD =client with dementia
How should the nurse position the head of the bed for a client receiving epidural opioids?
A. Flat
B. elevated 30 degrees
C. trendelenburg
D. reverse trendelenburg
B: Unless contraindicated. This minimizes upward migration of the opioid in the spinal cord, decreasing risk for resp. depression.
-Trendelenburg is when the feet are higher than the head.
-Reverse Trendelenburg = supine position = head higher than the feet
A client comes to the emergency department complaining of shooting pain in chest. When assessing client pain, which behavioral response would the nurse expect to find?
A. High blood pressure
B. Guarding of the chest area
C. Increase respiratory rate
D. Decreased heart rate
B: Behavioral includes: guarding painful area, grimacing, crying or moaning.
Physiologic (sympathetic) response to moderate pain = increase bp and resp. rate.
-Physiologic (parasympathetic) response to severe pain = decreased HR
A client tells the nurse that they are experiencing stabbing pain in the mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of:
A. diabetic neuropathy
B. trigeminal neuralgia
C. postherpetic neuralgia
D. complex regional pain syndrome
B: symptomology = paroxysoms of lightning-like stabs of intense pain in the distribution of one or more divisions of the trigeminal nerve, the 5th cranial nerve. Pain experienced in mouth, gums, lips, nose, cheek, chin, and surface of the head and may be triggered by everyday activities like talking, eating, shaving, or brushing one’s teeth.
-Postherpetic neuralgia affects nerve fibers and skin, causing burning pain that lasts long after the rash and blisters of shingles disappear, usually from chickenpox virus.
-Complex regional pain syndrome (CRPS) = chronic pain condition that most often affects one limb (arm, leg, hand, or foot), usually after an injury = caused by damage to or malfunction of the peripheral and CNS, developing after injury, surgery, stroke, or heart attack.
-Diabetic neuropathy= nerve damage that can occur if a client has diabetes-causing damages to the nerves in the legs and feet
A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as:
A. Your present pain is worse because you had your packing removed
B. Acute pain tends to increase during the day and is called a routine pain response
C. You will need more pain medication as the days progress
D. I will call your doctor because you may have loosened sutures when walking
B: occurs abruptly after injury or disease and persists until healing occurs. may be associated with anxiety and fear; consistently increases at night and during wound care, ambulation, coughing, and deep breathing
