Chapter 09 - Pain: Lewis’s Medical-Surgical Nursing, 12th Edition

Test Bank For Lewis's Medical-Surgical Nursing, 12th Edition by Mariann M. Harding, Jeffrey Kwong, Debra Hagler Chapter 09 - Pain: Lewis’s Medical-Surgical Nursing, 12th Edition MULTIPLE CHOICE 1. Which question asked by the nurse would elicit the most information about the patient‘s metastatic bone cancer pain? A. “How long have you had this pain?” B. “How would you describe your pain?” C. “How often do you take pain medication?” D. “How much medication do you take for pain?” ANS: B Asking a question that addresses the patient‘s multidimensional experience with the pain will elicit more information than asking for more specific information. All of these questions are appropriate, but the response beginning “How would you describe your pain?” is the best initial question because of its broad nature. 2. A patient who has had good control of chronic pain using a fentanyl (Duragesic) patch reports rapid onset pain at a level 9 (0 to 10 scale) and requests “something for pain that will work quickly.” Which type of pain is this patient describing? A. Somatic pain B. Referred pain C. Neuropathic pain D. Breakthrough pain ANS: D Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system. Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue. 3. Which factor would the nurse expect to decrease after administering ibuprofen to a patient? A. Pain impulses in the spinal cord B. Brain sensitivity to painful stimuli C. Production of pain-sensitizing chemicals D. Modulating effect of the descending nerves ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by NSAIDs. 4. A nurse assesses a patient with chronic cancer pain who is receiving imipramine (Tofranil) in addition to long-acting morphine (MS Contin). Which patient statement indicates that the patient is receiving adequate pain control? A. “I‘m not anxious during the day.” B. “Every night I get 8 hours of sleep.” C. “I can accomplish activities without much discomfort.” D. “Ifeel less depressed since I‘ve been taking the Tofranil.” ANS: C Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication is also prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level. 5. A patient with chronic back pain has learned to control the pain with the use of imagery and hypnosis. The patient‘s spouse asks the nurse how these techniques work. Which response by the nurse is accurate? A. “The strategies work byaffecting the perception of pain.” B. “These techniques block the pain pathways of the nerves.” C. “These strategies prevent transmission of stimuli from the back to the brain.” D. “The therapies slow the release of chemicals in the spinal cord that cause pain.” ANS: A Cognitive therapies affect the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn. 6. A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain now reports level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action would the nurse take? A. Administer lorazepam 1 mg orally. B. Give ibuprofen 400 to 800 mg orally. C. Offer immediate-release morphine 30 mg orally. D. Suggest the patient take amitriptyline 10 mg orally. ANS: C The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. Lorazepam and amitriptyline may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of antianxiety agents for pain control is inappropriate because this patient‘s anxiety is caused by the pain. 7. A patient with chronic neck pain is seen in the clinic for follow-up. Which question would the nurse select as most useful for evaluating the pain management outcome? A. “Has there been a change in pain location?” B. “Can you describe the quality of your pain?” C. “How would you rate your pain on a 0 to 10 scale?” D. “Does pain keep you from activitiesthat you enjoy?” ANS: D The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions are also appropriate to ask, but information about patient function is more useful in evaluating effectiveness. 8. A patient with a deep partial thickness burn has been receiving hydromorphone through a patient-controlled analgesia (PCA) pump for 1 week. The nurse caring for the patient during the previous shift reports that the patient woke up frequently during the night reporting pain. Which action would the nurse take? A. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. B. Consult with the health care provider about using a different treatment protocol to control the patient‘s pain. C. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. D. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal. ANS: B PCAs are best for controlling acute pain. This patient‘s history indicates a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the ongoing problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA. 9. A patient receiving epidural morphine has not voided for over 10 hours. Which action would the nurse take first? A. Place an indwelling urinary catheter. B. Monitor forsigns of narcotic overdose. C. Ask if the patient feels the need to void. D. Encourage the patient to drink more fluids. ANS: C Urinary retention is a common side effect of epidural opioids. First, ask whether the patient feels the need to void as that may solve the problem. Urinary retention is a possible side effect that does not indicate overdose. Placing an indwelling catheter requires an order from the health care provider. Usually an in-and-out catheter is performed to empty the bladder if the patient is unable to void because of the risk of infection with an indwelling catheter. Encouraging oral fluids may lead to bladder distention if the patient is unable to void but might be useful if a patient who is able to void has a fluid deficit. 10. A home hospice patient with terminal cancer has a respiratory rate of 11 breaths/min and reports severe pain. Which action should the nurse take? A. Tell the patient that increasing the morphine will cause the respiratory drive to fail. B. Titrate the prescribed morphine dose up until the patient indicates adequate pain relief. C. Inform the patient that more morphine can be given if the respiratory rate is at least 12. D. Administer a nonsteroidal antiinflammatory drug (NSAID) to improve patient pain control. ANS: B The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic such as ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient‘s respiratory rate. 11. The nurse is completing the medication reconciliation form for a patient admitted with chronic cancer pain. Which medication would be of most concern to the nurse? A. Amitriptyline 50 mg at bedtime B. Ibuprofen 800 mg 3 times daily C. Oxycodone (OxyContin) 80 mg twice daily D. Meperidine (Demerol) 25 mg every 4 hours ANS: D Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are appropriate medications for long-term pain management. 12. Which medication would the nurse anticipate being prescribed for a newly admitted patient with cancer who describes the pain as “deep, aching at a level 8 on a 0-10 scale”? A. Ketorolac tablets B. Fentanyl (Duragesic) patch C. Hydromorphone (Dilaudid) IV D. Acetaminophen (Tylenol) tablets ANS: C The patient‘s pain level indicates that a rapidly acting medication such as an IV opioid is needed. The other medications may also be appropriate to use at other times but will not work as rapidly or as effectively as the IV hydromorphone. 13. The nurse is caring for a patient who has diabetes and reports chronic, burning leg pain even when taking oxycodone (OxyContin) twice daily. Which prescribed medication would the nurse anticipate administering as an adjuvant to decrease the patient‘s pain? A. Aspirin B. Amitriptyline C. Celecoxib (Celebrex) D. Acetaminophen (Tylenol) ANS: B The patient‘s pain symptoms are consistent with neuropathic pain and the tricyclic antidepressants such as amitriptyline are effective for treating this type of pain. The other medications are more effective for nociceptive pain. 14. A patient who uses a fentanyl (Duragesic) patch for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone tablets, but the patient is asleep when the nurse returns with the medication. Which action would the nurse take? A. Wake the patient and administer the hydrocodone. B. Suggest the use of nondrug therapies for pain relief. C. Wait until the patient wakes up and reassess the pain. D. Consult with the health care provider about the fentanyl dose. ANS: A Because patients with chronic pain frequently use withdrawal and decreased activity as coping mechanisms for pain, sleep is not an indicator that the patient is pain free. The nurse should wake the patient and administer the hydrocodone. 15. The health care provider has prescribed the following medications for a middle-aged patient who uses long-acting morphine (MS Contin) but still has unrelieved chronic back pain. Which medication would the nurse question? A. Morphine B. Dexamethasone C. Butorphanol (Stadol) D. Celecoxib (Celebrex) ANS: C Opioid agonist-antagonists such as butorphanol can precipitate opioid withdrawal if used in a patient who is physically dependent on mu agonist drugs such as morphine. The other medications are appropriate for chronic back pain. 16. A patient who had abdominal surgery yesterday is receiving morphine through a patient-controlled analgesia (PCA) pump. Which action by the nurse is a priority? A. Assessing for nausea B. Auscultating bowel sounds C. Monitoring respiratory rate D. Evaluating forsacral redness ANS: C The patient‘s respiratory rate is the highest priority of care while using PCA medication because of the possible respiratory depression. The other areas also require assessment but do not reflect immediately life-threatening complications. 17. A patient who has fibromyalgia reports pain at level 7 (0-10 scale). The patient tells the nurse, “I feel depressed because I ache too much to play golf.” Which patient goal has the highest priority when the nurse is developing the treatment plan? A. The patient will report pain at a level 2 of 10. B. The patient will be able to play a round of golf. C. The patient will exhibit fewer signs of depression. D. The patient will say that the aching has decreased. ANS: B For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse should also assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play golf is the most appropriate. 18. A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic arthritic joint pain after a traumatic injury reports nausea and abdominal fullness. Which action would the nurse take initially? A. Administer the prescribed antiemetic medication. B. Order the patient a clear liquid diet until the nausea decreases. C. Tell the patient that the nausea should subside in about a week. D. Consult with the health care provider about using a different opioid. ANS: A Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics usually are prescribed to treat this expected side effect. The best choice would be to administer the antiemetic medication so the patient can eat. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops and the nausea will subside in about a week, it is not appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea but may not provide needed nutrients for injury healing. 19. A patient with terminal cancer–related pain and a history of opioid abuse reports breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action would the nurse take first? A. Use distraction bytalking about things the patient enjoys. B. Suggest the use of alternative therapies such as heat or cold. C. Administer the prescribed PRN immediate-acting morphine. D. Consult with the doctor about increasing the MS Contin dose. ANS: C The patient‘s pain requires rapid treatment, and the nurse should administer the immediate-acting morphine. Increasing the MS Contin dose and use of alternative therapies and distraction may also be needed, but the initial action should be to use the prescribed analgesic medications. 20. Which nursing action could the nurse delegate to assistive personnel (AP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? A. Check the skin under the heating pad. B. Obtain the respiratory rate every 2 hours. C. Ask the patient whether pain control is effective. D. Monitor sedation using the sedation assessment scale. ANS: B Obtaining the respiratory rate is included in AP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice. 21. A patient who is using both a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action would the nurse take first? A. Remove the fentanyl patch. B. Obtain complete vital signs. C. Notify the health care provider. D. Administer prescribed PRN naloxone. ANS: A The assessment data indicate a possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring are also needed, but the patient‘s data indicate that more rapid action is needed. The respiratory rate alone is an indicator for immediate action before obtaining blood pressure, pulse, and temperature. 22. The nurse reviews the medication orders for an older patient with arthritis in both hips who reports level 3 (0-10 scale) hip pain while ambulating. Which medication would the nurse offer as initial therapy? A. Naproxen 200 mg orally B. Oxycodone 5 mg orally C. Acetaminophen 650 mg orally D. Aspirin (acetylsalicylic acid) 650 mg orally ANS: C Acetaminophen is the best first-choice medication. The principle of “start low, go slow” is used to guide therapy when treating older adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Nonopioid analgesics are used first for mild to moderate pain, although opioids may be used later. Aspirin and nonsteroidal antiinflammatory drugs are associated with a high incidence of gastrointestinal bleeding in older patients. 23. The nurse on a surgical inpatient unit is caring for several patients. Which patient would the nurse assess first? A. Patient with postoperative pain who received morphine sulfate IV 15 minutes ago B. Patient who received hydromorphone (Dilaudid) 1 hour ago and is currently asleep C. Patient who was treated for pain just prior to return from the postanesthesia care unit D. Patient with neuropathic pain who is scheduled to receive a dose of hydrocodone (Lortab) now ANS: C The risk for oversedation is greatest in the first 4 hours after transfer from the postanesthesia care unit. Patients should be reassessed 30 minutes after receiving IV opioids for pain. A scheduled oral medication does not need to be administered exactly at the scheduled time. A patient who falls asleep after pain medication can be allowed to rest.