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TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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Chapter12:PainManagement  1.

Thenursewhoisamemberofthepalliativecareteamisassessingapatient.Thepatientindicatesthat hehasbeensavinghisPRNanalgesicsuntilthepainisintensebecausehispaincontrolhasbeen inadequate.Whatteachingshouldthenursedowiththispatient?

A)

Medicationshouldbetakenwhenpainlevelsarelowsothepainiseasiertoreduce.

B)

Painmedicationcanbeincreasedwhenthepainbecomesintense.

C)

Itisdifficulttocontrolchronicpain,sothisisaninevitablepartofthediseaseprocess.

D)

Thepatientwilllikelybenefitmorefromdistractionthanpharmacologicinterventions.

Ans:

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

2.

Twopatientsonyourunithaverecentlyreturnedtothepostsurgicalunitafterkneearthroplasty.One patientisreportingpainof8to9ona0-to-10painscale,whereastheotherpatientisreportingapain levelof3to4onthesamepainscale.Whatisthenursesmostplausiblerationaleforunderstandingthe patientsdifferentperceptionsofpain?

A)

Endorphinlevelsmayvarybetweenpatients,affectingtheperceptionofpain.

B)

Oneofthepatientsisexaggeratinghisorhersenseofpain.

C)

Thepatientsarelikelyexperiencingavarianceinvasoconstriction.

D)

Oneofthepatientsmaybeexperiencingopioidtolerance.

Ans:

A Feedback: Differentpeoplefeeldifferentdegreesofpainfromsimilarstimuli.Opioidtoleranceisassociatedwith chronicpaintreatmentandwouldnotlikelyapplytothesepatients.Thenurseshouldnotassumethe patientisexaggeratingthepainbecausethepatientisthebestauthorityofhisorherexistenceofpain,

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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anddefinitionsforpainstatethatpainiswhateverthepersonsaysitis,existingwheneverthe experiencingpersonsaysitdoes. 3.

Youarefrequentlyassessingan84-year-oldwomanspainaftershesufferedahumeralfractureinafall. Whenapplyingthenursingprocessinpainmanagementforapatientofthisage,whatprincipleshould youbestapply?

A)

Monitorforsignsofdrugtoxicityduetoadecreaseinmetabolism.

B)

Monitorforanincreaseinabsorptionofthedrugduetoage-relatedchanges.

C)

Monitorforaparadoxicalincreaseinpainwithopioidadministration.

D)

Administeranalgesicsevery4to6hoursasorderedtocontrolpain.

Ans:

A Feedback: Olderpeoplemayresponddifferentlytopainthanyoungerpeople.Becauseelderlypeoplehaveaslower metabolismandagreaterratioofbodyfattomusclemasscomparedwithyoungerpeople,smalldosesof analgesicagentsmaybesufficienttorelievepain,andthesedosesmaybeeffectivelonger.Thisfactalso correspondstoanincreasedriskofadverseeffects.Paradoxicaleffectsarenotacommonphenomenon. Frequencyofadministrationwillvarywidelyaccordingtonumerousvariables.

4.

Thenurseisassessingapatientspainwhilethepatientawaitsacholecystectomy.Thepatientistearful, hesitanttomove,andgrimacing.Whenasked,thepatientrateshispainasa2atthistimeusinga0-to-10 painscale.Howshouldthenursebestrespondtothisassessmentfinding?

A)

Remindthepatientthatheisindeedexperiencingpain.

B)

Reinforceteachingaboutthepainscalenumbersystem.

C)

Reassessthepatientspainin30minutes.

D)

Administerananalgesicandthenreassess.

Ans:

B Feedback: Thepatientisphysicallyexhibitingsignsandsymptomsofpain.Furtherteachingmayneedtobedone sothepatientcancorrectlyratethepain.Thenursemayalsoverifythatthesamescaleisbeingusedby thepatientandcaregivertopromotecontinuity.Althoughallanswersarecorrect,themostaccurate conclusionwouldbetoreinforceteachingaboutthepainscale.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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5.

Youarecreatinganursingcareplanforapatientwithaprimarydiagnosisofcellulitisandasecondary diagnosisofchronicpain.Whatcommontraitofpatientswholivewithchronicpainshouldinformyour careplanning?

A)

Theyaretypicallymorecomfortablewithunderlyingpainthanpatientswithoutchronicpain.

B)

Theyoftenhavealowerpainthresholdthanpatientswithoutchronicpain.

C)

Theyoftenhaveanincreasedtoleranceofpain.

D)

Theycanexperienceacutepaininadditiontochronicpain.

Ans:

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

6.

Thenurseiscaringfora51-year-oldfemalepatientwhosemedicalhistoryincludeschronicfatigueand poorlycontrolledbackpain.Thesemedicaldiagnosesshouldalertthenursetothepossibilityofwhat consequenthealthproblem?

A)

Anxiety

B)

Skinbreakdown

C)

Depression

D)

Hallucinations

Ans:

C Feedback: Depressionisassociatedwithchronicpainandcanbeexacerbatedbytheeffectsofchronicfatigue. Anxietyisalsoplausible,butdepressionisaparamountrisk.Skinbreakdownandhallucinationsare muchlesslikely.

7.

Yourpatienthasjustreturnedfromthepostanestheticcareunit(PACU)followinglefttibiaopen reductioninternalfixation(ORIF).Thepatientiscomplainingofpain,andyouarepreparingto administerthepatientsfirstscheduleddoseofhydromorphone(Dilaudid).Priortoadministeringthe drug,youwouldprioritizewhichofthefollowingassessments?

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

A)

Thepatientselectrolytelevels

B)

Thepatientsbloodpressure

C)

Thepatientsallergystatus

D)

Thepatientshydrationstatus

Ans:

C

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Feedback: Beforeadministeringmedicationssuchasnarcoticsforthefirsttime,thenurseshouldassessforany previousallergicreactions.Electrolytevalues,bloodpressure,andhydrationstatusarenotwhatyou needtoassesspriortogivingafirstdoseofnarcotics. 8.

Yourpatientisreceivingpostoperativemorphinethroughapatient-controlledanalgesic(PCA)pump andthepatientsordersspecifyaninitialbolusdose.Whatisyourpriorityassessment?

A)

Assessmentfordecreasedlevelofconsciousness(LOC)

B)

Assessmentforrespiratorydepression

C)

Assessmentforfluidoverload

D)

Assessmentforparadoxicalincreaseinpain

Ans:

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

9.

Yourpatientis12-hourspostORIFrightankle.Thepatientisaskingforabreakthroughdoseof analgesia.Thepain-medicationordersarewrittenasacombinationofanopioidanalgesicanda nonsteroidalanti-inflammatorydrug(NSAID)giventogether.Whatistheprimaryrationalefor administeringpainmedicationinthismanner?

A)

Topreventrespiratorydepressionfromtheopioid

B)

Toeliminatetheneedforadditionalmedicationduringthenight

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

C)

Toachievebetterpaincontrolthanwithonemedicationalone

D)

Toeliminatethepotentiallyadverseeffectsoftheopioid

Ans:

C

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Feedback: Amultimodalregimencombinesdrugswithdifferentunderlyingmechanisms,whichallowslowerdoses ofeachofthedrugsinthetreatmentplan,reducingthepotentialforeachtoproduceadverseeffects. Thismethodalsoreduces,butdoesnoteliminate,adverseeffectsoftheopioid.Thisregimenisnot motivatedbytheneedtopreventrespiratorydepressionortoeliminatenighttimedosing. 10. Thenurseiscaringforapatientwithmetastaticbonecancer.Thepatientasksthenursewhyhehashad tokeepgettinglargerdosesofhispainmedication,althoughtheydonotseemtoaffecthim.Whatisthe nursesbestresponse? A)

Overtimeyoubecomemoretolerantofthedrug.

B)

Youmayhavebecomeimmunetotheeffectsofthedrug.

C)

Youmaybedevelopingamildaddictiontothedrug.

D)

Yourbodyabsorbslessofthedrugduetothecancer.

Ans:

A Feedback: Overtime,thepatientislikelytobecomemoretolerantofthedosage.Littleevidenceindicatesthat patientswithcancerbecomeaddictedtotheopioidmedications.Patientsdonotbecomeimmunetothe effectsofthedrug,andthebodydoesnotabsorblessofthedrugbecauseofthecancer.

11. A52-year-oldfemalepatientisreceivingcareontheoncologyunitforbreastcancerthathas metastasizedtoherlungsandliver.Whenaddressingthepatientspaininherplanofnursingcare,the nurseshouldconsiderwhatcharacteristicofcancerpain? A)

Cancerpainisoftenrelatedtothestressofthepatientknowingshehascancerandrequires relativelylowdosesofpainmedicationsalongwithahighdoseofanti-anxietymedications.

B)

Cancerpainisalwayschronicandchallengingtotreat,sodistractionisoftenthebestintervention.

C)

Cancerpaincanbeacuteorchronicandittypicallyrequirescomparativelyhighdosesofpain medications.

D)

Cancerpainisoftenmisreportedbypatientsbecauseofconfusionrelatedtotheirdiseaseprocess.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

Ans:

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

12. Thenursecaringfora79-year-oldmanwhohasjustreturnedtothemedicalsurgicalunitfollowing surgeryforatotalkneereplacementreceivedreportfromthePACU.Partofthereporthadbeenpassed onfromthepreoperativeassessmentwhereitwasnotedthathehasbeenagitatedinthepastfollowing opioidadministration.Whatprincipleshouldguidethenursesmanagementofthepatientspain? A)

Theelderlymayrequirelowerdosesofmedicationandareeasilyconfusedwithnewmedications.

B)

Theelderlymayhavealteredabsorptionandmetabolism,whichprohibitstheuseofopioids.

C)

Theelderlymaybeconfusedfollowingsurgery,whichisanage-relatedphenomenonunrelatedto themedication.

D)

Theelderlymayrequireahigherinitialdoseofpainmedicationfollowedbyatapereddose.

Ans:

A Feedback: Theelderlyoftenrequirelowerdosesofmedicationandareeasilyconfusedwithnewmedications.The elderlyhaveslowedmetabolismandexcretion,and,therefore,theelderlyshouldreceivealowerdoseof painmedicationgivenoveralongerperiodtime,whichmayhelptolimitthepotentialforconfusion. Unfortunately,theelderlyareoftengiventhesamedoseasyoungeradults,andtheresultingconfusionis attributedtootherfactorslikeenvironment.Opioidsarenotabsolutelycontraindicatedandconfusion followingsurgeryisnevernormal.Medicationshouldbeginatalowdoseandslowlyincreaseuntilthe painismanaged.

13. Youarethenurseinapaincliniccaringforan88-year-oldmanwhoissufferingfromlong-term, intractablepain.Atthispoint,thepainteamfeelsthatfirst-linepharmacologicaland nonpharmacologicalmethodsofpainreliefhavebeenineffective.Whatrecommendationshouldguide thispatientssubsequentcare? A)

Thepatientmaywanttoinvestigatenewalternativepainmanagementoptionsthatareoutsidethe UnitedStates.

B)

Thepatientmaybenefitfromreferraltoaneurologistorneurosurgeontodiscusspain-management options.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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C)

Thepatientmaywanttoincreasehisexerciseandactivitiessignificantlytocreatedistractions.

D)

Thepatientmaywanttorelocatetolong-termcareinordertohavehisADLneedsmet.

Ans:

B Feedback: Insomesituations,especiallywithlong-termsevereintractablepain,usualpharmacologicand nonpharmacologicmethodsofpainreliefareineffective.Inthosesituations,neurologicand neurosurgicalapproachestopainmanagementmaybeconsidered.InvestigatingnewalternativepainmanagementoptionsthatareoutsidetheUnitedStatesisunrealisticandmayevenbedangerousadvice. Increasinghisexerciseandactivitiestocreatedistractionsisunrealisticwhenapatientisinintractable painandthisrecommendationconveystheattitudethatthepainisnotreal.Movingintoanursinghome soothersmaycareforhimisaninterventionthatdoesnotaddresstheissueofpain.

14. Youarethehomehealthnursecaringforahomeboundclientwhoisterminallyill.Youaredeliveringa patient-controlledanalgesia(PCA)pumptothepatientatyourvisittoday.Thefamilymemberswillbe takingcareofthepatient.Whatwouldyourprioritynursinginterventionsbeforthisvisit? A)

Teachthefamilythetheoryofpainmanagementandtheuseofalternativetherapies.

B)

Providepsychosocialfamilysupportduringthisemotionalexperience.

C)

Providepatientandfamilyteachingregardingtheoperationofthepump,monitoringtheIVsite, andknowingthesideeffectsofthemedication.

D)

Providefamilyteachingregardinguseofmorphine,recognizingmorphineoverdose,andoffering spiritualguidance.

Ans:

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

15. Themotherofacancerpatientcomestothenurseconcernedwithherdaughterssafety.Shestatesthat herdaughtersmorphinedosethatsheneedstocontrolherpainisgettinghigherandhigher.Asaresult, themotherisafraidthatherdaughterwilloverdose.Thenurseeducatesthemotheraboutwhataspectof herpainmanagement?

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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A)

Thedoserangeishigherwithcancerpatients,andthemedicalteamwillbeverycarefultoprevent addiction.

B)

Frequently,femalepatientsandyoungerpatientsneedhigherdosesofopioidstobecomfortable.

C)

Theincreasedriskofoverdoseisaninevitableriskofmaintainingadequatepaincontrolduring cancertreatment.

D)

Thereisnoabsolutemaximumopioiddoseandherdaughterisbecomingmoretoleranttothedrug

Ans:

D Feedback: Patientsrequiringopioidsforchronicpain,especiallycancerpatients,needincreasingdosestorelieve pain.Therequirementforhigherdrugdosesresultsinagreaterdrugtolerance,whichisaphysical dependencyasopposedtoaddiction,whichisapsychologicaldependency.Thedoserangeisusually higherwithcancerpatients.Althoughtolerancetothedrugwillincrease,addictionisnotdoserelated, butisaseparatepsychologicaldependencyissue.Noresearchindicatesthatwomenand/oryounger peopleneedhigherdosesofmorphinetobecomfortable.Overdoseisnotaninevitablerisk.

16. Youhavejustreceivedreportona27-year-oldwomanwhoiscomingtoyourunitfromtheemergency departmentwithatornmeniscus.YoureviewherPRNmedicationsandseethatshehasanNSAID (ibuprofen)orderedevery6hours.Ifyouwantedtoimplementpreventivepainmeasureswhenthe patientarrivestoyourunit,whatwouldyoudo? A)

Useapainscaletoassessthepatientspain,andletthepatientknowibuprofenisavailableevery6 hoursifsheneedsit.

B)

Doacompleteassessment,andgivepainmedicationbasedonthepatientsreportofpain.

C)

Checkforallergies,useapainscaletoassessthepatientspain,andoffertheibuprofenevery6 hoursuntilthepatientisdischarged.

D)

Providemedicationasperpatientrequestandofferrelaxationtechniquestopromotecomfort.

Ans:

C Feedback: OnewaypreventivepainmeasurescanbeimplementedisbyusingPRNmedicationsonamoreregular orscheduledbasistoallowformoreuniformpaincontrol.Smallerdrugdosesofmedicationareneeded withthepreventivepainmethodwhenPRNmedicationsaregivenaroundtheclock.Offering...