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Medical-Surgical Nursing Exam 12: PainManagement (25 Items)

1. A chronic pain client reports to you, the

charge nurse, that the nurse have notbeen responding to requests for painmedication. What is your initial action?

a. Check the MARs and nursesnotes for thepast several days.b. Ask the nurse educator to give an in-serviceabout pain management.c. Perform a complete pain assessment andhistory on the client.d. Have a conference with the nursesresponsible for the care of this client

2. Family members are encouraging yourclient to tough it out rather than run therisk of becoming addicted to narcotics.

The client is stoically abiding by thefamilys wishes. Priority nursinginterventions for this client should targetwhich dimension of pain?

a. Sensoryb. Affectivec. Socioculturald. Behaviorale. Cognitive

3. A client with diabetic neuropathyreports a burning, electrical-type in thelower extremities that is not respondingto NSAIDs. You anticipate that thephysician will order which adjuvantmedication for this type of pain?

a. Amitriptyline (Elavil)b. Corticosteroidsc. Methylphenidate (Ritalin)d. Lorazepam (Ativan)

4. Which client is most likely to receiveopioids for extended periods of time?

a. A client with fibrolyalgia

b. A client with phantom limb painc. A client with progressive pancreatic cancerd. A client with trigeminal neuralgia

5. As the charge nurse, you are reviewingthe charts of clients who were assigned toa newly graduated RN. The RN hascorrectly charted dose and time of

medication, but there is no documentationregarding non-pharmaceutical measures.What action should you take first?

a. Make a note in the nurses file and continueto observe clinical performanceb. Refer the new nurse to the in-serviceeducation department.c. Quiz the nurse about knowledge of painmanagementd. Give praise for the correct dose and timeand discuss the deficits in charting.

6. In caring for a young child with pain,which assessment tool is the most useful?

a. Simple description pain intensity scaleb. 0-10 numeric pain scalec. Faces pain-rating scaled. McGill-Melzack pain questionnaire

7. In applying the principles of paintreatment, what is the first consideration?

a. Treatment is based on client goals.b. A multidisciplinary approach is needed.c. The client must be believed aboutperceptions of own pain.d. Drug side effects must be prevented and

managed.

8. Which route of administration ispreferred if immediate analgesia andrapid titration are necessary?

a. Intraspinal

b. Patient-controlled analgesia (PCA)c. Intravenous (IV)d. Sublingual

9. When titrating an analgesic to managepain, what is the priority goal?

a. Administer smallest dose that provides reliefwith the fewest side effects.b. Titrate upward until the client is pain free.c. Titrate downwards to prevent toxicity.d. Ensure that the drug is adequate to meetthe clients subjective needs.

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10.In educating clients about non-pharmaceutical alternatives, which topiccould you delegate to an experiencedLPN/LVN, who will function under yourcontinued support and supervision?

a. Therapeutic touchb. Use of heat and cold applicationsc. Meditationd. Transcutaneous electrical nerve stimulation(TENS)

11.Place the examples of drugs in theorder of usage according to the WorldHealth Organization (WHO) analgesicladder.

a. Morphine, hydromorphone, acetaminophenand lorazepamb. NSAIDs and corticosteroids

c. Codeine, oxycodone and diphenhydramine

12.Which client is at greater risk forrespiratory depression while receivingopioids for analgesia?

a. An elderly chronic pain client with a hipfractureb. A client with a heroin addiction and backpainc. A young female client with advancedmultiple myeloma

d. A child with an arm fracture and cysticfibrosis

13.A client appears upset and tearful, butdenies pain and refuses pain medication,because my sibling is a drug addict andhas ruined out lives. What is the priorityintervention for this client?

a. Encourage expression of fears on pastexperiencesb. Provide accurate information about use ofpain medication

c. Explain that addiction is unlikely among

acute care clients.d. Seek family assistance in resolving thisproblem.

14.A client is being tapered off opioidsand the nurse is watchful for signs ofwithdrawal. What is one of the first signsof withdrawal?

a. Feverb. Nauseac. Diaphoresisd. Abdominal cramps

15.In caring for clients with pain anddiscomfort, which task is mostappropriate to delegate to the nursingassistant?

a. Assist the client with preparation of a sitzbath.b. Monitor the client for signs of discomfortwhile ambulatingc. Coach the client to deep breathe duringpainful proceduresd. Evaluate relief after applying a coldapplication.

16.The physician has ordered a placebo

for a chronic pain client. You are newlyhired nurse and you feel veryuncomfortable administering themedication. What is the first action thatyou should take?

a. Prepare the medication and hand it to thephysicianb. Check the hospital policy regarding use ofthe placebo.

c. Follow a personal code of ethics and refuseto give it.d. Contact the charge nurse for advice.

17.For a cognitively impaired client whocannot accurately report pain, what is thefirst action that you should take?

a. Closely assess for nonverbal signs such asgrimacing or rocking.b. Obtain baseline behavioral indicators fromfamily members.c. Look at the MAR and chart, to note the timeof the last dose and response.d. Give the maximum PRS dose within theminimum time frame for relief.

18.Which route of administration ispreferable for administration of dailyanalgesics (if all body systems arefunctional)?

a. IVb. IM or subcutaneousc. Orald. Transdermale. PCA

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19.A first day post-operative client on aPCA pump reports that the pain control isinadequate. What is the first action youshould take?

a. Deliver the bolus dose per standing order.b. Contact the physician to increase the dose.c. Try non-pharmacological comfort measures.d. Assess the pain for location, quality, andintensity.

20.Which non-pharmacological measure isparticularly useful for a client with acutepancreatitis?

a. Diversional therapy, such as playing cards orboard gamesb. Massage of back and neck with warmedlotionc. Side-lying position with knees to chest and

pillow against abdomend. Transcutaneous electrical nerve stimulation(TENS)

21.What is the best way to schedulemedication for a client with constantpain?

a. PRN at the clients requestb. Prior to painful proceduresc. IV bolus after pain assessmentd. Around-the-clock

22.Which client(s) are appropriate toassign to the LPN/LVN, who will functionunder the supervision of the RN or teamleader? (Choose all that apply.)

a. A client who needs pre-op teaching for useof a PCA pump

b. A client with a leg cast who needs neurologicchecks and PRN hydrocodonec. A client post-op toe amputation with diabeticneuropathic paind. A client with terminal cancer and severepain who is refusing medication

23.For a client who is taking aspirin,which laboratory value should be reportedto the physician?

a. Potassium 3.6 mEq/Lb. Hematocrit 41%

c. PT 14 secondsd. BUN 20 mg/dL

24.Which client(s) would be appropriateto assign to a newly graduated RN, whohas recently completed orientation?(Choose all that apply.)

a. An anxious, chronic pain client whofrequently uses the call buttonb. A client second day post-op who needs painmedication prior to dressing changesc. A client with HIV who reports headache andabdominal and pleuritic chest paind. A client who is being discharged with asurgically implanted catheter

25.A family member asks you, Why cantyou give more medicine? He is still havinga lot of pain. What is your best response?

a. The doctor ordered the medicine to begiven every 4 hours.

b. If the medication is given too frequently hecould suffer ill effects.c. Please tell him that I will be right there tocheck of him.d. Lets wait about 30-40 minutes. If there isno relief Ill call the doctor.

Here are the answers and rationalefor: Medical-Surgical Nursing Exam 12:Pain Management (25 Items)

1. Answer: D As charge nurse, you must

assess for the performance and attitude of thestaff in relation to this client. After gatheringdata from the nurses, additional informationfrom the records and the client can beobtained as necessary. The educator may be ofassistance if knowledge deficit or need forperformance improvement is the problem.

2. Answer: C The family is part of thesociocultural dimension of pain. They areinfluencing the client should be included in theteaching sessions about the appropriate use ofnarcotics and about the adverse effects of painon the healing process. The other dimensions

should be included to help the client/familyunderstand overall treatment plan and painmechanism

3. Answer: A Antidepressants such asamitriptyline can be given for diabetic

neuropathy. Corticosteroids are for painassociated with inflammation. Methylphenidateis given to counteract sedation if the client ison opioids. Lorazepam is an anxiolytic.

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4. Answer: C Cancer pain generally worsenswith disease progression and the use of opioidsis more generous. Fibromyalgia is more likelyto be treated with non-opiod and adjuvant

medicatios. Trigeminal neuralgia is treatedwith anti-seizure medications such ascarbamezapine (Tegretol). Phantom limb pain

usually subsides after ambulation begins.

5. Answer: D In supervising the new RN,good performance should be reinforced firstand then areas of improvement can beaddressed. Asking the nurse about knowledgeof pain management is also an option;however, it would be a more indirect and time-consuming approach. Making an ote andwatching do not help the nurse to correct theimmediate problem. In-service might beconsidered if the problem persists.

6. Answer: C The Faces pain rating scale(depicting smiling, neutral, frowning, crying,etc.) is appropriate for young children whomay have difficulty describing pain orunderstanding the correlation of pain tonumerical or verbal descriptors. The other toolsrequire abstract reasoning abilities to makeanalogies and use of advanced vocabulary.

7. Answer: C The client must be believed andhis or her experience of pain must beacknowledged as valid. The data gathered viaclient reports can then be applied to otheroptions in developing the treatment plan.

8. Answer: C the IV route is preferred as thefastest and most amenable to titration. A PCAbolus can be delivered; however, the pump willlimit the dosage that can be delivered unlessthe parameters are changed. Intraspinaladministration requires special catheterplacement and there are more potentialcomplications with this route. Sublingual is

reasonably fast, but not a good route fortitration, medication variety in this form islimited.

9. Answer: A the goal is to control pain whileminimizing side effects. For severe pain, themedication can be titrated upward until pain iscontrolled. Downward titration occurs when thepain begins to subside. Adequate dosing isimportant; however, the concept of controlled

dosing applies more to potent vasoactivedrugs.

10. Answer: B Use of heat and coldapplications is a standard therapy withguidelines for safe use and predictableoutcomes, and an LPN/LVN will be

implementing this therapy in the hospital,under the supervision of an RN. Therapeutictouch requires additional training and practice.

Meditation is not acceptable to all clients andan assessment of spiritual beliefs should beconducted. Transcutaneous electricalstimulation is usually applied by a physicaltherapist.

11. Answer: B, C, A Step 1 includes non-opioids and adjuvant drugs. Step 2 includesopioids for mild pain plus Step 1 drugs andadjuvant drugs as needed. Step 3 includesopioids for severe pain (replacing Step 2opioids) and continuing Step 1 drugs andadjuvant drugs as needed.

12. Answer: D at greatest risk are elderlyclients, opiate nave clients, and those withunderlying pulmonary disease. The child hastwo of the three risk factors.

13. Answer: A This client has strong beliefsand emotions related to the issue of siblingaddiction. First, encourage expression. Thisindicated to the client that the feelings are realand valid. It is also an opportunity to assessbeliefs and fears. Giving facts and informationis appropriate at the right time. Familyinvolvement is important, bearing in mind that

their beliefs about drug addiction may besimilar to those of the client.

14. Answer: C Diaphoresis is one of the earlysigns that occur between 6 and 12 hours.Fever, nausea, and abdominal cramps are latesigns that occur between 48 and 72 hours.

15. Answer: A The nursing assistant is ableto assist the client with hygiene issues andknows the principles of safety and comfort forthis procedure. Monitoring the client, teachingtechniques, and evaluating outcomes are

nursing responsibilities.

16. Answer: D the charge nurse is a resourceperson who can help locate and review thepolicy. If the physician is insistent, he or shecould give the placebo personally, but delayingthe administration does not endanger thehealth or safety of the client. While followingones own ethical code is correct, you must

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ensure that the client is not abandoned andthat care continues.

17. Answer: B Complete information fromthe family should be obtained during the initialcomprehensive history and assessment. If thisinformation is not obtained, the nursing staffwill have to rely on observation of nonverbalbehavior and careful documentation todetermine pain and relief patterns.

18. Answer: C If the gastrointestinal systemis function, the oral route is preferred forroutine analgesics because of lower cost andease of administration. Oral route is also lesspainful and less invasive than the IV, IM,subcutaneous, or PCA routes. Transdermal

route is slower and medication availability islimited compared to oral forms.

19. Answer: D Assess the pain for changes inlocation, quality, and intensity, as well aschanges in response to medication. Thisassessment will guide the next steps.

20. Answer: C The side-lying, knee-chestposition opens retroperitoneal space andprovides relief. The pillow provides a splintingaction. Diversional therapy is not the bestchoice for acute pain, especially if the activity

requires concentration. TENS is moreappropriate for chronic muscular pain. Theadditional stimulation of massage may bedistressing to the client.

21. Answer: D IF the pain is constant, thebest schedule is around-the-clock, to providesteady analgesia and pain control. The otheroptions may actually require higher doses toachieve control

22. Answer: B, C The clients with the castand the toe amputation are stable clients andneed ongoing assessment and painmanagement that are within the scope ofpractice for an LPN/LVN under the supervisionof an RN. The RN should take responsibility for

pre-operative teaching, and the terminalcancer needs a comprehensive assessment todetermine the reason for refusal of medication.

23. Answer: C When a client takes aspirin,monitor for increases in PT (normal range

11.0-12.5 seconds in 85%-100%). Alsomonitor for possible decreases in potassium(normal range 3.5-5.0 mEq/L). If bleedingsigns are noted, hematocrit should be

monitored (normal range male 42%-52%,female 37%-47%). An elevated BUN could beseen if the client is having chronicgastrointestinal bleeding (normal range 10-20mg/dL).

24. Answer: B A second day post-operativeclient who needs medication prior to dressingchanges has predictable and routine care thata new nurse can manage. Although chronicpain clients can be relatively stable, theinteraction with this client will be timeconsuming and may cause the new nurse tofall behind. The HIV client has complexcomplaints that require expert assessmentskills. The client pending discharge will needspecial and detailed instructions.

25. Answer: C directly ask the client aboutthe pain and do a complete pain assessment.

This information will determine which action totake next.