Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 10: Pain

MULTIPLE CHOICE 1. A 45-year-old patient has breast cancer that has spread to the liver and spine. The patient has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home but now has constant severe pain and is hospitalized for pain control and development of a pain-management program. When doing the initial assessment, which question will be most appropriate to ask first? a How would you describe your pain? . b How much medication do you take for the pain? . c How long have you had this pain? . d How many times a day do you medicate for pain? . Correct Answer: A Rationale: Because pain is a multidimensional experience, asking a question that addresses the patients experience with the pain is likely to elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning How would you describe your pain? is the best first question. Cognitive Level: Application Nursing Process: Assessment Text Reference: pp. 126, 131 NCLEX: Physiological Integrity

2. A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (of a 0-10 scale) and requests something for pain that will work quickly. The best way for the nurse to document this information is as a breakthrough pain. . b neuropathic pain. . c somatic pain. . d referred pain. .

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Correct Answer: A Rationale: 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 (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue. Cognitive Level: Application Text Reference: p. 132

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Test Bank Nursing Process: Implementation NCLEX: Physiological Integrity

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3. The health care provider tells a patient to use ibuprofen (Motrin, Advil) to relieve pain after treating a laceration on the patients forearm from a dog bite. The patient asks the nurse how ibuprofen will control the pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the a production of pain-sensitizing chemicals. . b spinal cord transmission of pain impulses. . c sensitivity of the brain to painful stimuli. . d modulating effect of descending nerves. . Correct Answer: A Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) 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 the NSAIDs. Cognitive Level: Application Nursing Process: Implementation Text Reference: p. 128 NCLEX: Physiological Integrity

4. A patient being treated for chronic musculoskeletal pain tells the nurse, I feel depressed because I cant even go out and play a round of golf. The patient describes the pain as aching and says it is usually at a level 7 of a scale of 1 to10. Based on these assessment data, which patient goal is most appropriate? After treatment, the patient will a state that pain is at a level 2 of 10. . b be able to play 1 to 2 rounds of golf. . c exhibit fewer signs of depression. . d say that the aching has decreased. . Correct Answer: B

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Test Bank

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Rationale: 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 or 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 1 or 2 rounds of golf is the most appropriate. Cognitive Level: Application Nursing Process: Planning Text Reference: p. 135 NCLEX: Physiological Integrity

5. A postoperative patient who has undergone extensive bowel surgery moves as little as possible and does not use the incentive spirometer unless specifically reminded. The patient rates the pain severity as an 8 on a 10-point scale but tells the nurse, I can tough it out. In encouraging the patient to use pain medication, the best explanation by the nurse is that a very few patients become addicted to opioids when using them for acute pain . control. b there is little need to worry about side effects because these problems decrease . over time. c there are many pain medications and if one drug is ineffective, other drugs may . be tried. d unrelieved pain can be harmful due to the effect on respiratory function and . activity level. Correct Answer: D Rationale: The patients low activity level, lack of spirometer use, and statement to the nurse indicate that there is a lack of understanding about the purpose of postoperative pain management. The patient did not indicate a concern about becoming addicted, a desire for alternate medications, or anxiety about analgesic side effects. Cognitive Level: Application Nursing Process: Implementation Text Reference: pp. 126, 131, 145 NCLEX: Physiological Integrity

6. A patient is receiving morphine sulfate intravenously (IV) for right flank pain associated with a kidney stone in the right ureter. The patient also complains of right inner thigh pain and asks the nurse whether something is wrong with the right leg. In responding to the question, the nurse understands that the patient a is experiencing referred pain from the kidney stone. . b has neuropathic pain from nerve damage caused by inflammation. . c has acute pain that may be progressing into chronic pain. . d is experiencing pain perception that has been affected by the morphine received

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Test Bank . earlier.

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Correct Answer: A Rationale: The spread of pain to uninjured tissue is termed referred pain. Neuropathic pain refers to pain caused by nerve damage rather than by tissue injury or damage. When pain has lasted less than 3 months and is associated with an acute event (such as a kidney stone), it is acute pain. Morphine administration will decrease the perception of pain intensity, but it will not change the location of the pain. Cognitive Level: Application Nursing Process: Assessment Text Reference: p. 129 NCLEX: Physiological Integrity

7. A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic pain complains of nausea and abdominal fullness. The most appropriate initial action by the nurse is to a consult with the health care provider about using a different opioid. . b administer the ordered metoclopramide (Reglan) 10 mg IV. . c tell the patient that the nausea will subside in about a week. . d order the patient a clear liquid diet until the nausea decreases. . Correct Answer: B Rationale: Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics are usually prescribed to treat this expected side effect. 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 (in about a week), the nausea will subside; therefore, it would not be appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea, but the best choice would be to administer the metoclopramide and allow the patient to eat. Cognitive Level: Application Nursing Process: Implementation Text Reference: p. 138 NCLEX: Physiological Integrity

8. The nurse is evaluating the effectiveness of imipramine (Tofranil), a tricyclic antidepressant, for a patient who is receiving the medication to help relieve chronic cancer pain. Which information is the best indicator that the imipramine is effective? a The patient states, I feel much less depressed since Ive been taking the . imipramine. b The patient sleeps 8 hours every night. . c The patient says that the pain is manageable and that he or she can accomplish

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Test Bank . desired activities. d The patient has no symptoms of anxiety. .

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Correct Answer: C Rationale: 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. Cognitive Level: Application Nursing Process: Evaluation Text Reference: p. 130 NCLEX: Physiological Integrity

9. A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurses reply will be based on the information that these strategies a impact the cognitive and affective components of pain. . b prevent transmission of nociceptive stimuli to the cortex. . c increase the modulating effect of the efferent pathways. . d slow the release of transmitter chemicals in the dorsal horn. . Correct Answer: A Rationale: Cognitive therapies impact on 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. Cognitive Level: Comprehension Nursing Process: Implementation Text Reference: p. 144 NCLEX: Physiological Integrity

10. A home health patient has a prescription for pentazocine (Talwin,) a mixed opioid agonist-antagonist. When teaching the patient and family about adverse effects, the nurse will plan to focus on how to monitor for a agitation. . b respiratory depression. . c hypotension. . d physical dependence. .

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Test Bank

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Correct Answer: A Rationale: This category of opioids causes more neurologic side effects, such as agitation, than the pure opioid opioids. The benefits to this category include less hypotension and respiratory depression and the absence of physical dependence. Cognitive Level: Application Nursing Process: Planning Text Reference: p. 138 NCLEX: Physiological Integrity

11. All the following medications are included in the admission orders for an 86-year-old patient with moderate degenerative arthritis in both hips. Which medication will the nurse use as an initial therapy? a Aspirin (Bayer) 650 mg orally . b Oxycodone (Roxicodone) 5 mg orally . c Acetaminophen (Tylenol) 650 mg orally . d Naproxen (Aleve) 200 mg orally . Correct Answer: C Rationale: Acetaminophen is the best first-choice medication. The principle of start low, go slow is used to guide therapy when treating elderly adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Non-opioid analgesics are used first, although opioids may be used later. Aspirin and the NSAIDs are associated with a high incidence of gastrointestinal bleeding in elderly patients. Cognitive Level: Application Nursing Process: Implementation Text Reference: pp. 135, 148 NCLEX: Physiological Integrity

12. A patient with chronic cancer pain experiences breakthrough pain (level 9 of 10) and anxiety while receiving sustained-release morphine sulfate (MS Contin) 160 mg every 12 hours. All these medications are ordered for the patient. Which one will be most appropriate for the nurse to administer first? a Ibuprofen (Motrin) 400-800 mg orally . b Immediate-release morphine 30 mg orally . c Amitriptyline (Elavil) 10 mg orally. . d Lorazepam (Ativan) 1 mg orally .

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Test Bank

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Correct Answer: B Rationale: The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. The ibuprofen and amitriptyline may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of anti-anxiety agents for pain control is inappropriate because this patients anxiety for this patient is caused by the pain. Cognitive Level: Analysis Nursing Process: Implementation Text Reference: pp. 137, 140 NCLEX: Physiological Integrity

13. To obtain the most complete assessment data about a patients chronic pain pattern, the nurse asks the patient a Can you describe where your pain is the worst? . b What is the intensity of your pain on a scale of 0 to 10? . c Would you describe your pain as aching, throbbing, or sharp? . d Can you describe your daily activities in relation to your pain? . Correct Answer: D Rationale: The assessment of chronic pain should focus on the impact of the pain on patient function and daily activities. The other questions are also appropriate to ask, but will not give as complete information. Cognitive Level: Application Nursing Process: Assessment Text Reference: p. 134 NCLEX: Physiological Integrity

14. Morphine 10 mg IV every 4 to 6 hours prn is ordered for a patient with a pancreatic tumor who has a distant history of opioid abuse. After 3 days of receiving the morphine every 6 hours, the patient tells the nurse that the medication is needed more frequently to control the pain. The best initial action by the nurse is to a administer the morphine every 4 hours as needed. . b consult with the doctor about initiating an appropriate weaning protocol for the . morphine. c remind the patient that the previous substance abuse increases the risk for . addiction. d use alternative therapies such as heat or cold. . Correct Answer: A

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Test Bank

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Rationale: These patient data indicate that tolerance for the morphine is developing and more frequent administration is needed to maintain pain control. A weaning protocol is not indicated, since the patient still has the pancreatic tumor and there is no indication that the physiologic basis of the pain has changed. Although the patient may be at risk for addiction, adequate pain management is the priority at present. Alternative therapies may be a useful adjuvant to the morphine but should not be the first nursing action. Cognitive Level: Application Nursing Process: Implementation Text Reference: p. 148 NCLEX: Physiological Integrity

15. A patient with extensive second-degree burns on the legs and trunk is using patientcontrolled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control the pain. Several times during the night, the patient awakens in severe pain, and it takes more than an hour to regain pain relief. The most appropriate action by the nurse is to a request that the health care provider order a bolus dose of morphine to be given . when the patient awakens with pain. b consult with the patients health care provider about adding a continuous . morphine infusion to the PCA regimen at night. c teach the patient to push the button every 10 minutes for an hour before going to . sleep even if the pain is minimal. d administer a dose of morphine every 1 to 2 hours from the PCA machine while . the patient is sleeping. Correct Answer: B Rationale: Adding a continuous dose of the morphine at night will allow the patient to sleep without being awakened by the pain. Administering a dose of morphine when the patient awakens would not address the problem. Teaching the patient to administer unneeded medication before going to sleep might result in oversedation and respiratory depression. It is inappropriate for the nurse to administer the morphine while the patient sleeps because the nurse could not assess the pain level. Cognitive Level: Application Nursing Process: Implementation Text Reference: p. 140 NCLEX: Physiological Integrity

16. When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication? a The patient complains of a pounding headache. . b The patient becomes restless and agitated. . c The patient has not voided for over 10 hours. .

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Test Bank d The patient has cramping abdominal pain. .

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Correct Answer: C Rationale: Urinary retention is a common side effect of epidural opioids. Headache is not an anticipated side effect of morphine, although if there is a cerebrospinal fluid leak, the patient may develop a spinal headache. Sedation (rather than restlessness or agitation) would be a possible side effect. Hypotonic bowel sounds and constipation (rather than abdominal cramping) are concerns. Cognitive Level: Application Nursing Process: Evaluation Text Reference: p. 142 NCLEX: Physiological Integrity

17. A patient receiving prn intermittent IV administration of opiates following gastric surgery watches a favorite television program every morning. The patient does not request pain medication during this time and when questioned denies the need for medication. The nurses evaluation of this situation is that a lying quietly in bed is the best method of controlling the patients incisional pain. . b encouraging the patient to watch other television programs will decrease the pain. . c the distraction of the television enables the patient to decrease the perception of . pain. d the patients dose of opiates needs to be decreased because her pain is well . controlled. Correct Answer: C Rationale: The distraction of watching a favorite program decreases the perception of pain by various brain structures. Immobilization may help to reduce pain, but it is not the best method for pain relief because immobility can lead to multiple postoperative complications. Other television programs are not likely to provide an adequate level of distraction. The patient will continue to require opioid analgesics when not watching the favorite program. Cognitive Level: Application Nursing Process: Evaluation Text Reference: p. 144 NCLEX: Physiological Integrity

18. A hospice patient is in continuous pain, and the health care provider has left orders to administer morphine at a rate that controls the pain. When the nurse visits the patient, the patient is awake but moaning with severe pain and asks for an increase in the morphine dosage. The respiratory rate is 10 breaths per minute. The most appropriate action by the nurse is to a titrate the morphine dose upward until the patient states there is adequate pain . relief.

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Test Bank b . c . d .

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administer a nonopioid analgesic, such as ibuprofen, to improve patient pain control. tell the patient that additional morphine can be administered when the respirations are 12. inform the patient that increasing the morphine will cause the respiratory drive to fail.

Correct Answer: A Rationale: The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like 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 patients respiratory rate. Cognitive Level: Application Nursing Process: Implementation Text Reference: p. 147 NCLEX: Physiological Integrity

19. A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patients home medications, which of these will be of most concern to the admitting nurse? a Oxycodone (OxyContin) 80 mg twice daily . b Ibuprofen (Advil) 800 mg three times daily . c Amitriptyline (Elavil) 50 mg at bedtime . d Meperidine (Demerol) 25 mg every 4 hours . Correct Answer: D Rationale: 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 all appropriate medications for long-term pain management. Cognitive Level: Application Nursing Process: Assessment Text Reference: p. 138 NCLEX: Physiological Integrity

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Test Bank

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20. The hospice RN obtains the following information about a 72-year-old terminally ill patient with cancer of the colon. The patient takes oxycodone (OxyContin) 100 mg twice daily for level 6 abdomen pain on a 10-point scale. The pain has made it difficult to continue with favorite activities such as playing cards with friends twice a week. The patients children are supportive of the patients wish to stop chemotherapy but express sadness that the patient does not have long to live. Based on this information, which nursing diagnosis has priority in planning the patients care? a Impaired social interaction related to disabling pain . b Anxiety related to poor patient coping skills . c Disabled family coping related to patient-family conflict . d Risk for aspiration related to opioid use . Correct Answer: A Rationale: The assessment data indicate that the patients priority is to be able to continue with favorite activities and that decreasing the pain level would accomplish this goal. There is no indication of anxiety, and the patients and familys coping skills appear to be good. Although the patient is taking a large dose of oxycodone, there is no evidence that this has suppressed the respiratory rate or the gag/cough reflexes. Cognitive Level: Analysis Nursing Process: Diagnosis MULTIPLE RESPONSE 1. The health care provider plans to titrate a patient-controlled opioid infusion (PCA) to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which of the following nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.) a Monitoring for therapeutic and adverse effects of opioid administration . b Teaching about the need to decrease opioid doses by the second postoperative day . c Assessing for signs that the patient is becoming addicted to the opioid . d Educating the patient about how analgesics improve postoperative activity level . e Emphasizing that the risk of opioid side effects increases over time . Correct Answer: A, D Text Reference: p. 145 NCLEX: Psychosocial Integrity

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Test Bank

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Rationale: Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain. Although postoperative patients usually need decreasing amount of opioids by the second postoperative day, each patients response is individual. Although tolerance may occur, addiction to opioids will not develop in the acute postoperative period. The patient should use the opioids to achieve adequate pain control, and so the nurse should not emphasize the adverse effects. Cognitive Level: Application Nursing Process: Implementation Text Reference: pp. 138, 142 NCLEX: Physiological Integrity

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