TEST BANK ; Potter & Perry: Fundamentals of Nursing, 7th Edition, Study notes of Nursing

Download TEST BANK ; Potter & Perry: Fundamentals of Nursing, 7th Edition and more Study notes Nursing in PDF only on Docsity! Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 43: Pain Management MULTIPLE CHOICE 1. Which one of the following nursing interventions for a client in pain is based on the gate- control theory? 1. Giving the client a back massage 2. Changing the client’s position in bed 3. Giving the client a pain medication 4. Limiting the number of visitors ANS: 1 The gate-control theory suggests that cutaneous stimulation activates larger, faster-trans- mitting A-beta sensory nerve fibers. This decreases pain transmission through small-dia- meter A-delta and C fibers. A back massage is a nursing intervention based on the gate- control theory. Changing the client’s position in bed is not a form of cutaneous stimula- tion used to relieve pain. Giving the client a pain medication is a pharmacological ap- proach to relieving pain. Limiting the number of visitors may provide a quiet environ- ment conducive to relaxation, but it is not based on the gate-control theory. 2. A priority nursing intervention when caring for a client who is receiving an epidural infu- sion for pain relief is to: 1. Use aseptic technique 2. Label the port as an epidural catheter 3. Monitor vital signs every 15 minutes 4. Avoid supplemental doses of sedatives ANS: 3 When clients are receiving epidural analgesia, monitoring occurs as often as every 15 minutes, including assessment of respiratory rate, respiratory effort, and skin color. Com- plications of epidural opioid use include nausea and vomiting, urinary retention, constipa- tion, respiratory depression, and pruritus. A common complication of epidural anesthesia is hypotension. Assessing vital signs is the priority nursing intervention. Because of the catheter location, strict surgical asepsis is needed to prevent a serious and potentially fatal infection. To reduce the risk for accidental epidural injection of drugs intended for IV use, the catheter should be clearly labeled “epidural catheter.” Supplemental doses of opioids or sedative/hypnotics are avoided because of possible additive central nervous system adverse effects. 3. The nurse should describe pain that is causing the client a “burning sensation in the epi- gastric region” as: 1. Referred 2. Radiating 3. Deep or visceral 4. Superficial or cutaneous ANS: 3 Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may be described as a burning sensation. Referred pain is felt in a part of the body separate from the source of pain, such as with a myocardial infarction, in which pain may be re- ferred to the jaw, left arm, and left shoulder. Radiating pain feels as though it travels down or along a body part, such as low back pain that is accompanied by pain radiating down the leg from sciatic nerve irritation. Superficial or cutaneous pain is of short dura- tion and is localized as in a small cut. 4. Which of the following is most appropriate when the nurse assesses the intensity of the client’s pain? 1. Ask about what precipitates the pain. 2. Question the client about the location of the pain. 3. Offer the client a pain scale to objectify the information. 4. Use open-ended questions to find out about the sensation. ANS: 3 Descriptive scales are a more objective means of measuring pain intensity. Asking the client what precipitates the pain does not assess intensity, but rather it is an assessment of the pain pattern. Asking the client about the location of pain does not assess the intensity of the client’s pain. To determine the quality of the client’s pain, the nurse may ask open- ended questions to find out about the sensation experienced. 5. The nurse on a postoperative care unit is assessing the quality of the client’s pain. In or- der to obtain this specific information about the pain experience from the client, the nurse should ask: 1. “What does your discomfort feel like?” 2. “What activities make the pain worse?” 3. “How much does it hurt on a scale of 0 to 10?” 4. “How much discomfort are you able to tolerate?” ANS: 1 To determine the quality of the client’s pain the nurse might say, “What does your dis- comfort feel like?” It is more accurate to have clients describe the pain in their own words whenever possible. Inquiring about what activities make the pain worse is a type of question directed at determining the pain pattern. Having the client rate his or her pain on a pain scale is a method of measuring the intensity of pain. To determine the client’s expectations, the nurse may ask the client, “How much discomfort are you able to toler- 2. Continue to change the analgesics until the right narcotic is found that completely alleviates the pain. 3. Adapt the analgesics as the nursing as- sessment reveals the need for specific medications. 4. Withhold analgesics because they are not being effective in relieving discomfort. ANS: 3 The best choice of treatment often changes as the client’s condition and the characterist- ics of pain change. It is realistic to expect that a terminally ill client’s need for pain med- ication will change over time with disease progression. The goal is not to oversedate the client but to provide pain control without excessive sedation. It would be unrealistic to expect that the pain of terminal cancer will be completely alleviated. Analgesics should not be withheld, because this would only increase the client’s level of pain. The medica- tion regimen may need to be adapted to meet the client’s needs. 12. A client is having severe, continuous discomfort from kidney stones. Based on the cli- ent’s experience, the nurse anticipates which of the following findings in the client’s as- sessment? 1. Tachycardia 2. Diaphoresis 3. Pupil dilation 4. Nausea and vomiting ANS: 4 Acute severe or deep pain, as with kidney stones, will cause a parasympathetic response. The client would likely exhibit nausea and vomiting. Tachycardia is a response of sym- pathetic stimulation, commonly seen with pain of low to moderate intensity and superfi- cial pain. Diaphoresis is a response of sympathetic stimulation, commonly seen with pain of low to moderate intensity and superficial pain. Pupil dilation is a response of sympath- etic stimulation, commonly seen with pain of low to moderate intensity and superficial pain. 13. Nurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct? 1. The client is the best authority on the pain experience. 2. Chronic pain is mostly psychological in nature. 3. Regular use of analgesics leads to drug addiction. 4. The amount of tissue damage is accurately reflected in the degree of pain perceived. ANS: 1 A client’s self-report of pain is the single most reliable indicator of the existence and in- tensity of pain and any related discomfort. Pain is individualistic. A misconception about pain is that chronic pain is psychological. The belief that administering analgesics regu- larly will lead to drug addiction is a misconception. Another misconception about pain is that the amount of tissue damage is accurately reflected in the degree of pain perceived. 14. A nonpharmacological approach that the nurse may implement for clients experiencing pain that focuses on promoting pleasurable and meaningful stimuli is: 1. Acupressure 2. Distraction 3. Biofeedback 4. Hypnosis ANS: 2 Pleasurable stimuli cause the release of endorphins. The nurse assesses activities enjoyed by the client that may act as distractions. Distraction directs a client’s attention to something else and thus can reduce the awareness of pain and even increase tolerance. Acupressure does not focus on promoting pleasurable and meaningful stimuli. Acupres- sure is finger pressure applied therapeutically at selected points on the body. Biofeedback focuses on an individual’s physiological responses (e.g., blood pressure or tension) and ways to exercise voluntary control over those responses. Hypnosis does not focus on pro- moting pleasurable and meaningful stimuli. Hypnosis is a condition resembling sleep in which the mind is susceptible to suggestions. 15. Which of the following is the most appropriate nursing intervention for a client who is re- ceiving epidural analgesia? 1. Change the tubing every 48 to 72 hours. 2. Change the dressing every shift. 3. Secure the catheter to the outside skin. 4. Use a bulky occlusive dressing over the site. ANS: 3 To prevent catheter displacement, the catheter should be secured carefully to the outside skin. The infusion tubing should be changed every 24 hours to prevent infection. To pre- vent infection, the dressing should not be routinely changed over the site. A transparent dressing should be used over the site to secure the catheter and aid inspection. DIF: A REF: 1078 OBJ: Comprehension 16. The client is experiencing breakthrough pain while receiving opioids. An order is written for the client to receive a transmucosal fentanyl “unit.” In teaching about this medication, the nurse should instruct the client to: 1. Swab the unit over the cheeks 2. Do not chew the unit after administration 3. Take no more than two units per episode of discomfort 4. Allow the unit to dissolve slowly in the mouth over 15 minutes or more ANS: 2 The unit needs to be left intact and not chewed. The unit is placed in the client’s mouth and swabbed over the inside of the cheeks and lower gums. No more than two units should be used per breakthrough pain episode. The unit needs to be allowed to dissolve and absorb over a 15-minute period. 17. When caring for a client who is experiencing continuous severe pain, the nurse should expect that the pain management plan would include: 1. Focusing on intramuscular administration of analgesics 2. Waiting for pain to become more intense before administering opioids 3. Administering opioids with nonopioid an- algesics for severe pain experiences 4. Administering large doses of opioids ini- tially to clients who have not taken the medications before ANS: 3 To treat a client who is experiencing continuous severe pain, the nurse should expect the client to receive opioid and nonopioid analgesics for severe pain experiences. Intramus- cular administration of analgesics is not expected because the injection itself is painful, and there may be inconsistent erratic absorption of the drug. The nurse should administer opioids before the client’s pain becomes intense. It is easier to maintain pain control than it is to get intense pain under control. Large doses of opioids are not given initially to cli- ents who have not taken the medications before because they may cause respiratory de- pression. The expectation is to begin with lower doses and titrate upward. 18. Which of the following symptoms would the nurse expect with a client who is experien- cing acute pain? 1. Bradycardia 2. Bradypnea 3. Diaphoresis 4. Decreased muscle tension ANS: 3 An expected assessment finding of a client experiencing acute pain would be diaphoresis resulting from sympathetic nerve stimulation. Additional assessment findings of a client experiencing acute pain would be an increased heart rate, respiratory rate, and muscle tension. 19. Which of the following statements made by a nurse shows the greatest understanding of the personal nature of the pain experience? sensitive to the client’s pain, they are not as overtly critical. DIF: C REF: 1057 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 24. The nurse recognizes that the most likely reason a runner who has injured his ankle dur- ing a race is not aware of it until after he crosses the finish line is that: 1. The emotional exhilaration of running the race masked the pain of the injury 2. His endorphin levels were high as a result of the physical stressors of the race 3. He was mentally distracted by the need to concentrate on the ever-changing nature of the race 4. The physical effects of the injury slowly increased during the race and reached pain-producing capacity only after the race ANS: 2 Stress, exercise, and other factors increase the release of endorphins, raising an individu- al’s pain threshold (the point at which a person feels pain). Because the amount of circu- lating substances varies with each individual, the response to pain will be different. Al- though the other options may have affected his pain perception, they did not exert as much influence as the answer. DIF: C REF: 1053 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 25. Which of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function? 1. “His pulse and blood pressure are within his normal baseline limits, so I’m sure the pain medication is working.” 2. “Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines.” 3. “If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain.” 4. “Unmanaged pain usually manifests itself in both an elevated pulse and blood pres- sure.” ANS: 1 Except in cases of severe traumatic pain, which sends a person into shock, most people reach a level of adaptation in which physical signs return to normal. Thus clients in pain will not always have changes in their vital signs. Changes in vital signs are more often in- dicative of problems other than pain. Although the remaining options recognize the phe- nomena, they are not assuming that no elevation of vital signs means the absence of pain. DIF: C REF: 1054 OBJ: Analysis TOP: Nursing Process: Assessment/Planning MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 26. A client with a history of chronic back pain is questioning the need to “keep asking for pain medication,” fearing that he will be viewed as being weak by his family. The most therapeutic nursing response to this client would be: 1. “Chronic back pain is very difficult to deal with; utilize the pain medication be- cause that’s what it’s there for.” 2. “Your family won’t think you’re weak; they want you to be comfortable, and the medication will help.” 3. “Taking the medication as prescribed will help you to be more active; your family will be happy you can do things with them again.” 4. “It’s important that you manage your pain as effectively as possible; it really doesn’t matter what other people think about you.” ANS: 3 As a nurse, you encourage clients to accept pain-relieving measures so that they remain active. Clients who have a low pain tolerance (level of pain a person is willing to put up with) are sometimes inaccurately perceived as whiners or weak. The client needs to learn that effective, appropriate pain management is essential to his physical and emotional well-being. Although the remaining options are not incorrect, they do not display the de- gree of understanding the answer does. DIF: C REF: 1081 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 27. A client who is scheduled for the second in a series of painful dressing changes asks for “my pain medication now so it’s working when the dressing is changed” is most likely expressing: 1. A great fear of the expected pain 2. A need to be in control of his pain 3. An understanding that it is easier to pre- vent the pain than to stop the pain 4. An acceptance of the pain that the dress- ing change will obviously cause him ANS: 3 Clients often seek relief before pain occurs, having learned that pain is easier to prevent than to treat. Although the other options may not be incorrect, the likelihood is greater for the answer. DIF: C REF: 1055 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 28. The nurse inquires of a postoperative client as to the need for pain medication. The client denies the need then but 30 minutes later reports, “I am really in a lot of pain. Can you bring me my pain pill now?” The nurse recognizes that the most immediate need for cli- ent education is related to explaining that: 1. His oral medication will take approxim- ately 30 minutes to affect his pain 2. There may be a need to administer his pain medication via the intravenous route 3. Pain medication is more effective if blood levels are maintained at a constant level 4. His pain will be more effectively managed if he reports a need for pain medication while the pain is still tolerable ANS: 4 Teach clients the importance of reporting their pain sooner rather than later because the pain is better managed while it is still tolerable. Medication routes do affect the amount of time it will take to feel relief, and blood levels are a factor in pain management as well. The answer addresses the most general and immediate educational need. DIF: C REF: 1055 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 29. The nurse is caring for a cognitively impaired client who has experienced a painful pro- cedure. The nurse is most effective in determining the client’s pain medication needs when using which of the following assessment methods? DIF: C REF: 1070 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 33. The greatest barrier to a 3-year-old client’s ability to self-assess her pain is: 1. A limited vocabulary 2. Increased separation anxiety 3. Reluctance to talk to strangers 4. Inability to grasp the concept of pain ANS: 1 Young children who have not developed full vocabularies have difficulty verbally de- scribing and expressing pain to parents or caregivers. Toddlers and preschoolers are un- able to recall explanations about pain or associate pain with experiences that occur in various situations. The remaining options may have an effect on self-assessment of pain, but only to a limited degree. DIF: C REF: 1057 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 34. The nurse is discussing the effects of pain with an older adult client diagnosed with os- teoarthritis. The most therapeutic response to the client’s comment of, “I wonder whether it would hurt if I took a nap in the afternoon?” would be: 1. “As long as it did not interfere with your getting a good night’s sleep.” 2. “I’d suggest taking your nap right after you take your pain medication.” 3. “If it helps you cope better with the pain, I don’t see any harm in taking a nap.” 4. “I think a nap is a good idea because we seem to feel pain more when we are tired.” ANS: 4 Fatigue heightens the perception of pain and decreases coping abilities. If fatigue occurs along with sleeplessness, the perception of pain is even greater. Pain is often experienced less after a restful sleep than at the end of a long day. The other options are not inappro- priate but are not as informative regarding the benefit of rest on the perception or effects of pain. DIF: A REF: 1057-1059 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 35. Which of the following statements is the most appropriate response to a client’s state- ment, “I thought you could tell I was in pain”? 1. “How do you express a need for pain medication if not by asking?” 2. “I’m so very sorry; may I get you your pain medication right now? 3. “I don’t think it’s wise to assume I can ef- fectively read your mind regarding the need for pain medication.” 4. “I will make a point of asking you to rate your pain at least every 2 hours, so this miscommunication won’t happen again.” ANS: 4 Be sensitive to variations in communication styles. Some cultures feel nonverbal expres- sion of pain is sufficient to describe the pain experience, whereas others assume that if pain medication is appropriate, the nurse will bring it; thus asking is inappropriate. The remaining options are not as effective at addressing the root of the problem or providing a possible solution. DIF: C REF: 1061-1062 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 36. A 44-year-old client shares with the admitting nurse that the client is having epigastric pain that the client identifies as a 7 on a 0 to 10 scale. In order to plan for the pain man- agement of this client, which is the most appropriate response from the nurse? 1. "What would be a satisfactory level of pain control for us to achieve?" 2. "You don’t look like you’re in that much pain." 3. "You’ll be pain-free following your sur- gery." 4. "I’ve cared for a client with a nail in his head who only rated his pain as a 5; are you sure your pain is a 7?" ANS: 1 Complete pain relief is not always achievable, but reducing pain to a tolerable level is realistic. Thus a primary nursing goal is to provide pain relief that allows clients to parti- cipate in their recovery. Successful pain management does not necessarily mean pain elimination, but rather attainment of a mutually agreed-upon pain-relief goal that allows clients to control their pain instead of the pain controlling them. A person in pain feels distress or suffering and seeks relief. However, you as the nurse cannot see or feel the cli- ent’s pain. It is realistic that the client will most likely experience postoperative pain. The nurse should not use a pain scale to compare the pain of one client to that of another cli- ent. DIF: B REF: 1060 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 37. The home care nurse notes that a 67-year-old female diabetic client’s blood glucose level has been elevated since she strained her back the previous week. The client states that she cannot understand why her blood glucose level is elevated. The nurse suspects the most likely cause for the elevated blood sugar is: 1. The decreased activity level of the client since the injury 2. Parasympathetic stimulation from the body’s normal response to pain 3. The client is consuming more food as a comfort measure 4. The client may not be taking her medica- tion as ordered ANS: 2 An increased blood glucose level is the body’s physiological response to pain, which is triggered by the parasympathetic nervous system in order to provide additional glucose for additional energy. DIF: A REF: 1067 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 38. A client with chronic pain presents in the emergency department of the local hospital stat- ing “I just can’t take this anymore.” On questioning the client, the nurse discovers that the client have experienced chronic pain since being involved in an accident 2 years pre- viously. The client states that he has been labeled a “drug seeker” because he is looking for relief for the pain and feels hopeless, angry, and powerless to do anything about the situation. The nurse understands that this client is at risk for: 1. Criminal activity 2. Opioid abuse 3. Suicide 4. Drug addiction ANS: 3 The possible unknown cause of noncancer pain, combined with the unrelenting pain and uncertainty of its duration, frustrates the client, frequently leading to psychological de- pression and perhaps suicide. There is no evidence to demonstrate a relationship between chronic pain and criminal activity. Health care workers are usually less willing to treat need to worry about hurting him when I touch the penis.” 2. “I need to be careful not to put his diaper on too tight to avoid discomfort.” 3. “I can comfort my baby following the pro- cedure by holding him.” 4. “The health care provider will numb the area before performing the procedure.” ANS: 1 Term neonates have the same sensitivity to pain as older infants and children. Preterm neonates have a greater sensitivity to pain than term neonates or older children. DIF: C REF: 1055 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 43. Taking into consideration the hospice client’s chronic pain from bone cancer, the most appropriate person to collaborate with regarding management of pain is: 1. Occupational therapist to devise a splint for the client’s leg 2. Physical therapist to determine exercises to strengthen the leg muscles 3. Art therapist to provide creative therapy as a diversion 4. An oncology nurse ANS: 4 An oncology nurse specialist is very familiar with pharmacological and nonpharmacolo- gical interventions that are most effective for chronic/persistent pain. The client is termin- ally ill, and although occupational therapy, physical therapy, and art therapy are all im- portant therapies to consider, in this case the most appropriate discipline is the nurse who cares for this type of client and is familiar with the interventions that would be most ap- propriate. DIF: C REF: 1056 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 44. In creating the plan of care for a newly diagnosed breast cancer client, the nurse is con- cerned about pain control. The client has expressed an interest in relaxation therapy as a complementary pain therapy. The nurse knows that the best time to teach the client is: 1. Immediately following the client’s mastectomy 2. Before giving pain medication to evaluate if the complementary therapy works 3. Immediately preceding surgery 4. When the client is comfortable ANS: 4 For effective relaxation, teach techniques only when the client is not distracted by acute discomfort. The nurse would want to teach the client before the surgery so that the client could practice the technique before experiencing postsurgical pain. DIF: B REF: 1057 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 45. A client who ruptured his spleen in a motor vehicle accident rates his postoperative pain as a level 8 on a 0 to 10 pain scale. After administering pain medication, the nurse dis- cusses the use of complementary therapies with the client to explore ways to reduce the pain. The client would like to try a massage. The nurse delegates this task to the assistive personnel (AP). Which of the following instructions is most important for the nurse to share with the AP? 1. "You need to warm the bottle of lotion be- fore using it." 2. "Report any changes in the client’s skin condition to me immediately." 3. "Do not massage the client’s legs." 4. "Massage each body part at least 10 minutes." ANS: 3 The nurse should instruct the AP not to massage the client’s legs or calf muscles, because there is a risk for dislodging a vascular clot. The nurse needs to know about changes in the condition of the client’s skin, but this can be obtained after the client’s massage—it is not as critical as the AP's knowing not to massage the client’s legs before beginning the massage. DIF: B REF: 1057 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort