Question 1

An older adult patient who has cancer and Alzheimer's disease is crying but shakes her head "no" when asked about pain. The prescriber has ordered morphine sulfate 2 to 4 mg IV every 2 hours PRN pain. It has been 4 hours since a dose has been given. What will the nurse do?

Accepted Answer

Older adult patients often are undertreated for pain, because assessing pain is difficult in patients with cognitive impairment and because practitioners often believe that reduced dosages are necessary to alleviate side effects. This patient does not verbalize pain, but her nonverbal cue (crying) indicates that pain is present. The nurse should give the higher dose, especially because the dosing interval has already been exceeded, and then monitor the patient's response to the medication. Giving 2 mg to avoid side effects is not indicated; patients with Alzheimer's disease will continue to have confusion unrelated to the opioid. Nonopioid analgesics and antidepressants are not indicated. Withholding pain medication is not appropriate, because this patient shows nonverbal signs of pain.

Question 2

A patient with cancer is admitted to the hospital. The nurse obtains an admission history and learns that the patient has been taking oxycodone and a nonsteroidal anti-inflammatory drug (NSAID) for a year. The patient reports a recent increase in the intensity of pain, along with a new pain described as "burning" and "shooting." The nurse anticipates that the prescriber will order:

Accepted Answer

As pain increases in severity, more powerful opioids should be used. This patient has been taking oxycodone, which is a moderate-strength opioid; fentanyl is stronger. Because the pain is chronic and is now severe and because the patient has opioid tolerance, a transdermal patch may be used. Long-term use of NSAIDs is not recommended because of the risk of thrombotic events. The patient also is describing neuropathic pain, which can be treated with an adjuvant analgesic. Fixed-dose combination drugs are not recommended for increasing pain. NSAIDs are not recommended long term. Intramuscular medications are not recommended because of the pain associated with administration.

Question 3

A patient with bone cancer has recently undergone chemotherapy and radiation therapy to reduce the size of the tumor. The patient is taking a large dose of an opioid analgesic, along with acetaminophen and an antidepressant. The nursing student caring for this patient is concerned that the patient is showing drug-seeking behaviors, because the individual requested an increased dose of the opioid. The student discusses this concern with the nurse. Which statement by the student indicates a need for further teaching?

Accepted Answer

Pain in cancer patients can arise both from the cancer itself and from the treatments. This patient has bone cancer, which causes somatic pain, and the treatments can increase this pain. Although neuropathic pain can occur as well, this patient is more likely to need analgesia for the nociceptive pain, so increasing the antidepressant dose is not indicated. Patients very often require more drug to achieve the same effect as tolerance develops. Radiation and chemotherapy can damage tissue and increase pain. When assessing pain in patients, the patient's own description of pain intensity is the most important.

Question 4

An 8-year-old child with advanced cancer has an order for oxycodone (OxyContin) PO, PRN for moderate to severe pain. The nurse notes that the child is constantly playing computer games and repeatedly denies having pain. What will the nurse do?

Accepted Answer

For a number of reasons, even children who can verbalize pain correctly often underreport it. The child may fear that reporting pain may lead to painful procedures or may worry caregivers, or the child may be unaware that pain can be alleviated. Children involved in activities such as computer games may actually be using the activity to distract themselves from the pain, so such an activity is not an indication that the child is comfortable. This child has advanced cancer and is likely to have severe pain. A PCA device would give the child control and provide adequate pain relief. The oxycodone order is for PRN dosing, so the nurse cannot administer it around the clock without a prescriber's order to do so. Also, because this child is more likely to have severe pain, a PCA would be more effective. Reassuring the parent that the child will report pain and asking the child to report pain do not take into account the fact that children often hide pain for the reasons previously mentioned.

Question 5

A patient is taking hydrocodone and ibuprofen for cancer pain and is admitted to the hospital for chemotherapy. The nurse anticipates that the prescriber will _____ ibuprofen.

Accepted Answer

NSAIDs are contraindicated in patients undergoing chemotherapy because of decreased platelet production caused by bone marrow suppression. Any NSAID further increases the risk of bruising and bleeding. ASA is especially dangerous, because it causes irreversible inhibition of platelet aggregation. Ibuprofen should be discontinued, not reduced or increased.

Question 6

Which nonpharmacologic therapies are effective in reducing cancer pain? (Select all that apply.)

Accepted Answer

Cold, heat, and exercise have been shown to reduce pain. Acupuncture and TENS have not been demonstrated to be effective, although in theory they should work.

Question 7

Over time, patients taking opioid analgesics develop tolerance to which side effects? (Select all that apply.)

Accepted Answer

With continuous use, tolerance develops to most side effects of opioids, except to constipation and physical dependence.

Question 8

A patient with cancer has been receiving codeine and a nonsteroidal anti-inflammatory medication for pain. The patient reports worsening of pain in both intensity and frequency. The nurse will tell the patient to contact the provider to discuss:

Accepted Answer

As patients have increased pain, it is important to increase the level of analgesia. Hydrocodone or oxycodone is useful as pain increases, after nonopioid analgesics have been tried. Fentanyl transdermal patches are used for chronic, severe pain in patients who are already tolerant to opioids. Adjuvant analgesics can be used at any stage of pain progression but are used for neuropathic pain. Codeine is not recommended for cancer pain, because it has dose-limiting side effects; increasing the dose of codeine is never recommended.

Question 9

A patient newly diagnosed with cancer is admitted to the hospital, and the provider orders oxycodone (OxyContin) every 4 to 6 hours PRN pain. The patient requests pain medication whenever he reports pain as a 7 or 8 on a scale of 1 to 10 (10 being the worst pain), but he tells the nurse the medication is not working well. The nurse will contact the provider to discuss:

Accepted Answer

Dosing should be done on a fixed schedule to prevent opioid levels from becoming subtherapeutic once patients begin to have more severe pain. IM and IV dosing are more invasive and should not be used unless other methods have failed. Transdermal fentanyl is used for chronic, severe pain in patients tolerant to opioids.

Question 10

A patient who is taking a fixed-dose combination drug with an opioid and acetaminophen for cancer pain reports increased muscular pain. The patient asks the nurse if the pain medication dose can be increased. What will the nurse tell this patient?

Accepted Answer

Fixed-dose combination products are not useful as pain increases, because the side effects of the nonopioid drug become intolerable as the dosage increases. As pain becomes more severe, the components of the combined regimen should be given separately. Adjuvant analgesics are used for neuropathic pain and not nociceptive pain (which this patient has described). Acetaminophen doses should not be increased. Increasing the dose of a fixed-dose combination drug is not recommended.

Question 11

A patient with cancer who has been receiving an opioid analgesic reports having pain at a new location even though the previous pain is well controlled. The nurse will contact the provider to discuss:

Accepted Answer

Caregivers should be alert for new pain; this usually results from a new cause, such as metastasis, infection, or fracture, and should be investigated. Breakthrough pain is pain that occurs even when adequate levels of analgesics are given. Drug-seeking behavior refers to patients who use drugs for euphoric effects instead of for intended effects. Tolerance occurs when more drug is required to receive the same effect.

Question 12

A nursing student caring for a patient with cancer tells the nurse that the patient seems to be exaggerating when reporting the degree of pain. Which statement by the nurse is an appropriate response to this concern?

Accepted Answer

The patient's description of his or her pain is the cornerstone of assessment. Pain is a personal experience, and caregivers must act on what the patient says, even if they suspect the patient is exaggerating or not telling the truth. Evaluation of vital signs can be used to monitor responses to pain medication, as can assessments of behaviors and facial expressions, but they are not determinants of the level of pain in initial assessments. Patients with pain in new locations should be evaluated for metastases or infection or other causes.

Question 13

A patient who has cancer reports pain as "burning" and "shooting" alternating with feelings of numbness and coldness. The nurse will contact the provider to discuss the use of which medication?

Accepted Answer

This patient is describing neuropathic pain, which results from injury to peripheral nerves. This type of pain responds poorly to opioid analgesics but does respond to adjuvant analgesics, which include antidepressants such as imipramine. Acetaminophen and ibuprofen are used for mild nociceptive pain, and oxycodone is used for more severe nociceptive pain.

Question 14

A nurse is teaching a group of nursing students about the differences between pure opioid agonists and agonist-antagonist opioids. Which statement by a student indicates understanding of the teaching?

Accepted Answer

Pure agonists are agonists at mu and kappa receptors. Agonist-antagonist opioids are agonists at kappa, not mu, receptors. At mu receptors, agonist-antagonists act as antagonists. Agonist-antagonists are not recommended for treating cancer pain; because of their antagonist effect, they block access of the pure agonists to mu receptors and thus block their actions.

Question 15

A patient who has had cancer for 1 year uses a fentanyl transdermal patch for pain relief. The patient reports having three or four episodes of pain (which she rates as 8 or 9 on a scale of 1 to 10) each day, and each episode lasts 15 to 30 minutes. The nurse will contact the provider to:

Accepted Answer

Breakthrough pain can occur in patients who otherwise have well-controlled pain, and it should be managed with extra doses of short-acting, strong opioids. This pain is moderate to severe and is not neuropathic, so adjuvant analgesics or NSAIDs are not useful. Increasing the dose of the long-acting opioid would not alleviate breakthrough pain.

Quiz 29: Pain Management in Patients With Cancer