Question 1

The nurse is caring for a patient with rheumatoid arthritis who is in constant severe pain.Which nursing diagnosis is the highest priority for this patient?

Accepted Answer

Chronic pain is the highest priority diagnosis for this patient because it is severe.The other diagnoses may be addressed once the patient's pain is controlled.

Question 2

The nurse is caring for a cancer patient with ongoing pain from widespread metastasis to her bones.The nurse notes that the patient's morphine dosage had to be increased to sufficiently manage her discomfort.What is the nurse's interpretation of this assessment finding?

Accepted Answer

The patient is requiring higher doses of narcotic pain medication because her body has become tolerant to the medication.This is common when patients require long-term pain medication.Since the patient is taking morphine to control ongoing pain,the patient is not addicted to it.Need for increased morphine dosage is not indicative of drug abuse or a wish to end her life.

Question 3

The nurse is caring for a 6-month-old infant who has just undergone surgery.The infant's facial muscles are tight with a furrowed brow and the infant's respirations are shallow and irregular.The infant is mildly fussy and softly crying without muscular rigidity in the arms and legs.What score will the nurse give to the infant on the Neonatal Infant Pain Scale?

Accepted Answer

Tight muscles and furrowed brow = 1 point.Softly crying = 1 point.Shallow,irregular respirations = 1 point.Relaxed arms and legs = 0 points.Mild fussiness = 1 point.Total = 4 points

Question 4

What is the priority nursing assessment for a patient who his receiving postoperative epidural analgesia with hydromorphone (Dilaudid)?

Accepted Answer

The respiratory system is the priority nursing assessment for patients receiving narcotic pain medication via any route.This is because narcotics can cause respiratory suppression.The other assessments are a lower priority and may be done after a respiratory assessment is completed.

Question 5

Which assessment question helps the nurse determine the character of the patient's pain?

Accepted Answer

Pain character should be assessed using questions to learn more about what the pain feels like.Examples like stabbing,aching,burning may be used so that patients can understand what the nurse is requesting.Onset is determined by asking when the pain started.Exacerbating/relieving factors are determined by asking which interventions make the pain better.Time course is determined by asking if there is a pattern to when the pain occurs.

Question 6

The nurse is caring for a patient who just underwent laparoscopic appendectomy.The patient tells the nurse that she is experiencing severe postoperative pain between her shoulder blades.Which term best describes the pain that this patient is having?

Accepted Answer

Referred pain is pain that occurs when discomfort is felt in a different area than the source of the pain.Phantom pain occurs in amputees when pain is felt in the missing limb.Neuropathic pain occurs in the nervous system and often feels like burning or tingling.Psychogenic pain is discomfort felt by the patient that has no physical cause.

Question 7

The nurse is caring for a trauma patient with the nursing diagnosis of Acute pain r/t fracture and muscle spasms.Which is an appropriate goal for this nursing diagnosis?

Accepted Answer

Goals must be measurable and objective so that nursing staff can determine when each of the goals has been met.Having the patient describe meditation techniques is measurable because the nursing staff can determine whether or not he can actually describe them.Goals are achieved by the patient,not nursing staff.The nursing staff cannot accurately measure whether or not the patient is experiencing or feeling less pain.The goal statements "The patient will report less pain… or state that he has less pain…" are not measurable and appropriate.

Question 8

The nurse is caring for a patient who will be using a hydromorphone (Dilaudid)PCA analgesia pump following surgery.Which intervention is the highest priority for the nurse to include in the patient's care plan for the diagnosis: Readiness for enhanced knowledge r/t appropriate management of PCA pump?

Accepted Answer

Interventions for the nursing diagnosis: Readiness for enhanced knowledge include teaching the about pain medication use when the patient is ready to learn.The other interventions do not apply to the enhanced knowledge nursing diagnosis.

Question 9

The nurse is caring for a patient who is recovering from knee replacement surgery.The patient complains of severe pain in the knee after receiving hydrocodone with acetaminophen (Vicodin)2 hours previously.What is the nurse's best action?

Accepted Answer

Application of ice packs will help reduce swelling and pain that was not relieved with the patient's pain medication.The nurse should not administer another dose of Vicodin without an order from the physician.Heat will increase blood flow to the area rather than reduce swelling.Gentle ROM will increase pain if done at this time.

Question 10

Which is the best pain medication option for a patient to manage severe long-term cancer pain at home?

Accepted Answer

Duragesic transdermal patch is the best pain management option for home use with patients who have long-term,severe cancer pain as no injections are required and the fentanyl is slowly released over 72 hours.Epidurals and PCA pumps are intended for hospital use.Frequent IM injections require nursing administration and are not optimal for chronic long-term pain.

Question 11

The nurse is caring for a patient who only speaks a foreign language.What is the best method for the nurse to assess the patient's pain level?

Accepted Answer

The best method to determine pain in a patient who speaks only a foreign language is to use an interpreter.The Universal Pain Assessment Tool is available with foreign-language phrases that may also be used.Measuring vital signs and seeing if the patient is resting comfortably are not accurate pain assessment techniques.

Question 12

The nurse administered 100 mcg sublingual fentanyl spray (Subsys)at 10:00 A.M.to a patient experiencing severe breakthrough pain.At what time will the nurse ask the patient if pain relief was obtained?

Accepted Answer

Sublingual pain medications should be working well 15 to 30 minutes after administration,so the nurse should reassess the patient's pain at 10:30 A.M.

Question 13

The nurse is caring for a patient who is recovering from thoracotomy surgery.The patient's respirations are regular but very shallow.Which intervention is the highest priority for the nurse to include in the patient's care plan for the diagnosis: Ineffective breathing pattern r/t fatigue and pain?

Accepted Answer

The highest priority intervention for the ineffective breathing pattern diagnosis is to have the patient use the incentive spirometer after pain medication has been given.The spirometer will encourage the patient to take needed deep breaths,and pain medication will make it less painful for the patient to do so.The other interventions do not address breathing pattern.

Question 14

The nurse is caring for a diabetic patient who has painful neuropathy in her feet.The patient asks why the nurse is administering gabapentin (Neurontin)when she does not have a history of seizure disorder.What is the nurse's best response?

Accepted Answer

Anticonvulsant medication like Neurontin and tricyclic antidepressants are often used to relieve neuropathic pain as they work directly on the nervous system.The other statements do not correctly indicate why the patient is receiving Neurontin.

Question 15

The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis.What type of pain is this patient experiencing?

Accepted Answer

Visceral pain arises from the organs of the body and occurs when inflammation and tissue damage occurs,such as with cholecystitis.Somatic pain occurs when there is tissue damage to skin,muscle,joints,and bones.Referred pain occurs when the discomfort is felt at a location other than the origin of the pain.Radiating pain extends to another area of the body.

Question 16

The nurse is caring for a patient who has a PCA pump following total hysterectomy surgery.The nurse sees the visitor push the PCA button while the patient is sleeping quietly.What is the best response of the nurse?

Accepted Answer

Only the patient should operate the PCA and push the administration button.Family members and visitors should never activate the PCA pump for the patient because too much medication could be delivered,resulting in overdose and respiratory suppression.

Question 17

The nurse is caring for a patient who has been taking ibuprofen (Advil,Motrin)800 mg TID for the last several months to relieve arthritis pain in her knees.Which assessment finding must be reported to the physician promptly?

Accepted Answer

A side effect of ibuprofen and other NSAIDs is the risk of gastrointestinal bleeding,especially with long-term use.Abdominal pain with pale skin in this patient may be indicative of a bleeding ulcer and should be reported to the physician promptly.

Question 18

Which patient is best suited for PCA analgesia?

Accepted Answer

Patients recuperating from surgery are often good candidates for PCA analgesia.Confusion,inability to push the PCA button,and psychogenic pain are all contraindications for PCA analgesia.

Question 19

The nurse is checking on the patient after administering pain medication 30 minutes previously.Which assessment finding best indicates to the nurse that the pain medication was effective?

Accepted Answer

The best way for the nurse to determine that the pain medication was effective is for the patient to state that she has no pain.The other assessment findings cannot definitively determine whether or not the patient is still in pain.

Question 20

The nurse is caring for a patient with severe chronic pain.The nurse applied the first 50 mcg transdermal fentanyl (Duragesic)patch 2 hours ago.The patient states that the pain is presently rated at 9 on a 1-10 scale.What is the nurse's best action?

Accepted Answer

Transdermal administration of medication does not become effective for 12 to 16 hours after application.Short-acting narcotic medication like Roxanol morphine liquid should be given in the meantime to make the patient comfortable.

Quiz 36: Pain Management

The nurse is caring for a patient with rheumatoid arthritis who is in constant severe pain.Which nursing diagnosis is the highest priority for this patient?

The nurse is caring for a cancer patient with ongoing pain from widespread metastasis to her bones.The nurse notes that the patient's morphine dosage had to be increased to sufficiently manage her discomfort.What is the nurse's interpretation of this assessment finding?

What is the priority nursing assessment for a patient who his receiving postoperative epidural analgesia with hydromorphone (Dilaudid) ?

Which assessment question helps the nurse determine the character of the patient's pain?

The nurse is caring for a patient who just underwent laparoscopic appendectomy.The patient tells the nurse that she is experiencing severe postoperative pain between her shoulder blades.Which term best describes the pain that this patient is having?

The nurse is caring for a trauma patient with the nursing diagnosis of Acute pain r/t fracture and muscle spasms.Which is an appropriate goal for this nursing diagnosis?

The nurse is caring for a patient who is recovering from knee replacement surgery.The patient complains of severe pain in the knee after receiving hydrocodone with acetaminophen (Vicodin) 2 hours previously.What is the nurse's best action?

Which is the best pain medication option for a patient to manage severe long-term cancer pain at home?

The nurse is caring for a patient who only speaks a foreign language.What is the best method for the nurse to assess the patient's pain level?

The nurse administered 100 mcg sublingual fentanyl spray (Subsys) at 10:00 A.M.to a patient experiencing severe breakthrough pain.At what time will the nurse ask the patient if pain relief was obtained?

The nurse is caring for a patient who is recovering from thoracotomy surgery.The patient's respirations are regular but very shallow.Which intervention is the highest priority for the nurse to include in the patient's care plan for the diagnosis: Ineffective breathing pattern r/t fatigue and pain?

The nurse is caring for a diabetic patient who has painful neuropathy in her feet.The patient asks why the nurse is administering gabapentin (Neurontin) when she does not have a history of seizure disorder.What is the nurse's best response?

The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis.What type of pain is this patient experiencing?

The nurse is caring for a patient who has a PCA pump following total hysterectomy surgery.The nurse sees the visitor push the PCA button while the patient is sleeping quietly.What is the best response of the nurse?

The nurse is caring for a patient who has been taking ibuprofen (Advil,Motrin) 800 mg TID for the last several months to relieve arthritis pain in her knees.Which assessment finding must be reported to the physician promptly?

Which patient is best suited for PCA analgesia?

The nurse is checking on the patient after administering pain medication 30 minutes previously.Which assessment finding best indicates to the nurse that the pain medication was effective?

The nurse is caring for a patient with severe chronic pain.The nurse applied the first 50 mcg transdermal fentanyl (Duragesic) patch 2 hours ago.The patient states that the pain is presently rated at 9 on a 1-10 scale.What is the nurse's best action?