Chapter 12 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 12

Question 1

Type: MCSA

Which statement explains why the nurse should assess each patients pain response individually in every situation?

1. Everyone has a unique tolerance to pain.

2. Everyone has the same pain threshold.

3. Everyone perceives painful stimuli at the same intensity.

4. Most people have the same pain response to surgery.

Correct Answer: 1

Rationale 1: Each persons pain tolerance is different and should be assessed on an individual basis.

Rationale 2: Everyone does not have the same pain threshold.

Rationale 3: Everyone perceives pain at a different intensity.

Rationale 4: Different people have a different pain response, even to the same surgery.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1

Question 2

Type: MCSA

A patient is being treated for chronic pain. The nurse realizes that which characteristic is typical of chronic pain?

1. The pain rating may be inconsistent with the underlying pathology.

2. Chronic pain usually has a clear, physiologic cause.

3. Chronic pain typically lasts 2 months or less.

4. The pain reported is usually less severe than acute pain.

Correct Answer: 1

Rationale 1: The patient might not exhibit signs of pain such as elevations in vital signs, grimacing, writhing, or moaning.

Rationale 2: There may not be an identified physiologic cause for chronic pain.

Rationale 3: Chronic pain is typically persistent beyond 3 to 6 months.

Rationale 4: There is no indication that chronic pain is less severe than acute pain, although in some instances it may be more diffuse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-3

Question 3

Type: MCMA

The nurse is managing care for a group of patients with pain. The nurse plans care for acute pain for which patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient who had a cholecystectomy this morning

2. A patient with phantom limb pain

3. A patient with a compound femur fracture that occurred 5 days ago

4. A patient with degenerative joint disease

5. A patient being treated for a burn that occurred 8 months ago

Correct Answer: 1,3,5

Rationale 1: Pain associated with surgery, such as gallbladder removal, is of relatively short duration and is considered acute pain.

Rationale 2: The neuropathic pain associated with amputation, phantom limb pain, may not begin immediately and may become a chronic problem lasting more than 6 months.

Rationale 3: A patient with a compound femur fracture will experience acute pain. The pain will still be considered acute 5 days after injury.

Rationale 4: Degenerative joint disease is associated with chronic rather than acute pain.

Rationale 5: The treatment is current, so pain is acute.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-3

Question 4

Type: MCSA

The nurse is planning care for a patient with chronic pain. What would be the most appropriate pain control goal for this patient?

1. The patient will reduce the focus on pain.

2. The patient will require minimal analgesic medications.

3. The patient will be completely pain free.

4. The patient will report that the pain is bearable.

Correct Answer: 1

Rationale 1: Pain management goals for the patient with chronic pain include reducing the focus on pain; optimizing comfort; increasing participation in activities of daily living, work, and relationships; and restoring a sense of joy and purpose.

Rationale 2: The goal should not be to use minimal analgesics; the patient should be provided with the amount required to control pain.

Rationale 3: Being completely pain free might be an unattainable goal for a patient with chronic pain.

Rationale 4: The goal is to make the patient comfortable, not to reduce pain simply to bearable levels.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-7

Question 5

Type: MCSA

The nurse, caring for a patient recovering from surgery, knows that which intervention will provide the most pain relief for the patient?

1. Offer pain relief before the patient complains of pain.

2. Wait until the patient can describe the pain specifically.

3. Assess the pain level every 4 hours around the clock.

4. Allow the patient to sleep off the anesthesia, and then offer pain medication.

Correct Answer: 1

Rationale 1: Anticipating a patients pain will ensure a more manageable pain experience than will waiting until the patient complains of pain.

Rationale 2: Pain management needs to be implemented before the patient can describe specific postoperative pain, or sleeping off anesthesia.

Rationale 3: The patient should not be awakened every 4 hours to assess pain unless there are other significant nonverbal signs during

sleep that indicate the patient is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site.

Rationale 4: Pain management should be implemented prior to the patient sleeping off anesthesia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-7

Question 6

Type: MCMA

A patient is receiving an opioid for severe acute pain. What information should the nurse provide regarding this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increase fluid intake.

2. Take a vitamin D supplement.

3. Eat more protein.

4. Increase intake of complex carbohydrates.

5. Take a stool softener daily.

Correct Answer: 1,5

Rationale 1: Patients receiving opioids are at risk for constipation. Increasing fluid intake helps to reduce this effect.

Rationale 2: Increasing vitamin D intake is not a recommendation specifically related to the effects of an opioid medication.

Rationale 3: Increasing protein intake is not a recommendation specifically related to the effects of opioid medication.

Rationale 4: Increasing carbohydrate intake is not a recommendation specifically related to the effects of an opioid medication.

Rationale 5: Opioids are constipating, so a stool softener is necessary.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-7

Question 7

Type: MCSA

The nurse is planning to administer a pain medication to a patient who has just returned to the unit following bowel resection surgery. The patient has four standing orders for pain medication. Which order should the nurse select?

1. The one to be administered intravenously by patient demand and under patient control

2. The one to be given intramuscularly to work quickly

3. The one ordered on a prn basis

4. The one to be administered orally

Correct Answer: 1

Rationale 1: Patient-controlled analgesia allows self-management of pain and is a common postoperative method of administering pain medication. The advantages to this method are dose precision, timeliness, and convenience.

Rationale 2: The medication that is administered intramuscularly is not typically recommended for moderate to severe pain that will require more than one dose.

Rationale 3: Administering a prn medication this soon after a major surgery would not be the most effective strategy.

Rationale 4: Administering an oral medication this soon after a major surgery would not be the most effective strategy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

Question 8

Type: MCMA

A patient recovering from abdominal surgery is refusing hydromorphone (Dilaudid) because she has heard that people may become addicted. She is crying and rates her pain 10 of 10. Which information should the nurse include as part of the patients education?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Because the patient will take the medication on a prn basis, addiction cannot occur.

2. Untreated pain can result in poor wound healing.

3. Patients with uncontrolled pain have a higher risk of blood clots.

4. Dehydration can result from poorly managed pain.

5. Family members do not want to visit patients with visible signs of pain.

Correct Answer: 2,3

Rationale 1: Pain medications should be dosed on a continuous basis after surgery. The use of prn dosing schedules does not guarantee that the patient will not become addicted if the medication is misused.

Rationale 2: Pain has physiological consequences, including poor wound healing.

Rationale 3: Pain has physiological consequences, including coagulation leading to DVT or PE.

Rationale 4: There is no evidence that poor pain relief causes dehydration.

Rationale 5: There is no evidence that poor pain relief causes family members to refuse to visit.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

Question 9

Type: MCSA

A patient with a history of chronic pain tells the nurse, I do a variety of things to make my body produce its own pain reliever. How should the nurse evaluate this statement?

1. This is a common denial technique.

2. The patient is trying to appear to be a pain expert.

3. This statement offers the nurse a reason to reduce the amount of pain medication prescribed.

4. The patient is taking advantage of the bodys ability to make endorphins.

Correct Answer: 4

Rationale 1: The patient did not deny the pain.

Rationale 2: The patient is an expert on his or her own pain. There is no evidence that this is the stimulus for this statement.

Rationale 3: There was no discussion of pain medication amounts.

Rationale 4: There is a pain inhibitory center within the dorsal horns of the spinal cord. The exact nature of this inhibitory mechanism is unknown. However, the most clearly defined chemical inhibitory mechanism is fueled by endorphins, which are naturally occurring opioid peptides in neurons in the brain, spinal cord, and gastrointestinal tract. Endorphins work by binding with opiate receptors on the neurons to inhibit pain impulse transmission.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-2

Question 10

Type: MCSA

A patient has periodic severe nerve pain that is not well controlled with the current pain medication regimen. The nurse anticipates adding a medication from which category?

1. Nonsteroidal anti-inflammatory drugs (NSAID)

2. Opioids

3. Antidepressants

4. Local anesthetics

Correct Answer: 3

Rationale 1: The NSAID group can have serious side effects, including bleeding tendencies, and would not be appropriate in a long-term situation.

Rationale 2: Other medications are prescribed before introducing opioids.

Rationale 3: Antidepressants within the tricyclic and related chemical groups act on the production and retention of serotonin in the CNS, thus inhibiting pain sensation. They also promote normal sleeping patterns, which further alleviates the suffering of the patient in pain. They are useful with neuropathic pain.

Rationale 4: A local anesthetic would not be appropriate for long-term pain management.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-4

Question 11

Type: MCSA

A patient who is receiving pain medication around the clock complains of an acute exacerbation of pain. What should the nurse do to help this patient?

1. Provide the medication ordered for breakthrough pain.

2. Talk the patient through the pain.

3. Encourage the patient to ignore the pain.

4. Give the patient a nonsteroidal anti-inflammatory drug (NSAID).

Correct Answer: 1

Rationale 1: Breakthrough pain (BTP) occurs in patients who are receiving long-acting analgesics for chronic pain. It is a transitory experience of moderate to severe pain that is often precipitated by coughing or movement but may occur spontaneously. A short-acting opioid for this type of pain should be administered as needed in addition to the around-the-clock (ATC) dose for chronic, persistent pain.

Rationale 2: The pain must be addressed; it is not appropriate to talk the patient through it.

Rationale 3: The pain must be addressed; it is not appropriate to encourage the patient to ignore it.

Rationale 4: NSAIDs can only be given with the physicians order.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-7

Question 12

Type: MCMA

A patient with chronic pain is being started on a patch. What should the nurse include when instructing the patient about this pain-relieving delivery system?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. It will not work as well as oral pain medications.

2. Do not apply heat over the area where the patch is placed.

3. The patient will never experience breakthrough pain.

4. The patient will never overdose with this delivery method.

5. Do not massage the area where the patch is placed.

Correct Answer: 2,5

Rationale 1: The continuous dosage of the transdermal or patch form of medication is an advantage over oral medications.

Rationale 2: Application of heat or massaging the skin increases blood flow to the area, resulting in rapid absorption and potential overdose.

Rationale 3: Additional short-acting medication is often needed for breakthrough pain.

Rationale 4: Overdose can occur with this route.

Rationale 5: Massaging the area where the patch is placed can increase blood flow to the area, resulting in rapid absorption and potential overdose.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

Question 13

Type: MCSA

A patient is seen talking and laughing in the clinics waiting room, yet complains of excruciating pain. The nurse realizes this patient is most likely demonstrating which behavior?

1. Opioid drug-seeking

2. Denial

3. Fake pain

4. Inconsistent behavioral response to pain

Correct Answer: 4

Rationale 1: There is no mention of the patient requesting opioids.

Rationale 2: The patient does not deny pain.

Rationale 3: The nurse cannot determine if the patients pain is real.

Rationale 4: Behavioral responses to pain may or may not coincide with the patients report of pain and are not very reliable cues to the pain experience. The nurse needs to manage the pain if the patient verbalizes that it is present, even if the nonverbal signs are not congruent.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-2

Question 14

Type: MCSA

Which patients (or patients) physiologic assessment findings are consistent with the classic signs of acute pain?

1. Patients A and C

2. Patient A only

3. Patients B and D

4. Patient C only

Correct Answer: 3

Rationale 1: Slight expiratory wheezes and lower-extremity edema are not changes caused by pain.

Rationale 2: Slight expiratory wheezes are not changes caused by pain.

Rationale 3: Predictable physiologic changes occur in the presence of acute pain. These may include muscle tension; tachycardia; rapid, shallow respirations; increased blood pressure; dilated pupils; sweating; and pallor.

Rationale 4: Lower-extremity edema is not a change caused by pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-2

Question 15

Type: MCSA

Which patient (or patients) is reporting symptoms that are most likely to be related to side effects of an opioid pain medication regimen?

1. Patients A and C

2. Patient C only

3. Patients B and D

4. Patient D only

Correct Answer: 1

Rationale 1: Nausea and vomiting are common adverse effects of opioid analgesics, as is constipation.

Rationale 2: Another patient is also experiencing the effects of opioid analgesics.

Rationale 3: Opioids may cause stomach upset, but bruising is not a common side effect of opioid administration.

Rationale 4: Bruising is not a common side effect of opioid administration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12-4

Question 16

Type: MCSA

While caring for a nonverbal patient, which action ensures appropriate and timely pain management?

1. Have the family medicate the patient, based on their knowledge of the patients response to pain.

2. Use the McGill pain questionnaire to determine the optimal pain management plan.

3. Administer opioids around the clock, adding NSAIDS when necessary.

4. Medicate the patient based on the pathologic condition, nonverbal cues, and pain procedures.

Correct Answer: 4

Rationale 1: The family members are not likely to have the understanding of pharmacology and physiologic parameters to make pain management decisions, and in fact, out of concern, may overread the presence of pain.

Rationale 2: The McGill questionnaire requires the clients input regarding pain and impact on ADLs and therefore is not an appropriate screening tool for this patient.

Rationale 3: The appropriate analgesic should be used for the situation. There is no indication that an opioid is necessary.

Rationale 4: Use of a behavioral pain assessment in addition to administering analgesics based on what would be considered a painful condition or procedure to others is the standard of practice.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-3

Question 17

Type: MCSA

A nurse in the emergency department is caring for a patient with a fractured tibia and fibula who admits to regular heroin use. Which factor should be used to determine the presence of pain and need for pain medication?

1. The patient has taken an opiate already today.

2. The shift report indicates the patient has been sleeping on and off.

3. The patient is angry about being in the hospital.

4. The patient reports pain in the leg of an intensity of 10 out of 10 on the numeric rating scale.

Correct Answer: 4

Rationale 1: A chronic opiate user/abuser will experience withdrawal symptoms if the usual or base dose of opiate is not given. The patient may require additional medication for pain.

Rationale 2: A patient in pain may appear asleep or have closed eyes, but the quality of sleep may be poor.

Rationale 3: Anger at the nursing staff does not reflect the presence or absence of pain.

Rationale 4: The nurse should accept all pain reports as valid but negotiate treatment goals early in care. The patients own report of pain is the best means of assessing pain intensity.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-6

Question 18

Type: MCSA

The nurse is assessing a patient with chronic pain and learns the patient is not able to sleep through the night. The nurse realizes this patient is demonstrating which problem?

1. The inability to cope with pain

2. A side effect of chronic pain medication use

3. Sleep deprivation because of poor pain control

4. Lying as a way to be prescribed more pain medication without an identified need

Correct Answer: 3

Rationale 1: There is no evidence that this patient does not have the ability to cope with pain.

Rationale 2: There is no evidence that this patient is experiencing a side effect of pain medication use.

Rationale 3: Pain has been associated with agitation, decreased mobility, and sleep deprivation.

Rationale 4: The nurse should be nonjudgmental and not assume the patient is attempting to obtain more pain medication without an identified need.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1

Question 19

Type: MCSA

The nurse is administering analgesic medication to a group of patients. Which statement should guide the nurse in this work?

1. Pain should be managed to improve the patients quality of life.

2. Opiates are not recommended for patients with addiction issues.

3. The nurse should be certain pain is present prior to administering opiates.

4. Patients with psychiatric diseases should avoid opiates for malignant pain.

Correct Answer: 1

Rationale 1: The purpose of effective pain management is to relieve or reduce pain to improve quality of life.

Rationale 2: Opiates may be needed by patients with addiction issues if the pain is severe; the dosage is adjusted to include the daily intake, plus additional medicine to control pain.

Rationale 3: If the nurse follows the definition of pain as what the patient describes, then the nurses role is to respond to the patients report of pain.

Rationale 4: Patients with psychiatric disorders still experience pain and are entitled to pain relief equivalent to that given to patients without psychiatric disorders.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-6

Question 20

Type: MCSA

A patient says that she has pain every day but never asks her health care provider for medication because she doesnt want to become addicted. What is the nurses best response to this patient?

1. Pain isnt always a bad thing to experience.

2. Its better to experience the pain than to cover it up.

3. There are many medications your doctor can prescribe that are not addicting.

4. I wouldnt want to become addicted either.

Correct Answer: 3

Rationale 1: The nurse should not minimize the impact of the patients pain on her ability to function or experience the pain.

Rationale 2: The nurse should not recommend that it is better to allow pain to continue without treatment.

Rationale 3: This patients fear of becoming addicted to pain medication is evidence of inaccurate consumer education and consumer fears. The nurse should suggest that the patient talk with her health care provider regarding pain medication options.

Rationale 4: The nurse should not support the patients fears regarding addiction.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-6

Question 21

Type: MCSA

The nurse, completing a pain assessment, would attribute which data to the affective dimension of pain?

1. The patient is pale and moaning.

2. The patient rates the pain as 9 on a scale of 1 to 10.

3. The patient states, The pain comes in waves in my abdomen.

4. The patient states that the pain is punishment for my misdeeds.

Correct Answer: 4

Rationale 1: Pallor and moaning are objective findings.

Rationale 2: Pain scales are tools to determine the severity of the pain.

Rationale 3: The quality of the pain is a subjective report of the sensory component of pain.

Rationale 4: The affective domain is the emotions or feelings associated with the pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1

Question 22

Type: MCSA

A patient is seen resting quietly; however, when the nurse enters the room, the patient grimaces and asks for more pain medication. What should the nurse do?

1. Tell the patient that medication cannot be provided at this time and leave the room.

2. Assess the level of pain and provide the requested pain medication.

3. Confront the patient and ask about the sudden demonstration of pain.

4. Refuse the medication and document that the patient appears to be faking the need for pain medication.

Correct Answer: 2

Rationale 1: The nurse should not deny the patient pain medication.

Rationale 2: The behavioral dimension of pain states that responses to pain can be situational, developmental, or learned. Failure to respond to a patients complaint of pain may lead to learned pain behaviors. The patient may have learned that without an open demonstration of pain, the complaint might be ignored. The nurse should assess the level of pain and provide the medication.

Rationale 3: There is no need to confront the patient about this behavior.

Rationale 4: The nurse should not document that the patient is faking pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-7

Question 23

Type: MCMA

The nurse is performing a multidimensional pain assessment. Which questions should be included in this type of assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Can you rate the pains severity?

2. Is there a history of similar pain in your family?

3. How are you managing your daily activities?

4. How does the pain make you feel?

5. Can you point to the area of pain?

Correct Answer: 1,3,4,5

Rationale 1: A multidimensional pain assessment tool assesses more than one dimension of pain, including pain intensity.

Rationale 2: The patient is the focus of the pain assessment, not the family.

Rationale 3: A multidimensional pain assessment tool assesses more than one dimension of pain, including quality of life and ability to participate in ADLs.

Rationale 4: A multidimensional pain assessment tool assesses more than one dimension of pain, including the quality and characteristics of pain.

Rationale 5: A multidimensional pain assessment tool assesses more than one dimension of pain, including the area of pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-2

Question 24

Type: MCSA

The nurse is assessing a patient who is unable to supply a self-report of pain. What should the nurse do to assess the patients pain?

1. Use a surrogate pain rating from the family or caregiver.

2. Document that the client cannot scale the pain.

3. Document the clients pain using a numeric rating scale.

4. Use the McGill pain questionnaire to assess the pain.

Correct Answer: 1

Rationale 1: Using a surrogate pain rating from caregivers and family is an acceptable assessment strategy for at-risk patients.

Rationale 2: Documenting that the patient cannot scale pain is not an assessment tool.

Rationale 3: The patient who cannot report pain will be unable to use the numeric rating scale.

Rationale 4: The patient must be aware and able to answer questions regarding pain and quality of life to use the McGill pain questionnaire.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-6

Question 25

Type: MCSA

The nurse is caring for a patient with prostate cancer with metastasis to S-1 and the adjacent nerve root. The patient complains of unrelenting pain. When collaborating with the provider, the nurse would advocate for which example of balanced analgesia?

1. Use escalating doses of an opioid analgesic per the third step of the World Health Organization (WHO) analgesic ladder.

2. Use an opioid around the clock rather than on an as-needed (prn) basis.

3. Begin with the first step of the analgesic ladder as described by the World Health Organization (WHO), and then evaluate the clients response.

4. Use an opioid for background pain and gabapentin (Neurontin) for the neuropathic pain.

Correct Answer: 4

Rationale 1: Using escalating doses of an opioid does not address balanced analgesia.

Rationale 2: The use of around-the-clock medication over prn is appropriate; however, it does not address balanced analgesia.

Rationale 3: The step approach, in which the provider begins at the lowest step and moves through each step to reach the top, is not necessary, nor does it address balanced analgesia.

Rationale 4: Balanced analgesia or multimodal analgesia facilitates improved analgesia that is not possible with a single medication; various medications and adjunctive therapies are used to target specific types of pain and provide optimal relief in a safe manner.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

Question 26

Type: MCMA

The nurse is evaluating a patient receiving hydromorphone (Dilaudid). Which findings are adverse effects of this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pruritus

2. Polyuria

3. Nausea

4. Decreased respiratory rate

5. Tachypnea

Correct Answer: 1,3,4

Rationale 1: Side effects of narcotic or opioid analgesics include itching (pruritus).

Rationale 2: Polyuria, or excessive urine output, does not occur with opiates.

Rationale 3: Side effects of narcotic or opioid analgesics include nausea and vomiting.

Rationale 4: Side effects of narcotic or opioid analgesics include respiratory depression.

Rationale 5: Tachypnea, or rapid breathing, is not an adverse effect associated with opioid analgesics.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12-4

Question 27

Type: MCSA

A patient is prescribed ibuprofen for back pain. The nurse preparing to educate this patient about the drug would consider which information?

1. The drug should be used with caution in patients who consume more than three alcoholic beverages per day.

2. The drug can be taken safely up to the day of a surgical procedure.

3. The drug should be taken at a higher dose if administered with an opioid.

4. The drug is a step 1 analgesic in the World Health Organizations three-step approach to pain management.

Correct Answer: 4

Rationale 1: Acetaminophen should be used with caution in patients who consume more than three alcoholic beverages per day.

Rationale 2: Nonsteroidal anti-inflammatory drugs should be discontinued 1 to 2 weeks prior to a surgical procedure to reduce the risk of bleeding.

Rationale 3: If a nonsteroidal anti-inflammatory drug is administered with an opioid, the opioid dose can be reduced. The NSAID dose does not need to be adjusted.

Rationale 4: Acetaminophen and nonsteroidal anti-inflammatory drugs such as ibuprofen are analgesics used in the first step in the World Health Organizations three-step approach to pain management.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-4

Question 28

Type: MCSA

A patient tells the nurse that putting a small pillow under the knee and rubbing the thigh helps reduce hip pain. How would the nurse interpret this statement?

1. As a way to deny the presence of the hip pain

2. As demonstrating fear of taking pain medication

3. As a way to hide a previous pain medication addiction

4. As a nonpharmacologic method to reduce the hip pain

Correct Answer: 4

Rationale 1: The patient is not denying the presence of pain.

Rationale 2: The nurse should not assume that the patient is fearful of taking pain medication.

Rationale 3: The nurse should not assume that the patient has a history of pain medication addiction.

Rationale 4: Although largely unsupported by scientific evidence, complementary therapies are often used in conjunction with medications, or alone, to control chronic pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-5

Question 29

Type: MCSA

When carrying out the order for morphine 2 mg IV every 3 hours prn, the nurse recognizes that which intervention is most appropriate?

1. The nurse should wait until the previous dose of morphine has worn off before administering more.

2. For best results, the patient should receive the morphine every 3 hours.

3. The nurse should assess pain every hour and routinely offer the drug.

4. The nurse should wait until the patient requests the morphine to administer the drug.

Correct Answer: 3

Rationale 1: Waiting for a previous dose of medication to wear off will reduce the blood level of analgesic; the patient may then need more than the ordered amount to regain control over pain.

Rationale 2: Administering the medication every 3 hours around the clock circumvents the nurses responsibility to assess the pain and administer medication when the patient needs it.

Rationale 3: While around-the-clock dosing has been proven more effective than as-needed (prn) dosing, the nurse should educate the patient about the medication, assess pain frequently, and offer the drug every 3 hours. If the patient is experiencing breakthrough pain, the nurse should contact the prescriber.

Rationale 4: Waiting for the patient to request the drug may allow too much time to elapse, resulting in severe pain that will require more than the ordered amount to relieve.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

Question 30

Type: FIB

A patient who had abdominal surgery this morning is receiving opioid pain medication on a routine basis. The nurse would hold the medication if the patients respirations fall below _____ per minute.

Standard Text:

Correct Answer: 12

Rationale : Opioid medications cause respiratory depression. If the respiratory rate falls below 12 per minute, the nurse should hold the medication. Frequent reassessment is necessary.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-6

 

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