chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) and nurses notes for the past several days 2. Ask the nurse educator to provide in-service training about pain management 3. Perform a complete pain assessment and take a pain history 4. Have a conference with the nurses responsible for the care of this client 1.1. Ans: 4 As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if knowledge decit or need for performance improvement is the problem. Focus: Supervision, prioritization 2. Family members are encouraging your client to tough out the pain rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. Where is the pain located, and does it radiate to other parts of your body? 2. How would you describe the pain, and how is it affecting you? 3. What do you believe about pain medication and drug addiction? 4. How is the pain affecting your activity level and your ability to function? 5. What information do you need about pain, healing, and addiction? 1.2. Ans: 3 Beliefs, attitudes, and familial inuence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization 3. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is not responding to nonsteroidal antiinammatory drugs. The client complains that the pain is particularly worse at night. Which medication will you advocate for rst? 1. Amitriptyline (Elavil) 2. Corticosteroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan) 1.3. Ans: 1 Antidepressants such as amitriptyline can be given to treat diabetic neuropathy; an added benet is the sedative effect. Corticosteroids are for pain associated with inammation. Hydromorphone is a stronger opioid, and it is not the rst choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic. Focus: Prioritization 4. Which client is most likely to receive opioids for extended periods of time? 1. A client with bromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia 1.4. Ans: 3 Cancecc v. r pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins. Focus: Prioritization 5. As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take rst? 1. Make a note in the nurse's le and continue to observe clinical performance 2. Refer the new nurse to the in- service education department 3. Quiz the nurse about knowledge of pain management 4. Give praise for correctly charting the dose and time and discuss the decits in charting 1.5. Ans: 4 In supervision of the new RN, good performance should be reinforced rst and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists. Focus: Supervision, delegation 6. In caring for a very young child with pain, which assessment question would be the most useful? 1. Can you point to the pain with one nger and tell me what that pain feels like inside of you? 2. If number 1 were a little pain and number 10 were a big pain, what number would your pain be? 3. The smiling face has no pain; the crying face has a really big pain. Which one of these several faces is like your pain? 4. One chip is a little bit of hurt and four chips are the most hurt. How many chips would you take for your hurt? 1.6. Ans: 3 Pain rating scales using faces (depicting smiling, neutral, frowning, crying, etc.) are appropriate for young children who may have difculty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and the use of advanced vocabulary. Focus: Prioritization 7. In application of the principles of pain treatment, what is the rst consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach is needed. 3. The client's perception of pain must be believed. 4. Drug side effects must be prevented and managed. 1.7. Ans: 3 The client must be believed, and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to the other options in developing the treatment plan. Focus: Prioritization 8. Which client has the most immediate need for intravenous (IV) access to deliver immediate analgesia with rapid titration? 1. A client who has sharp chest pain that increases with cough and shortness of breath 2. A client who complains of excruciating lower back pain with hematuria 3. A client who is having an acute myocardial infarction with severe chest pain 4. A client who is having a severe migraine with an elevated blood pressure 1.8. Ans: 3 The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain by increasing venous capacitance. Other clients may also need IV access for delivery of pain medication, other drugs, or IV uids, but the need is less urgent. Focus: Prioritization 9. When an analgesic is titrated to manage pain, what is the priority goal? 1. Administer the smallest dose that provides relief with the fewest side effects 2. Titrate upward until the client is pain free 3. Titrate downward to prevent toxicity 4. Ensure that the dosage is adequate to meet the client's subjective needs 1.9. Ans: 1 The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside. Adequate dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs. Focus: Prioritization 10. For client education about nonpharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function with your continued support and supervision? 1. Therapeutic touch 2. Application of heat and cold 3. Meditation 4. Transcutaneous electrical nerve stimulation (TENS) 1.10. Ans: 2 Application of heat and cold is a standard therapy with guidelines for safe use and predictable outcomes, and an LPN/LVN will be implementing this therapy in the hospital, under the supervision of an RN. Therapeutic touch requires additional training and practice. Meditation is not acceptable to all clients, and an assessment of spiritual beliefs should be conducted. TENS is usually applied by a physical therapist. Focus: Delegation 11. Which pediatric pain client should be assigned to a newly graduated RN? 1. An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia (PCA) device to a long-acting oral analgesic; he has been continually asking for an increased dose. 2. A child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness. 3. A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures. 4. A child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful. 1.11. Ans: 3 The set of circumstances is least complicated for the child with the fracture, and this would be the best client for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management the anxiety will resolve. The other three children have more complex social and psychologic issues related to pain management. Focus: Delegation 12. Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. An elderly client with chronic pain who has a hip fracture 2. A client with a heroin addiction and back pain 3. A young female client with advanced multiple myeloma 4. A child with an arm fracture and cystic brosis 1.12. Ans: 4 At greatest risk are elderly clients, opiate-naive clients, and those with underlying pulmonary disease. The child has two of the three risk factors. Focus: Prioritization 13. A client is crying and grimacing but denies pain and refuses pain medication, because my sibling is a drug addict and has ruined our lives. What is the priority intervention for this client? 1. Encourage expression of fears and past experiences 2. Provide accurate information about the use of pain medication 3. Explain that addiction is unlikely among acute care clients 4. Seek family assistance in resolving this problem 1.13. Ans: 1 This client has strong beliefs and emotions related to the issue of the sibling's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, but it should be kept in mind that their beliefs about drug addiction may be similar to those of the client. Focus: Prioritization 14. A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the rst signs of withdrawal? 1. 1.14. Ans: 3 Diaphoresis is one of the early signs that occur between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps and 72 hours after withdrawal. Focus: Prioritization 15. In the care of clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress 1.15. Ans: 1 The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities. Focus: Delegation 16. The physician has ordered a placebo for a client with chronic pain. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the rst action that you should take? 1. Prepare the medication and hand it to the physician 2. Check the hospital policy regarding use of a placebo 3. Follow a personal code of ethics and refuse to participate 4. Contact the charge nurse for advice 1.16. Ans: 4 Administering placebos is generally considered unethical. Consult the charge nurse as a resource person who can help you clarify the situation and locate and review the hospital policy. If the physician is insistent, he or she could give the placebo. While following your own ethical code is correct, you must ensure that the client is not abandoned and that care continues. Focus: Prioritization 17. For a cognitively impaired client who cannot accurately report pain, what is the rst action that you should take? 1. Closely assess for nonverbal signs such as grimacing or rocking 2. Obtain baseline behavioral indicators from family members 3. Look at the MAR and chart to note the time of the last dose of analgesic and the client's response 1.17. Ans: 2 Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns. Focus: Prioritization 18. You received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. 1. An adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He complains of continuous headache that is partially relieved by medication. 2. An elderly man who underwent total knee replacement surgery 2 days ago. He is using the PCA pump frequently with good relief and occasionally asks for bolus doses. 3. A middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. A confused elderly woman who underwent surgery 4 days ago for a hip fracture. She cries out and struggles during any type of nursing care, and it is difcult to assess her pain. 5. A young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today. _____, _____, _____, _____, _____ 1.18. Ans: 5, 3, 1, 2, 4 All of the clients are in relatively stable condition. The client with the pneumothorax has priority, because chest tubes can leak or become dislodged or blocked. Lung sounds and respiratory effort should be evaluated. The woman who is going for diagnostic testing should be assessed and medicated before she leaves for the procedure. In a client with meningitis, a headache is not an unexpected complaint, but neurologic status and pain should be assessed. The report of postoperative pain is expected, but this client is getting reasonable relief most of the time. Caring for and assessing the confused client is likely to be very time consuming; leaving her to the last prevents delaying care for all the others. Focus: Prioritization 19. On the rst day after surgery, a client receiving an analgesic via PCA pump reports that the pain control is inadequate. What is the rst action you should take? 1. Deliver the bolus dose per standing order 2. Contact the physician to increase the dose 3. Try nonpharmacologic comfort measures 4. Assess the pain for location, quality, and intensity 1.19. Ans: 4 Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps. Focus: Prioritization 20. Which nonpharmacologic measure is particularly useful for a client with acute pancreatitis? 1. Diversional therapy, such as playing cards or board games 2. Massage of the back and neck with warmed lotion 3. Placement in a side-lying position with knees to chest and pillow against the abdomen 4. Transcutaneous electrical nerve stimulation 1.20. Ans: 3 The side-lying, knee-chest position opens the retroperitoneal space and provides relief. The pillow supplies a splinting action. Diversional therapy is not the best choice for acute pain, especially if the activity requires concentration. TENS is more appropriate for chronic muscular pain. The additional stimulation of massage may be distressing for this client. Focus: Prioritization 21. What is the best way to schedule medication for a client with constant pain? 1. Prn at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around the clock 1.21. Ans: 4 If the pain is constant, the best schedule is around the clock, to provide steady analgesia and pain control. The other options may actually require higher dosages to achieve control. Focus: Prioritization 22. Which of these client(s) would be appropriate to assign to an LPN/LVN who will function under the supervision of an RN or team leader? (Select all that apply.) 1. A client who needs preoperative teaching for the use of a PCA pump 2. A client with a leg cast who needs neurologic and circulatory checks and prn hydrocodone 3. A client who underwent a toe amputation and has diabetic neuropathic pain 4. A client with terminal cancer and severe pain who is refusing medication 5. A client who complains of abdominal pain after being kicked, punched, and beaten 6. A client with arthritis who needs scheduled pain medications and heat applications 1.22. Ans: 2, 3, 6 The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the terminal cancer client needs a comprehensive assessment to determine the reason for refusal of medication. The trauma client needs serial assessments to detect occult trauma. Focus: Assignment 23. You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment ndings include the following: temperature, 100.3 F (38 C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the following report information in the correct order according to the SBAR (situation, background, assessment, recommendations) format. 1. He is restless and anxious: temperature is 100.3 F (38 C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds. 2. He had abdominal surgery yesterday. He is on PCA morphine, but he says the pain is getting progressively worse. 3. I 1.23. Ans: 5, 2, 1, 3, 4 Using the SBAR format, the nurse rst identies himself or herself, gives the client's name, and describes the current situation. Next, relevant background information, such as the client's diagnosis, medications, and laboratory data, is stated. The assessment includes both client assessment data that are of concern and the nurse's analysis of the situation. Finally, the nurse makes a recommendation indicating what action he or she thinks is needed. Focus: Prioritization have tried to make him comfortable and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation. 4. Would you like to give me an order for any laboratory tests or additional therapies at this time? 5. Dr. S, this is Nurse J. I'm calling about Mr. D, who is complaining of severe abdominal pain. _____, _____, _____, _____, ____ 24. Which client(s) is appropriate to assign to a newly graduated RN who has recently completed orientation? (Select all that apply.) 1. An anxious client with chronic pain who frequently uses the call button 2. A client on the second postoperative day who needs pain medication before dressing changes 3. A client with human immunodeciency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain 4. A client with chronic pain who is to be discharged with a new surgically implanted catheter 5. A client who is complaining of pain at the site of a peripheral IV line 6. A client with a kidney stone who needs frequent prn pain medication 1.24. Ans: 2, 5, 6 The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious client with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The client with HIV infection has complex complaints that require expert assessment skills. The client pending discharge will need special and detailed instructions. Focus: Assignment 24. Which client(s) is appropriate to assign to a newly graduated RN who has recently completed orientation? (Select all that apply.) 1. An anxious client with chronic pain who frequently uses the call button 2. A client on the second postoperative day who needs pain medication before dressing changes 3. A client with human immunodeciency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain 4. A client with chronic pain who is to be discharged with a new surgically implanted catheter 5. A client who is complaining of pain at the site of a peripheral IV line 6. A client with a kidney stone who needs frequent prn pain medication 1.25. Ans: 3 Directly ask the client about the pain and perform a complete pain assessment. This information will determine which action to take next. Focus: Prioritization 26. Pain disorder and depression have been diagnosed in a client. He reports chronic low back pain and complains, None of these doctors has done anything to help. Which client statement concerns you the most? 1. I twisted my back last night, and now the pain is a lot worse. 2. I'm so sick of this pain. I think I'm going to nd a way to end it. 3. Occasionally I buy pain killers from a guy in my neighborhood. 4. I'm going to sue you and the doctor; you aren't doing anything for me. 1.26. Ans: 2 This statement is a veiled suicide threat, and clients with pain disorder and depression have a high risk for suicide. New injuries must be evaluated, but this type of complaint is not uncommon for clients with pain disorder. Risk for substance abuse is very high and should eventually be addressed. He can threaten to sue, but current circumstances do not support his case. Focus: Prioritization 27. A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced nursing assistant states that she received training in Foley catheter insertion at a previous job. What task can be delegated to this nursing assistant? 1. Assess the bladder distention and the pain associated with urinary retention 2. Insert the Foley catheter, once you ascertain that she knows sterile technique 3. Evaluate the relief of pain and bladder distention after the catheter is inserted 4. Measure the urine output after the catheter is inserted and obtain a urine specimen 1.27. Ans: 4 Measuring output and obtaining a specimen are within the scope of practice of the nursing assistant. Insertion of the Foley catheter in this client should be done by the RN, because clients with obstruction and retention are usually very difcult to catheterize, and the nurse must evaluate the pain response during the procedure. The assistant's knowledge of sterile technique is not the issue for this particular client. Focus: Delegation 28. You are caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is an order to discontinue the PCA-delivered morphine and to start oral pain medication. The client begs, Please don't stop the morphine. My pain is really a lot worse today than it was yesterday. What is the best response? 1. Let me stop the pump and we can try oral pain medication to see if it relieves the pain. 2. I realize that you are scared of the pain, but we must try to wean you off morphine. 3. Show me where your pain is and describe how it feels compared to yesterday. 4. Let me take your vital signs, and then I will call the doctor and explain your concerns. 1.28. Ans: 3 Assessing the pain is the priority in this acute care setting, because there is a risk of infection or hemorrhage. The other options might be appropriate based on your assessment ndings. Focus: Prioritization 29. You are caring for a young client with 1.29. Ans: 2 Talk to the client about insulin and diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose level is 650 mg/dL, but she refuses insulin; however, she wants the pain medication. What is the best action? 1. Notify the charge nurse and obtain an order for a transfer to intensive care 2. Explain that insulin is a priority and inform the health care provider 3. Withhold the pain medication until she agrees to accept the insulin 4. Give her the pain medication and document the refusal of the insulin ketoacidosis. If she is already aware of the dangers of an elevated blood glucose level, then her refusal suggests ongoing suicidal intent and the provider should be notied so that steps can be taken to override her refusal (potentially a court order). A blood glucose level of over 600 mg/dL is typically a criterion for transfer to intensive care, but arranging for transfer is not the priority. Withholding the pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of possible ongoing suicidal intent. Focus: Prioritization