Deck 15: Pain Assessment and Basic Comfort Measures

Question 1

The patient had knee replacement surgery and has a local infusion pump to provide a local anesthetic to the surgical site.The patient puts on the call light and complains that pain at the site is more intense than it has ever been and is getting worse.The nurse checks the site and finds that the dressing is damp but intact.The infusion pump is pumping, and there is medication in the bag.The most probable cause of the problem might be the:

A)catheter may be clogged.
B)pump may be releasing too much drug into the site.
C)catheter may be displaced.
D)patient may be exaggerating the pain.

Answer 1

catheter may be displaced.

Question 2

A nurse is evaluating the epidural catheter insertion site and suspects that the intraspinal catheter has punctured the dura when _____ noted.

A)clear drainage is
B)bloody drainage is
C)purulent drainage is
D)redness, warmth, and swelling are

Answer 2

clear drainage is

Question 3

The nurse caring for a patient who has a PCA knows that it:

A)allows the family to participate in pain management for the patient.
B)prevents mistakes in medication administration.
C)can be used by all hospitalized patients.
D)provides a more constant level of medication.

Answer 3

provides a more constant level of medication.

Question 4

A nonpharmacological approach that the nurse may implement for patients who are experiencing pain that focuses on diverting the patient's attention away from the pain sensation by promoting pleasurable and meaningful stimuli is:

A)massage.
B)heat/cold.
C)guided imagery.
D)distraction.

Question 5

The nurse is caring for a patient who is a devout Orthodox Jew.The patient is on a patient-controlled analgesia ( PCA ) pump.What accommodations might the nurse have to make to conform to the patient's cultural needs?

A)Ask the patient whether he will need alternative forms of medication for the Sabbath.
B)Ask the patient specific questions because Jews tend to be stoic regarding pain.
C)Medicate the patient "around the clock" instead of as needed ( "prn" ).
D)Understand that Jews believe that suffering is a consequence of actions in a previous life.

Question 6

The nurse who is caring for a patient postoperatively notes that he is expressing discomfort and is diaphoretic.Which of the following interventions is most appropriate?

A)Straighten the bed linens.
B)Change the saturated surgical dressing.
C)Administer prescribed pain medications.
D)Check for displaced equipment underneath the patient.

Question 7

The nurse is preparing to administer a bolus of epidural medication.The nurse must remember to:

A)clean the injection cap of the epidural catheter with an anti-infective according to agency policy.
B)clean the injection cap of the epidural catheter with alcohol.
C)inject opioids quickly and smoothly.
D)flush with saline after the injection.

Question 8

The patient's family is concerned that the patient may get too much pain medication after surgery and become addicted to the medication if he is placed on a PCA pump.They also voice concern about the effectiveness of the PCA.The nurse should instruct the family and the patient that:

A)pain relief with the PCA pump is not as good as when the nurse provides it, but it does save on nursing time.
B)pain relief is good when the medication peaks, but less so when the levels drop, and that is when the patient will know that he needs more.
C)because the device provides medication as soon as the patient needs it, he will probably use less of the medication.
D)the patient will be kept in bed for several days after surgery to make sure it is safe to ambulate.

Question 9

While reviewing a patient's medication history, the nurse determines that intraspinal analgesia is contraindicated as a result of:

A)previous spinal anesthesia.
B)recent administration of anticoagulants.
C)a history of cardiac problems.
D)a diagnosis of advanced cancer.

Question 10

The nurse frequently must assess a patient who is experiencing pain.When assessing the intensity of the pain, the nurse should:

A)ask whether there are any precipitating factors.
B)question the patient about the location of the pain.
C)offer the patient a pain scale to objectify the information.
D)use open-ended questions to find out about the sensation.

Question 11

The nurse knows that an advantage of intraspinal analgesia is the:

A)smaller doses of epidural than intrathecal medication.
B)lack of significant patient complications.
C)systemic distribution of morphine faster than fentanyl.
D)ability to achieve appropriate analgesia with smaller dosages.

Question 12

When evaluating the effects of PCA, the nurse notes that the patient is sedated and is difficult to arouse.What step should the nurse take next?

A)Insert an airway.
B)Turn patient to the side.
C)Stop the PCA.
D)Expect this as a patient outcome of the therapy.

Question 13

The patient is in the hospital undergoing major abdominal surgery.When the patient returns from the recovery room, the nurse expects that he most likely will be receiving pain medication:

A)by mouth.
B)intramuscularly.
C)via the epidural route.
D)intravenously.

Question 14

When assessing a local infusion pump site, the nurse notes that which of the following requires an intervention?

A)The device is labeled, indicating that an anesthetic is being used.
B)The catheter connections are loose.
C)Surgical dressings are dry and intact.
D)No blood backup is present in the tubing.

Question 15

The patient is admitted with chronic pain.She states that nothing takes the pain away totally, but that "Dilaudid works best." The fact that the patient calls the medication by name should alert the nurse to:

A)suspect that the patient is drug seeking.
B)expect that the patient may need smaller doses than normal.
C)assess the patient's acceptable level of comfort.
D)accept the fact that nothing will help this patient's pain.

Question 16

The patient is admitted for chronic pain.He states that morphine sulfate (Morphine) has been used to relieve his pain, but recently he has been needing to use more of the medication to relieve pain.This patient's plan of care will have to incorporate interventions to deal with which of the following?

A)Addiction
B)Pseudoaddiction
C)Drug tolerance
D)Physical dependence

Question 17

The patient is scheduled for surgery late in the afternoon.His postoperative orders include PCA therapy.Which of the following nursing interventions is appropriate to perform?

A)Teach the patient about PCA after the patient comes out of recovery.
B)Teach the patient about PCA before surgery and before preoperative medication administration.
C)Tell the patient not to use PCA unless he can no longer tolerate the pain.
D)Inform the patient's family to watch him carefully and to depress the PCA administration button whenever they think he needs it.

Question 18

Before administering an epidural medication, the nurse aspirates and suspects that the catheter has migrated into the subarachnoid space when:

A)clear drainage is noted.
B)no drainage is noted.
C)purulent drainage is noted.
D)redness, warmth, and edema are noted.

Question 19

The patient is unable to rest even after pain medication has been administered.The nurse decides to give the patient a backrub.Which of the following strokes should the nurse use when finishing the backrub?

A)Long firm stroking movements down the back
B)Light strokes while moving up the back in a circular motion
C)Kneading movements toward the sacrum
D)Circular motion upward from buttocks to shoulders

Question 20

A nurse checks the continuous IV infusion for the intraspinal analgesia.The IV setup should be changed if:

A)tubing with a Y-port is attached.
B)an infusion pump is attached.
C)the tubing connections are all taped.
D)a diluted, preservative-free medication is used.

Question 21

Pain that extends beyond the period of healing and often lacks an identified pathology is known as _______________.

Question 22

The application of touch and movement to muscles, tendons, and ligaments without manipulation of the joints is called _________________.

Question 23

The patient has morphine sulfate ordered for pain every 4 hours "prn." The patient complains of severe pain and usually requests more morphine an hour before it is due.The nurse should: (Select all that apply.)

A)Request a "placebo order" from the physician.
B)Offer the patient medication "around the clock" instead of "prn".
C)Offer the patient massage between medication doses.
D)Offer the patient a nonopioid medication between morphine doses if ordered.

Question 24

The patient states that the PCA is not controlling his pain.The nurse checks the infusion setup and IV site and then evaluates the patient's ability to use the system.All looks in order.The nurse should notify the physician to: (Select all that apply.)

A)report suspected drug-seeking behavior.
B)possibly change the drug being used.
C)adjust the dosage of the drug being used.
D)request placebo medication to evaluate true pain.

Question 25

Drugs administered in the epidural space spread by: (Select all that apply.)

A)diffusion through the dura mater.
B)transport through blood vessels.
C)absorption by fat.
D)absorption through muscle.

Question 26

The patient voices concern to the nurse regarding his PCA pump.He states that he is afraid of getting an overdose if he pushes the button too many times.The nurse reassures the patient that: (Select all that apply.)

A)there is a time delay (lockout) between patient doses.
B)there is a maximum dose the patient can receive.
C)the patient has a right to be concerned and needs to be careful.
D)the patient could be put on a continuous infusion instead, because it is safer.

Question 27

Massaging upward and outward from the vertebral column and back again is known as __________________.

Question 28

Which of the following patient conditions is categorized as a neurobiological disease?

A)Physical dependence
B)Addiction
C)Pseudoaddiction
D)Drug tolerance

Question 29

________________ draws on internal experiences of memories, dreams, fantasies, and visions; explores the inner world of experience; protects the privacy of the patient; and fosters the imagination.

Question 30

___________ has an identifiable cause and rapid onset and generally disappears with healing.

Question 31

The _______________ is a potential space between the vertebral bones and the dura mater, the outermost meninges covering the brain and spinal cord.

Question 32

Which of the following statements about evaluating patients in pain is true?

A)The best judge of the existence of pain is the nurse.
B)Visible signs always accompany pain.
C)Patients often are hesitant to report pain.
D)Nonpharmacological interventions are better than pain medications.

Question 33

__________________ is an interactive method of pain management that permits patient control over pain through self-administration of analgesics.

Question 34

_______________________ is a massage technique used on tense muscles to "knead" muscles, promote relaxation, and stimulate local circulation.

Question 35

Catheter migration into the______________ can produce dangerously high medication levels.Only physicians and nurse anesthetists administer drugs in this space.

Question 36

Which of the following are characteristics of cancer pain? (Select all that apply.)

A)It may be acute.
B)It may be chronic.
C)It usually is related to tumor recurrence or treatment.
D)It often is of less intensity than the patient reports.

Question 37

Pain is experienced differently by different people, because pain perception is based on which of the following? (Select all that apply.)

A)Past pain experiences
B)Personal values
C)Cultural expectations
D)Emotions
E)None of above

Question 38

________________ is a method of preventing pain while reducing overall opioid use.