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Chapter 5: Pain: The Fifth Vital Sign

Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client who was medicated for pain 1 hour ago. The client states that

the medication is not working and the pain is still present. What is the first action that the
nurse will take?
a. Assess the client to determine a pain score.
b. Believe the clients report of pain.
c. Wait until it is time for the next pain medication dose.
d. Teach the client how to use guided imagery.
ANS: B

Health care providers often do not believe the clients report of pain. The nurses primary role
in pain management is to advocate for the client by believing reports of pain. It is important to
remember that self-reporting is always the most reliable indication of pain. After the clinician
believes that the client is in pain, the client can be assessed to obtain a pain score and can be
taught nonpharmacologic methods of relieving pain. The nurse needs to take action to
alleviate the pain and should not wait until the next medication dosage is due.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Advocacy)
MSC: Integrated Process: Nursing Process (Analysis)
2. When is the nurse correct in decreasing the dose of pain medication in a client with end-stage

cancer?
The spouse is worried that the client may become addicted.
The client wants to remain alert during the visit of a long-time friend.
The client has lost considerable weight and does not want to eat.
The client is becoming combative at night.

a.
b.
c.
d.

ANS: B

The client has the right to choose whether to take the pain medication. The analgesic regimen
should not interfere with the clients sleep, rest, appetite, level of physical mobility, or driving
ability. Close relationships are important in providing ongoing support for effective pain
management intervention.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Advocacy)
MSC: Integrated Process: Nursing Process (Implementation)
3. A client with chronic pain is being discharged from the hospital. When planning the clients

pain relief regimen for home, it is most important for the nurse to communicate with which
member of the health care team?
a. Advanced practice nurse
b. Home health care nurse
c. Primary physician
d. Psychologist

ANS: B

All members of the listed health care team are important. However, the home health care
nurse will provide immediate home supervision and assistance to the client and family. The
home health care nurse can refer to other health care team members as necessary. For the
home health care nurse to carry out the role, it is essential that the acute care nurse
communicate the clients physical condition and support network, and any issues with pain
management.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 62
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Collaboration with Interdisciplinary Team)
MSC: Integrated Process: Communication and Documentation
4. A client with arthritic pain is considering taking an herbal supplement to relieve arthritic pain.

What teaching is most important for the nurse to carry out with this client?
Inform any health care providers about the use of this supplement.
Practice imagery along with taking the herbal supplement.
Take only herbal supplements that are prescribed.
Take herbal supplement at the onset of pain.

a.
b.
c.
d.

ANS: A

Always ask the client about the use of herbal supplements, because some can cause serious
interactions with other pharmacologic agents. The other responses are not considered the most
important.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications of Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Teaching/Learning
5. What instruction should the nurse include in the discharge teaching plan of a client who has a

transcutaneous electrical nerve stimulation (TENS) unit?


Pain relief is sustained when stimulation is stopped.
The current is adjusted by the physician.
The electrodes are placed away from the painful site.
You can perceive a pins and needles sensation.

a.
b.
c.
d.

ANS: D

The TENS unit works through electrodes that are placed near the painful area site. These
electrodes are connected to a small box that contains the current needed for pain relief. The
current can be adjusted by any health care provider. Adjustment of this current can cause a
pins and needles sensation. Pain relief with cutaneous therapy generally is sustained only as
long as the stimulation continues.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 59
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
6. Why does the nurse always ask the client his or her pain level after taking routine vital signs?
a. To determine whether pain is influencing blood pressure and heart rate
b. To determine the need for more frequent vital sign measurement
c. To ensure that pain assessment occurs on a regular basis

d. To follow McCafferys guidelines on pain management


ANS: C

Making pain the fifth vital sign allows more frequent and accurate assessment, which can
contribute to better pain management.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 46
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical
Assessment)
MSC: Integrated Process: Nursing Process (Assessment)
7. A client with cholecystitis has pain in the right shoulder area and asks, What is happening to

me? What did I do to my shoulder? What is the nurses best response?


You are weak from staying in bed.
Does your other arm hurt too?
Sometimes pain from a certain organ is referred elsewhere in the body.
I am going to hold your medication until we can determine what is happening.

a.
b.
c.
d.

ANS: C

Many types of visceral pain can be felt in body areas other than the originating site. This is
known as referred pain. Pain originating in the gallbladder can be referred to the right
posterior shoulder. The client should be reassured that this is normal and should be medicated
appropriately.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
8. The nurse is assigned to care for the following four clients who have the potential for having

pain. Which client is most likely not to be treated adequately for this problem?
Middle-aged woman with a fractured arm
Client with expressive aphasia
Younger adult with metastatic cancer
Client who has undergone an appendectomy

a.
b.
c.
d.

ANS: B

Populations at highest risk for inadequate pain treatment include older adults, minorities, and
those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain
because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate
reporting.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Advocacy)
MSC: Integrated Process: Nursing Process (Assessment)
9. The physician orders a dose of medication that does not resolve the clients chronic pain.

When the nurse questions the order, the physician explains that he or she fears the client will
develop an addiction with higher drug dosages. What is the nurses best response?
a. Administer the medication as ordered.
b. Assist the client to use guided imagery.
c. Consult with the pain control specialist.
d. Explain to the client that lower doses are better.

ANS: C

A health care provider may underprescribe medications for clients in pain for many reasons,
such as regulatory scrutiny and cultural and societal attitudes. Undertreatment of pain is a
serious problem in the United States and in the rest of the world. The nurse can act as an
advocate for the client in pain by consulting with a pain care specialist.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Implementation)
10. A client who has been taking oxycodone (OxyContin) for an extended period of time comes to

the clinic reporting that the drug is no longer relieving his pain. Which category would be
given to the clients complaint?
a. Addiction
b. Physical dependence
c. Pseudoaddiction
d. Tolerance
ANS: D

Tolerance is a state of the bodys adaptation to a drug so that it takes an increase in dosage to
produce similar effects. This differs from addiction, which is characterized by compulsive
craving for a medication, or physical dependence that manifests as the appearance of
withdrawal symptoms when a drug is abruptly stopped or an antagonist is administered.
Pseudoaddiction is the strong desire for a medication related to undertreatment of pain.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 44
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes) MSC:
Integrated Process: Nursing Process (Assessment)
11. A home care client who is taking morphine for pain management abruptly stops taking the

medication. Which symptom would indicate physical dependence?


Abdominal cramping
Craving for morphine
Decreased heart rate
Elevated temperature

a.
b.
c.
d.

ANS: A

Physiologic dependence on opioids such as morphine allows tissues to adapt to their presence.
When opioids are suddenly removed, the dependent tissues stimulate an autonomic nervous
system response that includes nausea and vomiting, abdominal cramping, muscle twitching,
profuse perspiration, delirium, and convulsions.
DIF: Cognitive Level: Comprehension/Understanding
REF: pp. 44-45
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body
Systems)
MSC: Integrated Process: Nursing Process (Assessment)
12. A home care client who is currently on hydromorphone (Dilaudid) for pain management

presents to the hospital reporting abdominal cramping, nausea, and sweating. When taking the
clients history, the nurse asks which question first?
a. Are you currently in severe pain?

b. Did you take more Dilaudid than prescribed?


c. When did you take your last dose of Dilaudid?
d. When was your last bowel movement?
ANS: C

Physical dependence occurs in everyone who takes opioids over a period of time. Withdrawal
syndrome occurs when the client abruptly stops taking the medication. Symptoms include
abdominal cramping, nausea, sweating, delirium, and convulsions. Although the other
distractors may be asked about as part of the admission assessment, they are not of priority.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body
Systems)
MSC: Integrated Process: Nursing Process (Assessment)
13. The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a

heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the
nurse carry out first?
a. Administer blood pressure medication.
b. Administer a drug to lower the heart rate.
c. Assess whether the client needs anti-arthritis medication.
d. Continue to assess for possible causes of elevated vital signs.
ANS: D

Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the
sympathetic nervous system; this normally causes tachycardia and increased blood pressure.
Therefore, this clients high blood pressure and heart rate are not caused by chronic pain and
may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse
to establish whether the client is having pain other than arthritic pain, and then to decide
which intervention should be carried out.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body
Systems)
MSC: Integrated Process: Nursing Process (Implementation)
14. The nurse is caring for four clients who are reporting pain. Based on the following

assessments and histories, which clients pain is most likely chronic in nature?
Foley catheter inserted 30 minutes ago with a heart rate of 100 beats/min
History of heart disease with a heart rate of 120 beats/min
History of fibromyalgia with a blood pressure of 110/70 mm Hg
Hip replacement surgery with a blood pressure of 170/90 mm Hg

a.
b.
c.
d.

ANS: C

The definition of chronic pain involves the length of time the pain is experienced and/or the
progressive nature of the problem causing the pain. Both heart disease and fibromyalgia could
fit into this category. However, pain of a chronic nature does not call the sympathetic nervous
system into play. Therefore, a rise in heart rate and blood pressure is not seen in a client who
has chronic pain. The client with fibromyalgia who is having pain is not experiencing the
increased blood pressure that would be seen with acute pain.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Analysis)

15. When a client is assessed, which behavior best indicates that he or she is experiencing changes

associated with acute pain?


Anger and hostility
Expressed hopelessness
Inability to concentrate
Psychosocial withdrawal

a.
b.
c.
d.

ANS: C

The characteristics most common to chronic pain are psychosocial withdrawal, anger and
hostility, depression, and hopelessness. The inability to concentrate is associated much more
with acute pain, before any physiologic or behavioral adaptation has occurred.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 41
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body
Systems)
MSC: Integrated Process: Nursing Process (Assessment)
16. The nurse anticipates that the client who rates pain as 10 on a scale of 1 to 10 has undergone

which surgical procedure?


Cranial surgery
Leg surgery
Neck surgery
Upper abdominal surgery

a.
b.
c.
d.

ANS: D

In general, intrathoracic and upper intra-abdominal surgical approaches are associated with
more severe pain. Muscle-splitting procedures generally are far more painful than musclestretching procedures.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 41
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body
Systems)
MSC: Integrated Process: Nursing Process (Assessment)
17. Which assessment finding is cause for concern in a client who has taken 4 grams of

acetaminophen (Tylenol) to relieve back pain?


Difficulty with urination
Decreased respiratory rate
Gastrointestinal bleeding
Increased liver function tests

a.
b.
c.
d.

ANS: D

Tylenol has few anti-inflammatory properties. Therefore, it will not cause bleeding. Unlike
nerve blocks and opioid drugs, it does not affect the respiratory rate or cause difficulty with
urination. It can cause liver toxicity, especially in higher doses and taken more frequently than
every 4 hours for long-term use.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Analysis)

18. During preoperative assessment, the client tells the nurse about taking NSAIDs for years.

What question is most important for the nurse to ask?


Did you ever have a problem with bleeding?
Do you bruise easily?
How many tablets do you take every day?
When was the last time you took your NSAID?

a.
b.
c.
d.

ANS: D

NSAIDs can prevent platelet aggregation; this results in a tendency toward bleeding. Before
notifying the surgeon, the nurse should find out the last time the client took the medication
and should check the chart to see whether there is a note that clarifies the surgeons awareness
of the clients use of this medication.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Assessment)
19. The client is taking an oxycodone-acetaminophen combination (Tylox) at home daily for

chronic pain management. What instruction does the nurse give this client?
a. Avoid taking aspirin while you are on this medication.
b. Drink plenty of water and eat foods high in fiber.
c. Stop this medication after 3 days if the pain persists.
d. Weigh yourself daily to determine whether you are retaining sodium or water.
ANS: B

Opioid agonists, like oxycodone, act on systemic and neural opioid receptors and decrease
gastrointestinal motility. Constipation is common and can be an aggravating problem. Fluids
and foods high in fiber can prevent constipation. The other instructions would not be
appropriate for this medication.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Teaching/Learning
20. The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the

client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10
breaths/min. What is the nurses first action?
a. Administering naloxone (Narcan) IV push
b. Administering oxygen by nasal cannula
c. Arousing the client by calling his or her name
d. Documenting the findings and continuing to monitor
ANS: C

Many clients experience some degree of respiratory depression with opioid analgesics. If the
client can be aroused with minimally intrusive techniques and the rate of respiration is
increased spontaneously, no further intervention is required.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)


21. The nurse accidentally administers 10 mg of morphine intravenously to a client who had been

given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the
nurse be prepared to take?
a. Administer naloxone (Narcan).
b. Administer oxygen.
c. Assist with intubation.
d. Monitor pain level.
ANS: A

A combined dose of 15 mg of morphine may cause severe respiratory depression in some


clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first
intervention to reverse respiratory depression due to a morphine overdose. Then
administration of oxygen may be needed if the clients oxygen saturation decreases. Intubation
may occur if the client does not respond to the Narcan, and respiratory depression becomes a
respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be
monitored because Narcan can promote withdrawal symptoms.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Planning)
22. A client is admitted to the hospital with a history of oxycodone (Percodan) abuse. For which

clinical manifestations does the nurse observe the client?


Anorexia and weight loss
Decreased heart rate and respirations
Muscle twitching and profuse perspiration
Sedation and constipation

a.
b.
c.
d.

ANS: C

Physiologic dependence on opioids allows tissues to adapt to their presence. When opioids are
suddenly removed, the dependent tissues stimulate an autonomic nervous system response
that includes nausea and vomiting, abdominal cramping, muscle twitching, profuse
perspiration, delirium, and convulsions.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Chemical and Other Dependencies)
MSC: Integrated Process: Nursing Process (Assessment)
23. Which client would the nurse suggest should try subcutaneous opioid analgesia for pain

management?
Client who has had a surgical procedure
Client with back pain who likes to walk
Client with cancer who is nauseous
Client experiencing acute chest pain

a.
b.
c.
d.

ANS: C

Subcutaneous opioid analgesia is recommended for cancer clients who cannot take anything
by mouth. It is not recommended for acute pain, such as pain from a surgical procedure,
because subcutaneous boluses have slower onset and a lower peak effect than IV boluses. It
also requires the use of an ambulatory infusion pump, which may not always be acceptable to
someone who is physically active.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Analysis)
24. A client with colon cancer is discharged to home with morphine for pain management. He is

having episodes of nausea and vomiting. Which route of morphine administration would be
most advantageous to use?
a. Oral
b. Rectal
c. Intravenous
d. Intramuscular
ANS: B

Rectal administration of opioids is recommended for clients who are NPO, nauseated, or at
home. Oral agents are the preferred route of analgesia in many cases. However, because of his
nausea and vomiting, this client does not have the functional GI system needed for good
absorption of oral agents. Intramuscular agents are not recommended for cancer pain.
Intravenous agents are recommended when oral and rectal routes fail to provide pain control.
DIF: Cognitive Level: Comprehension/Understanding
REF: Table 5-7, p. 55
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Assessment)
25. The nurse is caring for four clients. Which client assessment is the most indicative of having

pain?
Blood pressure 150/70 mm Hg and sleeping
Client stating that he is anxious
Heart rate of 105 beats/min and restlessness
Postoperative client with a neck incision

a.
b.
c.
d.

ANS: C

At times clients are unable to verbalize that they are in pain but there are indicators that the
client may have acute pain such as increased heart rate, increased blood pressure, increased
respirations, sweating, restlessness, and overall distress. All the other distractors could
indicate clients who have the potential for being in pain, but restlessness with tachycardia is
the most indicative.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body
Systems)
MSC: Integrated Process: Nursing Process (Analysis)
26. A client has a history of alcohol abuse. Which pain relief regimen does the nurse anticipate if

morphine (MS Contin) is given for pain?

a.
b.
c.
d.

A higher dose of opioids will be needed to provide effective pain relief.


A lower dose of opioids will be needed to provide effective pain relief.
The appropriate drug selection is an opioid agonist-antagonist combination.
The client will receive no pain relief from the morphine.

ANS: A

People who drink significant amounts of alcohol daily have elevated liver enzyme activity that
degrades morphine and morphine agonists. As a result, these clients frequently have tolerance
for opioid analgesics and require higher doses of agonists to achieve an acceptable level of
pain relief during acute pain episodes.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Analysis)
27. Which instruction is the most accurate for the nurse to give a client who has a patient-

controlled analgesia device (PCA) after abdominal surgery?


Instruct your visitors to press the button for you when you are sleeping.
Push the button every 15 minutes whether you feel pain at that time or not.
Push the button when you first feel pain instead of waiting until pain is severe.
Try to go as long as you possibly can before you press the button.

a.
b.
c.
d.

ANS: C

Clients should be instructed to push the button to release medication when the pain begins
rather than waiting until the pain becomes so great that the dose given by the pump cannot
control the pain. No one should push the button for the client. Clients should not be instructed
to bear the pain as long as possible before using PCA.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 54
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Teaching/Learning
28. The nurse assesses several postoperative clients receiving patient-controlled epidural

analgesia (PCEA). Which client does the nurse prioritize to assess first?
Client receiving bupivacaine (Marcaine) describing inability to move legs
Client receiving fentanyl (Sublimaze) describing itchy arms
Client receiving hydromorphone (Dilaudid) describing full feeling
Client receiving morphine describing difficulty staying awake

a.
b.
c.
d.

ANS: A

Epidural analgesia can cause sensory and motor deficits. The inability to move the legs could
mean that the client is receiving too high a dose of the drug or that damage has been done to
the spinal cord. This requires immediate intervention. Itchy arms, a full feeling, and difficulty
staying awake could be side effects of the medications, but they are not matters of priority.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Planning)

29. A client has epidural analgesia with bupivacaine (Marcaine) for pain relief. For which

condition should the nurse assess this client?


Extremity itching
Inability to raise legs off the bed
Nausea and vomiting
Respiratory rate of 8 breaths/min

a.
b.
c.
d.

ANS: B

Lower motor weakness is more common when an epidural local anesthetic (such as
bupivacaine) is used. The other three problems are seen more often when opioids are used.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Planning)
30. When assessing a client who is taking long-term ibuprofen (Motrin) for pain, the nurse finds

numerous areas of bruising. What is the nurses first action?


Assess for gastric discomfort.
Assess for the presence of pain.
Continue to monitor bruising.
Place client on falls precaution.

a.
b.
c.
d.

ANS: A

NSAIDs can cause gastrointestinal disturbances and can prevent platelet aggregation, which
results in GI bleeding. Therefore, clients should be observed for gastric discomfort or
vomiting and bleeding.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Reactions/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Evaluation)
31. Which statement made by a nurse represents the need for further education regarding pain

management in older adult clients?


Older adults are at greatest risk for undertreated pain.
Older adults tend to report pain less often than younger adults.
Older clients usually have more experience with pain than younger clients.
Older clients have a different pain mechanism and do not feel it as much.

a.
b.
c.
d.

ANS: D

There is no evidence to support the idea that older adult clients perceive pain any differently
than younger clients. The other statements are accurate regarding older clients and pain.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Adaptation (Physiological Adaptation
Pathophysiology)
MSC: Integrated Process: Teaching/Learning
32. Before surgery, the nurse observes the client listening to music on the radio. Based on this

observation, the nurse may try which nonpharmacologic intervention for pain relief in the
postoperative setting?
a. Cutaneous skin stimulation

b. Hypnosis
c. Imagery
d. Radiofrequency ablation
ANS: C

Imagery is a form of distraction in which the client is encouraged to visualize about some
pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a
clients capacity for imagery include being able to listen to music or other auditory stimuli.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNonPharmacological Comfort Interventions)
MSC: Integrated Process: Nursing Process (Assessment)
33. A client who is at the end of life is being given morphine for pain management. The family

expresses concern that the morphine may cause the client to stop breathing and die. What is
the nurses best response?
a. He needs the morphine to prevent pain.
b. His respirations are not affected by the morphine.
c. We will decrease the dose if his breathing slows.
d. We will give him oxygen to help with his breathing.
ANS: B

Because clients become tolerant to the respiratory effects of an opioid, it does not hasten death
unless the dose was not properly and gradually titrated. Decreasing the drug would cause pain
to occur, and oxygen will not help with his rate of respirations.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Reactions/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Teaching/Learning
34. A client is stating that he has the sensation of burning, aching, and dullness. Which afferent

nerve fibers should be transmitting the pain?


a. A delta fibers
b. C fibers
c. A alpha fibers
d. A beta fibers
ANS: B

The sensation of burning, aching, and dullness is transmitted by the C fibers in contrast to the
A delta fibers, which carry rapid, sharp, pricking, or piercing sensations. A alpha and A beta
fibers are large-diameter fibers that may close the gate and decrease pain.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 43
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
35. A client is postoperative day one and has a patient-controlled analgesia (PCA) pump with a

continuous basal dose for pain control. Currently, the client is stating that the operative pain is
escalating. What is the first action of the nurse?
a. Try diversion to take the clients mind off the pain.

b. Ask the client to ambulate around the unit.


c. Assess the clients pain according to PQRST.
d. Call the physician to request an order to increase the basal dose.
ANS: C

Assessment is the first step in the nursing process. The nurse will need the information
gleaned from the assessment using PQRST (factors precipitating the pain, quality of the pain,
region and radiation of the pain, severity of the pain, and timing of the pain) to request a
change in medication order. Diversion and ambulation can be used in client care but will not
control escalating pain in the postoperative client.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Medication Administration) MSC:
Integrated Process: Nursing Process (Assessment)
36. Which client does the nurse assess first for pain control?
a. Older client with chronic rheumatoid arthritis
b. Client postoperative day three walking in the hallway
c. Sleeping client with an epidural pump
d. Quiet client with pancreatic cancer curled up in bed
ANS: D

The pain of pancreatic cancer is usually severe. This client should be assessed first because
the clients present behavior may indicate suffering and pain. The client with arthritis has had
this condition for a while and may not be experiencing severe pain. The client who is walking
in the hallway and the client who is sleeping do not demonstrate nonverbal pain behaviors.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Medication Administration) MSC:
Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. Which is most indicative of pain in an older client who is confused? (Select all that apply.)
a. Decreased blood pressure
b. Screaming
c. Facial grimace
d. Restlessness
e. Crying
f. Decreased respirations
ANS: B, C, D, E

No one scale has been found to be the best tool to use in pain assessment for adults with
cognitive impairment. Facial expression, motor behavior, mood, socialization, and
vocalization are common indicators of pain in cognitively impaired adults. In acute pain,
nonverbal indicators of pain could include increased blood pressure and respirations.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 49
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Assessment)

2. An older client just returned from surgery and is rating pain as 8 on a 0 to 10 scale. Which

medications are unsafe choices for treatment of severe pain in this older adult?
Meperidine (Demerol)
Methadone (Dolophine)
Propoxyphene (Darvocet)
Morphine (Durmorph)
Codeine

a.
b.
c.
d.
e.

ANS: A, B, C, E

Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic
metabolites may accumulate. Codeine may cause constipation as well. Methadone has an
extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory
depression. Morphine is considered the gold standard and may be used in the older adult while
monitoring for sedation and respiratory depression is conducted.
DIF: Cognitive Level: Comprehension/Understanding
REF: Chart 5-1, p. 45
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Planning)

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