Chapter: Chapter 13: Pain Management
1. The nurse in a pain clinic is assessing a palliative patient. The patient indicates that he has
been saving his analgesics until the pain is intense because the pain control has been poor. What
teaching does the nurse knows should be done with this patient?
A) Medication should be taken when pain levels are low so the pain is easier to reduce.
B) Pain medication can be increased when the pain is intense.
C) It is difficult to control chronic pain, so little can be done.
D) Instruct the patient to lie still and think of something else during intense pain.
Feedback: Better pain control can be achieved with a preventive approach, reducing the amount
of time patients are in pain. Low levels of pain are easier to reduce or control than intense levels
of pain. Pain medication is used to prevent pain so pain medication is not increased when pain
becomes intense. Chronic pain is treatable. Giving the patient alternative methods to control pain
is good, but it will not work if the patient is in so much pain that he cannot institute reliable
alternative methods.
2. Two patients on your unit have returned from right knee arthroscopies. Patient A is reporting
pain of an eight to nine on a zero-to-ten pain scale. Patient B is reporting a pain level of three to
four on the same pain scale. What may provide a rationale for the different perceptions of pain?
A) Endorphin levels may vary between patients, affecting the perception of pain.
B) One of the patients is exaggerating her sense of pain.
C) The patients are likely experiencing a variance in vasoconstriction.
D) One of the patients may be experiencing opiate tolerance.
Feedback: The existence of enkephalins and endorphins helps explain why different people feel
different amounts of pain from similar stimuli. Endorphin levels vary among individuals as do
factors that influence endorphin levels, such as anxiety. People with more endorphins feel less
pain; those with fewer endorphins feel more pain. Opioid tolerance is associated with chronic
pain treatment and would not apply to this patient. The nurse should not assume the patient is
exaggerating the pain as the patient is the best authority of her existence of pain, and definitions
for pain state that pain is “whatever the person says it is, existing whenever the experiencing
person says it does.”
3. You are discussing pain relief in the elderly with your senior nursing students. When
administering an analgesic to an elderly patient for pain, what interventions would you teach
your students should be implemented in the plan of care for the patient?
A) Monitor for signs of drug toxicity due to a decrease in metabolism.
B) Monitor for an increase in absorption of the drug due to increased metabolism.
C) Monitor for an increase in respiratory rates.
D) Analgesics should be given every 4 to 6 hours as ordered to control pain.
Feedback: Older people may respond differently to pain than younger people. Because elderly
people have a slower metabolism and a greater ratio of body fat to muscle mass compared to
younger people, small doses of analgesic agents may be sufficient to relieve pain, and these
doses may be effective longer. This makes option B and D incorrect. Pain medication can
decrease respiratory rates, not increase them.
4. The nurse is assessing a patient's pain. The patient is tearful, hesitant to move, and grimacing.
When asked, the patient rates the pain as a two at this time using a zero-to-ten pain scale. What
conclusion would be most accurate?
A) The patient has rated the pain as minimal according to the scale.
B) The nurse should reinforce teaching about the pain scale number system.
C) The nurse should reassess the pain in 30 minutes.
D) The medication the patient is receiving is not adequate for pain relief.
Feedback: The patient is physically exhibiting signs and symptoms of pain. Further teaching
may need to be done so the patient can correctly rate the pain. The nurse may also verify that the
same scale is being used by the patient and caregiver to promote continuity. All answers are
correct, however, the most accurate conclusion would be to reinforce teaching about the pain
scale. This makes the other options incorrect.
5. You are caring for a patient with a diagnosis of cellulitis. Your patient has a secondary
diagnosis of chronic pain. You know that patients who experience chronic pain can be expected
to
A) be less anxious.
B) have a lower pain threshold.
C) have an increased tolerance of pain.
D) ask for pain medication before the next dose is due.
Feedback: It is tempting to expect that people who have had multiple or prolonged experiences
with pain will be less anxious and more tolerant of pain than those who have had little
experience with pain. However, this is not true for many people. The more experience a person
has had with pain, the more frightened he or she is likely to be about subsequent painful events.
People with multiple or past experiences with pain are generally more frightened, anxious, and
less able to tolerate pain. They may ask for pain relief before the next dose is due because of the
fear of intense pain. Therefore, options A, B, and C are incorrect.
6. The nurse is caring for a patient with chronic fatigue and poorly controlled back pain. What
would the nurse know to assess for other than pain in this patient?
A) Potential contractures
B) The need for a placebo
C) Depression
D) Sleep-pattern disturbances
Feedback: Depression is associated with chronic pain and unrelieved cancer pain. In cases of
chronic pain, the incidence of depression is increased. Pain management may help alleviate the
depression. Neither potential contractures nor the need for a placebo to alleviate pain are an issue
in the pain management of this patient. Sleep-pattern disturbances can be caused by either/both
pain and depression. Pain management may assist in alleviating sleep problems.
7. Your patient has just returned from the PACU following left tibia ORIF. The patient is
complaining of pain, and you are preparing to administer a first dose of meperidine. Prior to
administering the drug, you would assess for the patient's
A) electrolyte values.
B) blood pressure.
C) allergies to any medications.
D) hydration status.
Feedback: Before administering medications such as narcotics for the first time, the nurse
should assess for any previous allergic reactions. Electrolyte values, blood pressure, and
hydration status are not what you need to assess prior to giving a first dose of narcotics.
8. Your patient is receiving postoperative analgesic through a PCA pump. You have given the
patient a bolus of a narcotic medication. What is it important for you to assess the patient for?
A) Sedation
B) Respiratory depression
C) Fluid overload
D) Changes in the skin integrity
Feedback: A patient who receives opioids by any route must be assessed frequently for changes
in respiratory status. Sedation is an expected effect of a narcotic analgesic. Fluid overload and
changes in skin integrity are not what you would assess for when giving narcotic medications.
9. Your patient is 12-hours post ORIF right ankle. The patient is asking for pain medication. The
pain-medication orders are written as a combination of a narcotic analgesic and a nonsteroidal
anti-inflammatory (NSAID) given together. What is the rationale for administering pain
medication in this manner?
A) To prevent respiratory depression from the narcotic
B) To eliminate the need for additional medication during the night
C) To combine the medications more effectively and relieve the patient's pain with fewer
narcotics
D) To eliminate toxic effects of the narcotic
Feedback: A regimen of a fixed-dose, periodically-dosed NSAID (eg, every 4 hours) and a
separately administered fluctuating dose of opioid may be effective in managing moderate to
severe cancer pain. In more severe pain, the opioid dose is also fixed with an additional
fluctuating dose as needed for breakthrough pain (a sudden increase in pain despite the
administration of pain-relieving medications). These regimens result in better pain relief with
fewer opioid-related side effects. Use of the narcotic with the NSAID requires fewer narcotics to
relieve the patient's pain. This method also reduces, but does not eliminate, the potential for toxic
effects of the narcotic. This makes option A, B, and D incorrect.
10. The nurse is caring for a patient with metastatic bone cancer. The patient asks the nurse why
he has had to keep getting larger doses of his pain medication although it doesn't seem to affect
him. What is the nurse's best response?
A) “Over time you become more tolerant of the drug.”
B) “You are immune to the effects of the drug.”
C) “You may have formed an addiction to the drug.”
D) “Your body absorbs less of the drug due to the cancer.”
Feedback: Over time, the patient is likely to become more tolerant of the dosage. There is little
evidence that patients with cancer become addicted to the opioid medications. Patients do not
become immune to the effects of the drug, and the body does not absorb less of the drug because
of the cancer. Therefore, options B, C, and D are incorrect.
11. A 52-year-old female patient is seeing the nurse on the oncology unit for pain control related
to breast cancer that has metastasized to her lungs and liver. The nurse wants to prevent further
pain and is aware that cancer
A) pain is often related to the stress of the patient knowing she has cancer and requires a very
low dose of pain medications along with a high dose of anti-anxiety medications.
B) pain is always chronic and difficult to treat so distraction is often the best intervention.
C) pain can be acute or chronic; it may even be the result of the cancer treatment and usually
requires high doses of pain medications.
D) patients often misreport pain because of confusion related to their disease process.
Feedback: Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so
ubiquitous that when cancer patients are asked about possible outcomes, pain is reported to be
the most feared outcome. Higher doses of pain medication are usually needed with cancer
patients, especially with metastasis. Option A is incorrect; cancer pain is often related to the
stress of the patient knowing she has cancer, but treatment usually requires high doses of pain
medications and may include anti-anxiety medications. Option B is incorrect; cancer pain can be
chronic and difficult to treat so distraction may help, but higher doses of pain medications are
usually the best intervention. Option D is incorrect; there is no research that indicates cancer
patients “often misreport pain because of confusion related to their disease process.”
12. The nurse caring for a 74-year-old man who has just returned to the medical-surgical unit
following surgery for a total knee replacement received report from the PACU. Part of the report
had been passed on from the pre-operative assessment where the patient stated that he has “been
confused in the past when he takes pain medications.” What does the nurse realize that the
elderly may do?
A) The elderly may require lower doses of medication and are easily confused with new
medications.
B) The elderly may have altered absorption and metabolism, which prohibits the use of opiates.
C) The elderly may be confused following surgery, and that is related to normal aging and
unrelated to the medication.
D) The elderly may require a higher initial dose of pain medication followed by a tapered dose.
Feedback: The elderly often require lower doses of medication and are easily confused with new
medications. The elderly have slowed metabolism and excretion, and, therefore, the elderly
should receive a lower dose of pain medication given over a longer period time, which may help
to limit the potential for confusion. Unfortunately, the elderly are often given the same dose as
younger adults, and the resulting confusion is attributed to other factors like environment. Option
B is incorrect; the elderly may have altered absorption and metabolism, but the use of lower dose
opiates is encouraged for pain. Option C is incorrect; confusion following surgery is never
normal. Option D is incorrect; with the elderly, we should start medication at a low dose and
slowly increase the dose until the pain is managed.
13. You are the nurse in a pain clinic caring for an 88-year-old man who is suffering from long-
term severe intractable pain. At this point, the pain team feels that all pharmacologic and
nonpharmacologic methods of pain relief have been ineffective. What recommendation could
you make to this patient?
A) The patient may want to investigate new alternative pain management options that are
outside the United States.
B) The patient may want to consult a neurologist or neurosurgeon to discuss pain-management
options.
C) The patient may want to significantly increase his exercise and activities to create
distractions.
D) The patient may want to move into a nursing home so others may care for him.
Feedback: In some situations, especially with long-term severe intractable pain, usual
pharmacologic and nonpharmacologic methods of pain relief are ineffective. In those situations,
neurologic and neurosurgical approaches to pain management may be considered. Pain resulting
from malignancy (especially of the cervix, bladder, prostate, and lower bowel) may need special
surgical and neurologic interventions. Option A is incorrect; investigating new alternative pain-
management options that are outside the United States is unrealistic and may even be dangerous
advice. Option C is incorrect; significantly increasing his exercise and activities to create
distractions is unrealistic when a patient is in intractable pain and conveys the attitude that the
pain is not real. Option D is incorrect; moving into a nursing home so others may care for him is
an intervention that does not address the issue of pain.
14. You are the home health nurse caring for a homebound client who is terminally ill. You are
delivering a patient-controlled analgesia (PCA) pump to the patient at your visit today. The
family members will be taking care of the patient. What would your priority nursing
interventions be for this visit?
A) Teach the family the theory of pain management and the use of alternative therapies.
B) Provide family support during this emotional experience.
C) Provide patient and family teaching regarding the operation of the pump, monitoring the IV
site, and knowing the side effects of the medication.
D) Provide family teaching regarding use of morphine, recognizing morphine overdose, and
offering spiritual guidance.
Feedback: If PCA is to be used in the patient's home, the patient and family are taught about the
operation of the pump as well as the side effects of the medication and strategies to manage
them. The family would also need to monitor the IV site and notify the nurse of any changes,
such as infiltration, that could endanger the patient. Options A and B are incorrect; teaching the
family the theory of pain management or the use of alternative therapies and the nurse providing
emotional support are important, but the family must be able to operate the pump as well as
know the side effects of the medication and strategies to manage them. Option D is incorrect; the
question does not indicate morphine is being used, and offering spiritual guidance would not be a
priority at this point.
15. The mother of a cancer patient comes to the nurse concerned with her daughter's safety; the
morphine dose she needs to control her pain is getting “higher and higher.” The mother is afraid
that her daughter will overdose. The nurse educates the mother to the fact that
A) the dose range is higher with cancer patients, and the medical team will be very careful to
prevent addiction.
B) frequently, women need higher doses of morphine to be comfortable.
C) cancer is a terminal illness that requires higher doses of narcotics.
D) there is no maximum opioid dose, and her daughter is just becoming more tolerant to the
drug.
Feedback: There is no maximum dose of morphine, and the dose is pain dependent. Patients
requiring opioids for chronic pain, especially cancer patients, need increasing doses to relieve
pain. The requirement for higher drug doses results in a greater drug tolerance, which is a
physical dependency as opposed to addiction, which is a psychological dependency. Option A is
incorrect; the dose range is usually higher with cancer patients, and, although tolerance to the
drug will increase, addiction is not dose related but is a separate psychological dependency issue.
Option B is incorrect; there is no research that indicates that women need higher doses of
morphine to be comfortable. Option C is incorrect, telling the mother that cancer is a terminal
illness that requires higher doses of narcotics does not answer the mother's question.
16. You have just received report on a 47-year-old woman who is coming to your unit from the
emergency department with a severely broken leg. You review her PRN medications and see that
she has an NSAID (ibuprofen) ordered every 4 hours. If you wanted to implement preventive
pain measures when the patient arrives to your unit, what would you do?
A) Check for allergies, use a pain scale to assess the patient's pain, and let the patient know
ibuprofen is available every 4 hours if she needs it.
B) Do a complete assessment, and give pain medication based on the patient's report of pain.
C) Check for allergies, use a pain scale to assess the patient's pain, and offer the ibuprofen every
4 hours until the patient is discharged.
D) Provide medication as per patient request and offer relaxation techniques to promote
comfort.
Feedback: One way preventive pain measures can be implemented is by using PRN medications
on a more regular or scheduled basis to allow for more uniform pain control. Smaller drug doses
of medication are needed with the preventive pain method when PRN medications are given
around the clock. Options A and B are incorrect; letting the patient know ibuprofen is available
every 4 hours if she needs it or when the patient reports pain is simply offering the medication
PRN. Option D is incorrect; providing medication as per patient request is simply offering the
medication PRN, although offering relaxation techniques to promote comfort would work well
along with preventive pain measures.
17. A 60-year-old patient who has diabetes had a below-knee amputation 1 week ago. The
patient asks “why does it still feel like my leg is attached, and why does it still hurt?” The nurse
explains that our minds gather information and develop patterns called a neurosignature. All the
parts of our bodies become a part of the pattern, and it takes time for the pattern to adapt to
change or loss. What is this pattern a part of?
A) The personal-pattern analysis
B) The past experience
C) The anxiety-control measures
D) The extended gate-control theory
Feedback: The extended gate-control theory proposes that information is processed in a
neuromatrix, from which a characteristic pattern emerges called the neurosignature. When the
patient had his leg removed, the pattern is changed, and his body perceived the change as pain.
Option A is incorrect; personal-pattern analysis sounds good but is not a theory and is used to
distract the test-taker. Option B is incorrect; past experience is not a theory of neurosignature
patterns. Option C is incorrect; anxiety-control measures are interventions that are not directly
related to a theory of neurosignature patterns.
18. You are the case manager for a 35-year-old man being seen at a primary care clinic for
chronic low back pain. When you meet with the patient, he says that he is having problems at
work; in the past year he has been absent from work about once every 2 weeks, is short-tempered
with other workers, feels tired all the time, and is worried about losing his job. You are
developing this patient's plan of care. What should the goals for the plan of care focus on?
A) Increasing pain tolerance and exercise
B) Decrease the need to work and increase sleep to 8 hours per night
C) Evaluate other work options to decrease the risk of depression
D) Decrease the time lost from work to increase the quality of interpersonal relationships and
decrease anxiety
Feedback: Chronic pain may affect the patient's quality of life by interfering with work,
interpersonal relationships, or sleep. Thus, the best set of goals would be to “decrease time lost
from work to increase the quality of interpersonal relationships, and decrease anxiety.” Option A
is incorrect; increasing pain tolerance is an unrealistic goal, and exercise could help but would
not be the focus of the plan of care. Option B is incorrect; decreasing the need to work and
increasing sleep to 8 hours per night are reasonable interventions but not goals. Option C is
incorrect; evaluating other work options to decrease the risk of depression is a misdirected
diagnosis.
19. A nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of
pain that she rates as an eight on a ten-point scale. The NA tells the nurse that he thinks the
patient is exaggerating and does not need pain medication. What is the nurse's best response?
A) “Pain often comes and goes with postsurgical patients. Please ask her about pain again in
about 30 minutes.”
B) “We need to provide pain medications because it is the law, and we must always follow the
law.”
C) “Professionally, I believe 'pain is whatever the patient says it is.'”
D) “Patients often misreport pain 'to get our attention when we are busy.'”
Feedback: A broad definition of pain is “whatever the person says it is, existing whenever the
experiencing person says it does.” We treat pain when the patient report is above an acceptable
limit based on a pain scale, which usually is three on a ten-point scale. Pain is always included as
a part of any assessment and, therefore, needs to be verified by the nurse. Option A is incorrect;
pain that is eight on a ten-point scale needs to be treated. Option B is incorrect; providing pain
relief is not a law, but failure to provide pain relief could be considered abusive treatment.
Option D is incorrect; nurses who believe that patients “often misreport pain to get our attention
when we are busy” are misinformed.
20. The home health nurse is developing a plan of care for a patient who will be managing his
chronic pain at home. Using the nursing process, which concepts should the nurse focus the
patient teaching on?
A) Self-care and safety
B) Autonomy and need
C) Health promotion and exercise
D) Dependence and health
Feedback: The patient will be at home monitoring his own pain management, administering his
own medication, and monitoring and reporting side effects. This requires the ability to perform
self-care activities in a safe manner. Option B is incorrect; creating autonomy is important, but
need is a poorly defined concept. Option C is a good answer; health promotion is an important
global concept for maintaining health, and exercise is an appropriate activity; however, self-care
and safety are the priorities. Option D is incorrect; dependence is not a concept used to develop a
nursing plan of care, and health is too broad of a concept to use as a basis for a nursing plan of
care.
21. You are the emergency department (ED) nurse caring for a 9-year-old who was in a motor
vehicle accident. The mother arrives at the ED, and you explain that the child is in pain from a
broken arm that will need surgical intervention to set the bones. You ask the mother to comfort
the child. What type of pain are you dealing with in this patient?
A) Chronic
B) Acute
C) Intermittent
D) Phantom
Feedback: Acute pain is usually of recent onset and commonly associated with a specific injury.
Acute pain indicates that damage or injury has occurred. Options A and C are incorrect; chronic
pain is constant or intermittent pain that persists beyond the expected healing time and that can
seldom be attributed to a specific cause or injury. Option D is incorrect; phantom pain occurs
when the body experiences a loss, such as an amputation, and still feels pain in the missing part.
22. The wife of a patient you are caring for asks to speak with you. She tells you that she is
concerned because her husband is requiring more and more pain medication. She states, “He was
in pain long before he got cancer because he broke his back about 20 years ago. His pain
medicine wasn't just raised and raised for that pain.” What would be the nurses' best response?
A) “I didn't know that. I will speak to the doctor about your husband's pain control.”
B) “Cancer pain can be either acute or chronic. Most cancer pain is caused by tumor
involvement and needs to be treated in a way that brings the patient relief.”
C) “Cancer is an acute kind of pain so the more it hurts the patient, the more medicine we give
the patient until it doesn't hurt anymore.”
D) “Does the increasing medication dosage concern you?”
Feedback: Pain associated with cancer may be acute or chronic. Most pain associated with
cancer is a direct result of tumor involvement. Option A is incorrect; conveying patient/family
concerns to the physician is something a nurse does, but it does not give the best response by the
nurse. Option C is incorrect; cancer pain can be either acute or chronic, and you do not tell a
family member that you are going to keep increasing the dosage of the medication until “it
doesn't hurt anymore.” Option D is incorrect; it is an appropriate question for the nurse to ask,
but it is not the best answer for the scenario provided.
23. You are part of the health care team caring for a 77-year-old woman who has been admitted
to your rehabilitation facility after falling and breaking both legs. The patient complains of pain
in both legs. Pain management has become an issue for the patient and her family. The patient
appears to be getting more and more ill and may have to be readmitted to an acute-care facility.
What do you know about the negative effects of the stress of pain?
A) It makes children more vulnerable.
B) It is particularly harmful in the elderly who have been injured or who are ill.
C) It affects only those who are already debilitated.
D) It has no negative effects; it just alerts the person/health care team of something wrong in the
body.
Feedback: The widespread endocrine, immunologic, and inflammatory changes that occur with
stress can have significant negative effects. This is particularly harmful in patients whose health
is already compromised by age, illness, or injury. Option A is incorrect; it is an incomplete
answer that does not address what the woman is more vulnerable to. Option C is incorrect; the
negative effects of stress/pain affect everyone, not just those who are already debilitated. Option
D is incorrect; research has shown that there are negative effects on the body caused by
stress/pain.
24. You are the nurse caring for the 25-year-old victim of a motor vehicle accident with a
fractured pelvis and a ruptured bladder. The nurse's aide (NA) tells you that she is concerned
because the patient's resting heart rate is 110 beats per minute, her respirations are 24 breaths per
minute, temperature is 99.1°F axillary, and the blood pressure is 125/85. What other information
is most important as you assess this patient's physiologic status?
A) The patient's blood-alcohol level
B) The patient's serum glucose level
C) The patient's white blood cell count
D) The patient's pain level
Feedback: Unrelieved acute pain can affect the pulmonary, cardiovascular, gastrointestinal,
endocrine, and immune systems. The stress response (“neuroendocrine response to stress”) that
occurs with trauma also occurs with other causes of severe pain. Options A and B are incorrect;
nowhere in the scenario does it indicate that this patient has been drinking or is a diabetic. Option
C is incorrect; the patient's white count would indicate possible infection, which would not
increase the resting heart rate or respiratory rate unless the infection was systemic. The first
indication of an infection is increased temperature.
25. You are the nurse coming on shift in a rehabilitation hospital. You receive information in
report about a new patient who has fibromyalgia and has difficulty with her ADLs. The off-going
nurse also reports that the patient is withdrawn, refusing visitors, and has been vacillating
between tears and anger all afternoon. What do you know about chronic pain syndromes that
could account for your new patient's behavior?
A) Fibromyalgia is not a chronic pain syndrome, so you would not know what is causing the
patient's behavior.
B) The patient is upset because she has to be in the hospital.
C) The patient really has a psychiatric disorder.
D) Chronic pain can cause depression, anger, and fatigue.
Feedback: Regardless of how patients cope with chronic pain, pain that lasts for an extended
period can result in disability. Patients with a number of chronic pain syndromes report
depression, anger, and fatigue. Patients may be unable to continue the activities and interpersonal
relationships they engaged in before the pain began. Disabilities may range from an impaired
ability to participate in physical activities to an inability to take care of personal needs, such as
dressing or eating. Option A is incorrect; fibromyalgia is a chronic pain syndrome and it could
cause the patient to behave the way she is behaving. Options B and C are incorrect; nowhere in
the scenario does it indicate the patient is upset about the hospitalization or that she has a
psychiatric disorder.
26. You are caring for a patient admitted to the medical-surgical unit after falling from a horse.
The patient states “I hurt so bad. I suffer from chronic pain anyway, and now it is so much
worse.” As a nurse, what should you understand about chronic pain? (Mark all that apply.)
A) How it affects patients and families
B) Where the resources are to assist the patient with pain management
C) How to cope with acute pain
D) What pain-relief strategies are available
E) The difference between acute and intermittent pain
Feedback: Nurses should understand the effects of chronic pain on patients and families and
should be knowledgeable about pain-relief strategies and appropriate resources to assist
effectively with pain management. Options C and D are incorrect; acute pain is not the issue with
this patient, and the difference between acute and intermittent pain has no bearing on this patient.
27. Research has shown that patients with the same basic demographics who have experienced
the same event (ie, knee-replacement surgery) report differing levels of pain. Which physiologic
processes are involved in a patient's perception of pain?
A) Lymph system
B) Reticular activating system
C) Neuromuscular matrix
D) Endorphins and enkephalins
Feedback: The involvement of the reticular formation, limbic, and reticular activating systems is
responsible for the individual variations in the perception of noxious stimuli. Option A is
incorrect; the limbic system, not the lymph system is involved in the perception of pain. Option
C is incorrect; this is a test question put in as a distracter. Endorphins and enkephalins are not
physiologic processes so option D is incorrect.
28. What theory about pain was the first to implicate psychological factors in the perception of
pain?
A) The descending-control theory
B) The neuromatrix theory
C) The nonpharmacologic-pain theory
D) The gate-control theory
Feedback: The gate-control theory was the first theory to suggest that psychological factors play
a role in the perception of pain. The theory guided research toward identifying cognitive-
behavioral approaches to pain management. Therefore, this theory helps explain how
interventions such as distraction and music therapy relieve pain. Option A is incorrect; there is a
descending-control system, not a descending-control theory in regard to perception of pain.
Option B is incorrect; the neuromatrix theory highlights the role of the brain in sustaining the
experience of pain. Option C is incorrect as it is nonexistent and only a distracter to this test
question.
29. You are the nurse caring for an elderly patient who is Asian-American who speaks little
English. How would you assess this patient's pain?
A) Make a chart with English on one side and the patient's native language on the other so he
can pick which word best describes his pain.
B) Use the regular zero-to-ten pain scale
C) Use the Faces Pain Scale
D) Have a translator come in every time you assess the patient so you can document what the
patient said
Feedback: If a patient does not speak English or cannot clearly communicate information
needed to manage pain, an interpreter, translator, or family member familiar with the person's
method of communication should be consulted and a method established for pain assessment.
Often a chart can be constructed with English words on one side and the foreign language on the
other. Then the patient can point to the corresponding word to tell the nurse about the pain.
30. Research has shown that in some instances, just the expectation that a medication or
treatment will work is enough for relief to be felt. This is called the placebo effect and is a true
physiologic response. What can reverse the placebo effect?
A) Morphine
B) Naloxone
C) Celecoxib
D) Acetylsalicylic Acid
Feedback: The placebo effect results from natural (endogenous) production of endorphins in the
descending-control system. It is a true physiologic response that can be reversed by naloxone, an
opioid antagonist. Option A is incorrect; morphine is a narcotic and could not reverse the placebo
effect caused by the endogenous production of morphine-like substances in the body. Options C
and D are incorrect; Celecoxib or Celebrex is a Cox 2 inhibitor, an NSAID, and Acetylsalicylic
Acid is aspirin, neither of which can act as an opioid antagonist.
31. You are assessing an 86-year-old postoperative patient who is very stoic. When you enter
the room, the patient is curled into the fetal position, and he is moaning. His vital signs are
elevated and he is perspiring. You ask the patient what his pain level is on a zero-to-ten scale that
you did patient education on with this patient prior to surgery. The patient indicates a pain level
of two to three. You review your pain-management orders and find that all medications are
ordered PRN. How would you treat this patient's pain?
A) Treat the clinical symptoms you see
B) Call the physician for new orders because it is obvious that the pain medicine is not working
C) Believe what the patient says
D) Ask the family what they think and treat accordingly
Feedback: As always, the best guide to pain management and administration of analgesic agents
in all patients, regardless of age, is what the individual patient says. Option A is a good answer,
but you cannot treat pain the patient denies having if the orders are PRN only. Option B is
incorrect; the scenario does not indicate the present pain-management orders are not working for
this patient. Option D is also a good answer to get insight into past behavior of this patient but
does not indicate whether the patient will accept pain medication if he denies having appreciable
pain.
32. The nurse caring for a 91-year-old patient with osteoarthritis is reviewing the patient's chart.
This patient is on a variety of medications prescribed by different doctors. What is the nurse
most concerned about with this patient?
A) Depression
B) Chronic illness
C) Physical disability
D) Drug interactions
Feedback: Drug interactions are more likely to occur in older adults because of the higher
incidence of chronic illness and the increased use of prescription and OTC medications. Options
A, B, and C are all good answers for this patient because of the patient's age and disease process.
However, they are not what the nurse would be most concerned about in the inpatient setting.
33. You are caring for a patient with sickle cell disease in her home. Over the years, there has
been joint damage, and the patient is in chronic pain. The patient has developed a tolerance to
pain medication. When does the tolerance to pain medication become a problem?
A) When delivering or administering the medication
B) When dealing with the withdrawal symptoms from the tolerance
C) When having to report the patient's addiction to her physician
D) When the family becomes concerned about increasing dosage
Feedback: Tolerance to opioids is common and becomes a problem primarily in terms of
delivering or administering the medication (eg, how to administer very large doses of morphine
to a patient). Option B is relevant; symptoms of physical dependence may occur when opiates
are discontinued, but they are not usually a problem. Option C is incorrect; this patient does not
have an addiction. Option D is incorrect; tolerance to pain medication is not a problem here;
educating the family is what is necessary.
34. You are admitting a patient to your rehabilitation unit who has a diagnosis of persistent,
severe pain. According to the patient's history, the patient's pain has not responded to previous
treatment. What treatment would you expect might be tried with this patient?
A) Intravenous analgesia
B) Long-term intrathecal or epidural catheter
C) Oral analgesia
D) Intramuscular analgesia
Feedback: For patients who have persistent, severe pain that fails to respond to other treatments
or who obtain pain relief only with the risk of serious side effects, medication administered by a
long-term intrathecal or epidural catheter may be effective. Options A, C, and D are incorrect;
these means of pain control would already have been tried in a patient with persistent severe pain
that has not responded to previous treatment.
35. You are caring for a 20 year-old patient with a diagnosis of cerebral palsy who has been
admitted for the relief of painful contractures in his lower extremities. What does the nursing
care of this patient depend on? (Mark all that apply.)
A) The age of the patient
B) The patient's secondary diagnosis
C) The type of procedure performed
D) The changes in neurologic function due to the procedure
E) Effectiveness in relieving the pain
Feedback: The specific nursing care of patients who undergo neurologic and neurosurgical
procedures for the relief of chronic pain depends on the type of procedure performed, its
effectiveness in relieving the pain, and the changes in neurologic function that accompany the
procedure. Options A and B are incorrect; the age of the patient would be of no consequence in
this scenario and the patient's secondary diagnosis would not dictate the nursing care of this
patient.
36. You are caring for a terminal patient who has just had a cordotomy for intractable pain.
What is a cordotomy performed for?
A) To reroute the transmission of pain
B) To destroy neuronal dysfunction
C) To reduce nociceptive input
D) To interrupt the transmission of pain
Feedback: Cordotomy is performed to interrupt the transmission of pain. Care is taken to destroy
only the sensation of pain, leaving motor functions intact. Option A is incorrect; a cordotomy
does not reroute the transmission of pain. Options B and C are incorrect; destroying neuronal
dysfunction and reducing nociceptive input are done by rhizotomy.
37. Deep brain stimulation is a procedure that is performed for special pain problems when there
is no response to the usual techniques of pain control. It is a procedure used on patients with
neuropathic pain that may be caused by what? (Mark all that apply.)
A) Phantom-limb pain
B) Stroke
C) Contractures
D) Severe burns
E) Brain injuries
Feedback: Deep brain stimulation is used for patients with neuropathic pain that may be caused
by damage or injury from a stroke, brain or spinal cord injuries, or phantom-limb pain. Use of
deep brain stimulation is also effective for chronic cluster headaches. Deep brain stimulation is
not used for contractures or severe burns so options C and D are incorrect.
38. Assessment of the intervention of pain control is of utmost importance. If the intervention is
deemed ineffective, goals need to be reassessed and other measures need to be considered. What
is the role of the nurse in obtaining additional pain relief for the patient?
A) Primary caregiver
B) Patient advocate
C) Team leader
D) Case manager
Feedback: If the intervention was ineffective, the nurse should consider other measures. If these
are ineffective, pain-relief goals need to be reassessed in collaboration with the physician. The
nurse serves as the patient's advocate in obtaining additional pain relief. Option A is incorrect;
the nurse is not the primary caregiver, the physician is. Options C and D are incorrect; the
scenario does not mention a team approach to the patient or a case-management approach.
39. A patient is admitted to your unit with a diagnosis of end-stage prostate cancer. He is in
intractable pain. What type of pain control could be considered at this point?
A) Pharmacologic
B) Alternative
C) Neurosurgical
D) Nontraditional
Feedback: In some situations, especially with long-term and severe intractable pain, usual
pharmacologic and comfort methods of pain relief are ineffective. In those situations, neurologic
and neurosurgical approaches to pain management may be considered. Options A and B are
incorrect; a patient with end-stage prostate cancer would have already had pharmacologic and
alternative pain-control management. Option D is incorrect; nontraditional pain-control measures
would already have been tried by the time this patient is admitted with intractable pain.
40. Patients who suffer from chronic pain often look to alternative therapies for relief. Most of
the alternative “therapies” may not be harmful with the exception of one. Which alternative
therapy for pain control is considered potentially harmful?
A) Homeopathy
B) Chelation
C) Polarity therapy
D) Macrobiotic dieting
Feedback: Information about an array of potential therapies can be found on the Internet and in
the self-help section of many bookstores. Therapies recommended for pain from these sources
include, but are not limited to, chelation, therapeutic touch, herbal therapy, reflexology, magnetic
therapy, electrotherapy, polarity therapy, acupressure, emu oil, pectin therapy, aromatherapy,
homeopathy, and macrobiotic dieting. Many of these “therapies” (with the exception of
macrobiotic dieting) are probably not harmful. However, they have yet to be proved effective by
the standards used to evaluate the effectiveness of medical and nursing interventions.