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A nurse on an adult surgical floor enters a patient room and observes a family member pressing the button to administer a dose of PCA via the infusion pump. What response by the nurse is most appropriate?
- A. That dose will sure be helpful after their type of surgery.
- B. Having only the patient use the pump prevents respiratory complications.
- C. If the patient asked you to press the button, then it's OK.
- D. Since the pump has built in safeguards, you can help with pain management.
Correct Answer: B
Rationale: PCA by proxy (family administering doses) risks overdose, oversedation, and respiratory depression (B). Only the patient should press the PCA button, regardless of safeguards (D) or patient requests (C), and option A ignores the safety issue.
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Based on this information, the provider decides to add pharmacologic strategies to the plan of care. Which interventions are the priority for Carla? Select all that apply.
- A. Provide information about a multimodal pain regimen
- B. Focus on the side effects of high-dose immediate-release opioids
- C. Discuss the significant risk for addiction with Carla and her wife
- D. Teach adjuvant medications such as gabapentin for treatment of neuropathic pain
- E. Integrate elements from the biopsychosocial model when designing interventions
Correct Answer: A,D,E
Rationale: Priority interventions include educating about a multimodal pain regimen (A), teaching about adjuvant medications like gabapentin for neuropathic pain (D), and integrating biopsychosocial elements (E) to address Carla's chronic pain holistically. Focusing on high-dose opioid side effects (B) or addiction risks (C) is less relevant, as Carla prefers avoiding pain medications and no high-dose opioids are indicated.
A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors?
- A. Older adult on bedrest following cervical spine surgery
- B. Patient with a severe sunburn being treated for dehydration
- C. Industrial worker who has burns caused by a caustic acid
- D. Patient experiencing cardiac disturbances from an electrical shock
Correct Answer: A
Rationale: Mechanical activation of pain receptors occurs from friction or pressure, such as pressure sores from bedrest in an older adult post-cervical spine surgery (A). Sunburn (B) and acid burns (C) are thermal and chemical stimulants, respectively, while electrical shock (D) is an electrical stimulant.
Which question by the nurse will be most helpful in determining whether a patient who is experiencing a myocardial infarction has referred pain?
- A. Did your chest pain last 2 minutes or less?
- B. Was the pain on the surface of your chest?
- C. Is this pain in your residual limb shooting or burning?
- D. Are you having any arm or shoulder pain?
Correct Answer: D
Rationale: Referred pain is perceived in an area distant from its origin, such as arm or shoulder pain during a myocardial infarction (D). Questions about duration (A), surface location (B), or phantom limb pain (C) are less relevant to identifying referred pain in this context.
A nurse plans to promote a patient's natural pain mediators by using a whirlpool following intensive physical therapy to the legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques?
- A. Prostaglandins
- B. Substance P
- C. Endorphins
- D. Serotonin
Correct Answer: C
Rationale: Endorphins are powerful pain-blocking neuromodulators released through relaxation techniques like whirlpool therapy (C). Prostaglandins and substance P (A, B) enhance pain transmission, and serotonin (D) primarily affects mood and smooth muscle function.
A patient reports diffuse abdominal pain that is difficult to localize. The nurse documents this as which type of pain?
- A. Cutaneous
- B. Visceral
- C. Superficial
- D. Somatic
Correct Answer: B
Rationale: Visceral pain is poorly localized and originates in body organs like the abdomen (B). Cutaneous and superficial pain (A, C) involve the skin or subcutaneous tissue, while somatic pain (D) originates in tendons, ligaments, bones, or nerves and is more localized.