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Flashcards in Chapter 7 Deck (30):
1

1. A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which pain assessment tool should the nurse use to assess this child for the presence of pain?
a. FACES pain rating tool
b. Numeric scale
c. Oucher scale
d. FLACC tool

ANS: D
A behavioral pain tool should be used when the child is preverbal or doesn’t have the language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all self-report pain rating tools. Self-report measures are not sufficiently valid for children younger than 3 years of age because many are not able to accurately self-report their pain.

2

2. The nurse is caring for a 6-year-old girl who had surgery 12 hours ago. The child tells the nurse that she does not have pain, but a few minutes later she tells her parents that she does. Which should the nurse consider when interpreting this?
a. Truthful reporting of pain should occur by this age.
b. Inconsistency in pain reporting suggests that pain is not present.
c. Children use pain experiences to manipulate their parents.
d. Children may be experiencing pain even though they deny it to the nurse.

ANS: D
Children may deny pain to the nurse because they fear receiving an injectable analgesic or because they believe they deserve to suffer as a punishment for a misdeed. They may refuse to admit pain to a stranger but readily tell a parent. Truthfully reporting pain and inconsistency in pain reporting suggesting that pain is not present are common fallacies about children and pain. Pain is whatever the experiencing person says it is, whenever the person says it exists. Pain would not be questioned in an adult 12 hours after surgery

3

3. A nurse is gathering a history on a school-age child admitted for a migraine headache. The child states, “I have been getting a migraine every 2 or 3 months for the last year.” The nurse documents this as which type of pain?
a. Acute
b. Chronic
c. Recurrent
d. Subacute

ANS: C
Pain that is episodic and reoccurs is defined as recurrent pain. The time frame within which episodes of pain recur is at least 3 months. Recurrent pain in children includes migraine headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain. Acute pain is pain that lasts for less than 3 months. Chronic pain is pain that lasts, on a daily basis, for more than 3 months. Subacute is not a term for documenting type of pain.

4

4. Physiologic measurements in children’s pain assessment are:
a. the best indicator of pain in children of all ages.
b. essential to determine whether a child is telling the truth about pain.
c. of most value when children also report having pain.
d. of limited value as sole indicator of pain.

ANS: D
Physiologic manifestations of pain may vary considerably, not providing a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain-rating scale, behavioral assessment, and parental report. When the child states that pain exists, it does. That is the truth.

5

5. Nonpharmacologic strategies for pain management:
a. may reduce pain perception.
b. make pharmacologic strategies unnecessary.
c. usually take too long to implement.
d. trick children into believing they do not have pain.

ANS: A
Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. Nonpharmacologic techniques should be learned before the pain occurs. With severe pain, it is best to use both pharmacologic and nonpharmacologic measures for pain control. The nonpharmacologic strategy should be matched with the child’s pain severity and taught to the child before the onset of the painful experience. Some of the techniques may facilitate the child’s experience with mild pain, but the child will still know the discomfort was present.

6

6. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?
a. Codeine
b. Morphine
c. Methadone
d. Meperidine

ANS: B
The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in parenteral form in the United States. Meperidine is not used for continuous and extended pain relief.

7

7. A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply _____ before the procedure.
a. TAC (tetracaine-adrenaline-cocaine) 15 minutes
b. transdermal fentanyl (Duragesic) patch immediately
c. EMLA (eutectic mixture of local anesthetics) 1 hour
d. EMLA (eutectic mixture of local anesthetics) 30 minutes

ANS: C
EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin. The gel can be placed on the wound for suturing. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control. For maximal effectiveness, EMLA must be applied approximately 60 minutes in advance.

8

8. The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to:
a. administer naloxone (Narcan).
b. discontinue IV infusion.
c. discontinue morphine until child is fully awake.
d. stimulate child by calling name, shaking gently, and asking to breathe deeply.

ANS: A
The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive. The child is unresponsive, therefore naloxone is indicated.

9

9. The nurse is completing a pain assessment on a 4-year-old child. Which of the depicted pain scale tools should the nurse use with a child this age?
a.
b.
c.
d.

ANS: A
The pain scale appropriate for a 4-year-old child is the FACES pain scale. Numeric pain scales can be used on children as young as age 5 as long as they can count and have some concept of numbers and their values in relation to other numbers. Word graphic scales and visual analogue scales are used preferably for school-age children.

10

1. A nurse recognizes which physiologic responses as a manifestation of pain in a neonate? (Select all that apply.)
a. Decreased respirations
b. Diaphoresis
c. Decreased SaO2
d. Decreased blood pressure
e. Increased heart rate

ANS: B, C, E
The physiologic responses that indicate pain in neonates are increased heart rate, increased blood pressure, rapid, shallow respirations, decreased arterial oxygen saturation (SaO2), pallor or flushing, diaphoresis, and palmar sweating.

11

2. A nurse is monitoring a patient for side effects associated with opioid analgesics. Which side effects should the nurse expect to monitor for? (Select all that apply.)
a. Diarrhea
b. Respiratory depression
c. Hypertension
d. Pruritus
e. Sweating

ANS: B, D, E
Side effects of opioids include respiratory depression, pruritus, and sweating. Constipation may occur, not diarrhea, and orthostatic hypotension may occur but not hypertension.

12

3. Which dietary recommendations should a nurse make to an adolescent patient to manage constipation related to opioid analgesic administration? (Select all that apply.)
a. Bran cereal
b. Decrease fluid intake
c. Prune juice
d. Cheese
e. Vegetables

ANS: A, D, E
To manage the side effect of constipation caused by opioids, fluids should be increased, and bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause constipation so it should not be recommended.

13

4. Surgery has informed a nurse that the patient returning to the floor after spinal surgery has an opioid epidural catheter for pain management. The nurse should prepare to monitor the patient for which side effects of an opioid epidural catheter? (Select all that apply.)
a. Urinary frequency
b. Nausea
c. Itching
d. Respiratory depression

ANS: B, C, D
Respiratory depression, nausea, itching, and urinary retention are dose-related side effects from an epidural opioid. Urinary retention, not urinary frequency, would be seen.

14

1. A dose of oxycodone (OxyContin) 2 mg/kg has been ordered for a child weighing 33 lb. How many milligrams of OxyContin should the nurse administer? (Record your answer as a whole number.)

ANS:
30
The child’s weight is divided by 2.2 to get the weight in kilograms. Kilograms in weight are then multiplied by the prescribed 2 mg. 33 lb/2.2 = 15 kg. 15 kg  2 mg = 30 mg.

15

2. A nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the following assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense; Cry: no cry; Consolability: content, relaxed. The nurse records the FLACC assessment as which number? (Record your answer as a whole number.)

ANS:
2
The FLACC scale is recorded per the following table:
0 1 2
Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking
Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints
Consolability Content, relaxed Reassured by occasional touching, hugging, or talking to; distractible Difficult to console or comfort
Because the child has a grimace and is squirming and tense, 2 total points are given. Relaxed legs, no cry, and content and relaxed consolability get 0 points.

16

1. A patient on an intravenous opioid analgesic has become apneic. The nurse should implement which interventions? Place the interventions in order from the highest priority (first intervention) to the lowest priority (last intervention). Provide your answer using lowercase letters separated by commas (e.g., a, b, c, d).
a. Place the patient on continuous pulse oximetry to assess SaO2.
b. Administer the prescribed naloxone (Narcan) dose by slow IV push.
c. Ensure oxygen is available.
d. Prepare to calm the child as analgesia is reversed.

ANS:
b, a, c, d
The Narcan prescribed dose should be given, first by slow IV push every 2 minutes until effect is obtained. The second intervention should be assessment of the patient’s SaO2 status. Oxygen should be made available and administered if the SaO2 status indicates hypoxemia. Last, the child should be calmed as the analgesia is reversed.

17

The nurse is using the C.R.I.E.S. pain assessment tool on a preterm infant in the neonatal intensive care unit (NICU). Which is a component of this tool?
a. Color
b. Reflexes
c. Oxygen saturation
d. Posture of the arms and legs

Ans: C
The components of the scale are Crying, Requires increased oxygen, Increased vital signs, Expression, and Sleepless. Changes in oxygen saturation would affect scoring.
Color is not a component of this scale.
Reflexes are not a component of this scale.
Posture of the arms and legs is not a component of this scale.

18

A child who is terminally ill with bone cancer is in severe pain. Nursing interventions should be based on the knowledge that
a. children tend to be overmedicated for pain.
b. giving large doses of opioids causes euthanasia.
c. narcotic addiction is common in terminally ill children.
d. large doses of opioids are justified when there are no other treatment options

Ans: D
Large doses of opioids may be needed because the child has become physiologically tolerant to the drug, requiring higher doses to achieve the same degree of pain control. Pain is considered the fifth vital sign, and management of pain is critical to treatment of a child with bone cancer.
Continuing studies report that children are consistently undermedicated for pain.
The dosage of opioids is titrated to relieve pain, not cause death.
Addiction refers to a psychological dependence on the narcotic medication, which does not occur in terminal care.

19

The most consistent indicator of pain in infants is
a. increased respirations.
b. increased heart rate.
c. clenching the teeth and lips.
d. a facial expression of discomfort.

Ans: D
A facial expression of discomfort is the most consistent behavioral manifestation of pain in infants.
The respiratory pattern may be markedly variable in an infant in pain and, therefore, is not a consistent indicator of pain.
The heart rate may initially decrease in some infants with pain and then increase; therefore, it is not a consistent indicator of pain.
Clenching the teeth and lips is a sign of pain often assessed in toddlers, not infants.

20

A nurse is starting an intravenous (IV) line for a school-age child with cancer. The child says, "I have had a million IVs. They hurt." The nurse's response should be based on the knowledge that
a. children tolerate pain better than adults.
b. children become accustomed to painful procedures.
c. children often lie about experiencing pain.
d. children often demonstrate increased behavioral signs of discomfort with repeated painful procedures.

Ans: D
Children with chronic illnesses are more likely to identify invasive procedures as stressful compared with children with acute illnesses.
There are no data to support the theory that children tolerate pain better than adults.
The child has increasing difficulty with numerous and repeated painful procedures rather than becoming accustomed to them.
Pain is whatever the experiencing person defines it to be.

21

Which is an important consideration when using the FACES Pain Rating Scale with children?
a. Children color the face with the color they choose to best describe their pain.
b. The scale can be used with most children as young as 3 years of age.
c. The scale is not appropriate for use with adolescents.
d. The scale is useful in pain assessment but is not as accurate when assessing physiologic responses.

Ans: B
The FACES scale has been validated for children as young as 3 years of age to rate pain.
The child points at the face that best describes the pain being experienced.
The scale is useful for all ages above 3 years, including adults.
The scale does not have a means of assessing physiologic data.

22

Nonpharmacologic strategies for pain management
a. may reduce pain perception.
b. make pharmacologic strategies unnecessary.
c. usually take too long to implement.
d. trick children into believing they do not have pain.

Ans: A
Nonpharmacologic techniques for pain management may help the child with associated fears and stress related to pain. The strategies may provide assistance with coping that may reduce the perception of pain, decrease anxiety, and increase the effectiveness of medications.
The child with moderate or severe pain will require pharmacologic intervention.
The child should be taught nonpharmacologic pain management strategies before pain occurs, therefore reducing the implementation time.
The child will still have the pain, but the perception may be altered.

23

The nurses caring for a child are concerned about the child's frequent requests for pain medication. During a team conference, a nurse suggests that they consider administering a placebo instead of the usual pain medication. This decision should be based on knowledge that
a. it is unjustified and unethical to administer placebos instead of pain medication.
b. the absence of a response to a placebo means the child's pain has an organic basis.
c. a positive response to a placebo will not occur if the child's pain has an organic basis.
d. administering a placebo instead of the usual pain medication is effective in determining whether a child's pain is real.

Ans: A
Placebos should never be given by any route in the assessment or management of pain.
The response to a placebo is not a measure of the origin of pain and should never be used as a means of assessing pain.
The response to a placebo is not a measure of the origin of pain and should never be used as a means of assessing pain.
Placebos should never be given as a means to determine whether pain is real. Individuals respond differently to placebos; therefore, the patient's response may not be an accurate measure of pain.

24

A child who has been receiving morphine by the intravenous (IV) route will now start receiving it orally. In order for equianalgesia (equal analgesic effect) to be achieved, the oral dose will be
a. same as the IV dose.
b. greater than the IV dose.
c. one half of the IV dose.
d. one fourth of the IV dose.

Ans: B
When the route of morphine administration is changed from IV to PO (by mouth), it is essential that the dose be increased to achieve an equianalgesic effect.
Oral morphine is not as effective at the same dose as IV morphine.
The dosage of morphine is increased, not decreased, when the administration route changes from IV to PO.
The dosage of morphine is increased, not decreased, when the administration route changes from IV to PO.

25

Transdermal fentanyl (Duragesic) is being used for an adolescent with cancer who is in hospice care. The adolescent has been comfortable for several hours but now complains of severe pain. The most appropriate nursing action is to
a. administer meperidine (Demerol) intramuscularly.
b. administer morphine sulfate immediate release (MSIR) intravenously.
c. use a nonpharmacologic strategy.
d. place another fentanyl (Duragesic) patch on the adolescent.

Ans: B
The nurse should administer an immediate-release opioid intravenously, such as MSIR, for the breakthrough pain.
Intramuscular (IM) injections should be avoided in cancer patients because of an increased risk of bleeding and the fact that IM injections do not act immediately.
Nonpharmacologic strategies will not be effective in severe pain.
Transdermal fentanyl will take up to 24 hours to reach peak effect and therefore is not effective for severe breakthrough pain.

26

A nurse is caring postoperatively for an 8-year-old child with multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. Which is an important consideration in managing the child's pain?
a. Give only an opioid analgesic at this time.
b. Increase the dosage of analgesic until the child is adequately sedated.
c. Plan a preventive schedule of pain medication around the clock.
d. Give the child a clock and explain when he or she can have pain medications.

Ans: C
An around-the-clock administration strategy should be used for a child recovering from trauma and surgery. This schedule will help prevent low plasma levels of the drug, leading to breakthrough pain.
It is appropriate for the immediate concern of the child's pain to give an opioid analgesic, but this will not facilitate the more long-term plan of pain management.
The dosage of analgesic is increased until the pain is controlled, not until sedation is adequate.
The child should be frequently assessed for pain and medication doses titrated accordingly. It is inappropriate to give a child a clock with instructions as to when pain medication can be given, especially a child who has experienced a traumatic event.

27

The nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain
a. cannot occur if child is comatose.
b. may occur if child regains consciousness.
c. requires astute nursing assessment and management.
d. is best assessed by family members who are familiar with child.

Ans: C
Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations to accurately assess pain.
Pain can occur in the comatose child.
The child can be in pain while comatose.
The family can provide insight into the child's different responses, but the nurse should be monitoring physiologic and behavioral manifestations.

28

A child is being seen in the emergency department with multiple facial abrasions and lacerations. The combination agent lidocaine, adrenaline, and tetracaine (LAT) is applied topically to the wounds. The purpose of this combination therapy is to
a. cleanse the wound.
b. promote scab formation.
c. prevent infection of the wound.
d. provide anesthesia to the wound.

Ans: D
The combination of lidocaine, adrenaline, and tetracaine provides anesthesia within 10 to 15 minutes of application.
LAT does not have a cleansing effect.
LAT has no effect on scab formation.
LAT has no antibacterial effect.

29

The nurse is caring for a 12-year-old child who sustained major burns when putting charcoal lighter on a campfire. The nurse observes that the child is "very brave" and appears to accept pain with little or no response. What is the most appropriate nursing action?
a. Request a psychological consultation.
b. Ask why the child does not have pain.
c. Praise the child for the ability to withstand pain.
d. Encourage continued bravery as a coping strategy.

Ans: A
A psychological consultation will assist the child in verbalizing fears. This age-group is very concerned with physical appearance. The psychologist can help integrate the issues the child is facing.
It is likely that the child is having pain but not acknowledging the pain. Speaking with a psychologist might assist the child in relaying fears and pain.
If the child is feeling pain, the nurse should not offer praise for hiding the pain. The nurse should encourage the child to speak up during painful episodes so that the pain can be managed appropriately.
Bravery may not be an effective coping strategy if the child is in severe pain.

30

A 6-year-old is hospitalized with a fractured femur. Based on the nurse’s knowledge of pain assessment tools and child development, which assessment tools are most appropriate for this age child? (Select all that apply)
a. Oucher scale
b. CRIES scale
c. Poker chip tool
d. Faces pain scale
e. Postoperative pain score

Ans: A, C, D