ABCDE assessment
Airway, Breathing, Circulation, Disability, and Exposure/Environmental control
AVPU scale
Alert, Verbal, Pain stimuli, Unresponsive
fluid resuscitation is indicated for any patient with nonsuperficial burns covering more than
15% of TBSA
Fluid resuscitation is usually accomplished with...
...an isotonic crystalloid such as lactated Ringer's solution; the lactate helps to buffer the metabolic acidosis commonly seen with hypoperfusion and burn shock
1. The definition of pain with the most clinical significance is that pain is:
a. an uncomfortable experience present only in the patient with an intact nervous system.
b. an unpleasant experience accompanied by crying and tachycardia.
c. activation of th
ANS: D
The definition of pain with the most clinical significance is that pain is whatever the patient experiencing it says it is, and it occurs when that patient says it does.
2. The nerve endings responsible for pain are known as the:
a. baroreceptors.
b. nociceptors.
c. unmyelinated receptors.
d. thermal receptors.
ANS: B
The nerve endings responsible for pain are the nociceptors.
3. Transdermal fentanyl is not typically used in the critically ill patient because it:
a. can cause respiratory depression.
b. produces toxic metabolites.
c. requires 12 to 16 hours for the onset of action.
d. is not well absorbed because of the stress r
ANS: C
The use of transdermal fentanyl is rarely indicated in the critically ill patient. Transdermal fentanyl in critical care is used for the patient who requires extended pain control. Transdermal delivery requires 12 to 16 hours for onset of action an
4. Using a specific pain intensity scale in the critical care unit:
a. eliminates the need for the subjectivity of the patient.
b. allows for one tool for all patient types.
c. provides consistency of assessment and documentation.
d. is not necessary, bec
ANS: C
Many CCUs are using a specific pain intensity scale because a single tool provides consistency of assessment and documentation. A pain intensity scale is useful in the critical care environment. Asking the patient to grade his or her pain on a scal
5. Mr. K is mechanically ventilated and unable to communicate any aspects of his pain to his nurse. The nurse knows that the best tool for pain assessment for Mr. K is:
a. FLACC.
b. Wong-Baker FACES.
c. BIS.
d. BPS.
ANS: D
FLACC is a pediatric pain assessment tool. The Wong-Baker FACES tool requires the patient to associate a level of pain to a facial representation. BIS is an objective measure of sedation levels during neuromuscular blockade in the ICU. The BPS was
6. Which of the following patients is most likely to be experiencing a life-threatening opioid side effect?
a. Patient with respiratory rate of 10, breathing deeply
b. Patient with a respiratory rate of 8, snoring
c. Patient with blood pressure of 150/75,
ANS: B
Respiratory depression is the most life-threatening opioid side effect and is defined as a decrease in the rate or depth of respirations, not necessarily a specific number of respirations per minute. This means that a patient breathing deeply, but
7. The nurse caring for Ms. T is treating her with naloxone for opioid reversal related to critical respiratory depression and increased sedation. The nurse recognizes that the patient will potentially need:
a. nonopioid medication for pain management.
b.
ANS: A
Naloxone is carefully monitored for reversal of the respiratory signs. Another dose of naloxone may be needed as early as 30 minutes after the first dose. The benefits of reversing respiratory depression with naloxone must be carefully weighed agai
8. Localized pain associated with muscle ischemia and spasm is:
a. neuropathic.
b. somatic.
c. visceral.
d. deafferentative.
ANS: B
Somatic pain involves superficial tissues such as the skin, muscles, joints, and bones. Its location is well defined.
9. A patient with an acute inflammatory process is most likely to have what type of pain?
a. Somatic
b. Chronic
c. Visceral
d. Deafferentative
ANS: D
Neuropathic or deafferentative pain is described as an abnormal sensory process caused by changes in the excitability of nerve cells. These changes are associated with an acute inflammatory process or with nociceptive nerve damage, which can be cau
10. Accurate pain assessment may be enhanced by:
a. knowing the patient's culture as it relates to experiencing and reporting pain.
b. using the proper mechanical tools for measurement.
c. limiting the assessment to a minimum amount of time.
d. withholdin
ANS: A
Barriers to accurate pain assessment include cultural influences on pain and pain reporting.
11. The patient has the greatest control over dosing of pain medication with:
a. a round-the-clock administration schedule.
b. a patient-controlled analgesia (PCA) pump.
c. long-acting dosage forms.
d. a skin patch delivery system.
ANS: B
PCA is a method of drug delivery that uses the intravenous route and an infusion pump. It allows the patient to self-administer small doses of analgesics and, thus, gives the patient the greatest control over dosing of pain medication.
12. For the patient with pain in the thorax, upper abdomen, or lower extremities, the nurse knows that one possible option for analgesia might be:
a. intraosseous.
b. intravenous.
c. intraspinal.
d. intermittent.
ANS: C
The benefits of the intraspinal route include good-to-excellent pain control, particularly in the thorax, upper abdomen, and lower extremities, with typically lower dosages of opioids; increased patient mobility; minimal sedation; and increased pat
13. Which of the following is the most valid and accurate evidence of the patient's pain?
a. Observable disruption of activities of daily living
b. Facial expressions of the patient
c. The patient's self-report of what the pain is like and when it occurs
ANS: C
Pain is recognized as a subjective experience. Pain is whatever the patient says it is and exists whenever the patient says it does. Thus, the subjective component of pain assessment refers to the patient's self-report of pain about his or her sens
14. In assessing the patient with severe head injury who is unconscious, the nurse knows that the patient:
a. cannot perceive external stimuli.
b. may be able to hear, understand, and respond emotionally to verbal stimuli.
c. can only perceive and respond
ANS: B
Because pain recognition depends on cortical response, there is the mistaken belief that a patient without higher cortical function has no perception of pain. Interviews with 100 patients who experienced being unconscious revealed that 27% of them
15. In discussing pain management with the patient, which of the following would the nurse say?
a. "If you don't tell me when you are hurting, I can't give you medicine to make you more comfortable."
b. "Sometimes people are afraid that taking large or fr
ANS: B
Many patients and their families are frightened by the risk of addiction to pain medication. They fear that addiction will occur if the patient is medicated frequently or with amounts of opiates necessary to relieve the pain. This concern is so pow
16. The family is concerned that frequent use of pain medications will cause the patient to have difficulty breathing. The nurse explains:
a. "We are always prepared to deal with respiratory problems."
b. "Because the patient is on a ventilator, that will
ANS: C
Opioids can cause respiratory depression, but in the critically ill this is a rare phenomenon. The incidence of respiratory depression is less than 1%. Respiratory depression from the administration of opioids can be managed with diligent assessmen
17. Which of the following would be a first-line pain management strategy for the critical care patient?
a. Use of aspirin, acetaminophen, or naproxen
b. Use of prednisone, cortisone, or hydrocortisone
c. Use of morphine, fentanyl, hydromorphone, or meper
ANS: C
Opioid agonists are the most commonly used and are recommended as first-line analgesics. As a clinical practice guideline, scheduled opioid doses or a continuous infusion is preferred over an "as needed" regimen to ensure consistent analgesia in cr
1. The four processes of __________ include transduction, transmission, perception, and modulation.
nociception
2. Activation of the sympathetic nervous system in response to pain triggers physiological signs such as __________ and __________.
increased blood pressure, tachycardia
3. The ________________ activated by pain allows for the observation of relevant physiological signs that could be associated with pain and that represent a source of stress.
biological stress response
1. Which of the following statements are true regarding pain assessment and management? (Select all that apply)
a. The single most important assessment tool available to the nurse is the patient's self-report.
b. The only way to assess pain in patients un
ANS: A, C, D
The importance of understanding pain assessment components and the pharmacological and nonpharmacological interventions is essential to successful pain management.
Match each of the following types of pain with the statement that best describes it:
a. Acute
b. Chronic
c. Somatic
d. Visceral
e. Neuropathic
1. Well defined; usually involves skin, muscle, joints, or bones
2. Persists over time, often after the process
1. ANS: C DIF: Cognitive Level: Comprehension REF: 77
OBJ: Nursing Process: Assessment TOP: Pain
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. ANS: B DIF: Cognitive Level: Comprehension REF: 77
OBJ: Nursing Process: Assessment TOP: Pain