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Chapter 35: Somatosensory Function, Pain, and Headache-Patho taken from http://thepoint.lww.com/Book/Show Level 3
Terms in this set (73)
Which of the following patients is exhibiting headache symptoms that indicate a need for further evaluation?
a) College student with unilateral headache after eating a chocolate bar
b) Older adult with a headache after missing the evening meal
c) Pregnant mother with drowsiness and unrelenting headache
d) Parent with general head pain after a night caring for an ill child
Pregnant mother with drowsiness and unrelenting headache
Primary headaches such as migraine, tension headache, cluster headache, and chronic daily headache do not require additional evaluation.
-Patients with secondary headaches should receive further evaluation.
-Possible causes of secondary headaches are cerebral hemorrhage or aneurysm, meningitis, cancer, and nerve lesions.
-Additional patients requiring further evaluation are those with sudden onset or progression of headaches or someone who is immunosuppressed or pregnant.
What will the nurse teach a patient with trigeminal neuralgia about the condition?
a) Avoid eating if it triggers the pain.
b) It is good to spend time alone every day.
c) Surgery will relieve the condition.
d) Carbamazepine is a first-line treatment. v
Carbamazepine is a first-line treatment.
Trigeminal neuralgia is a condition in which patients experience brief, severe, repetitive lightninglike or throbbing pain along the distribution of one or more of the branches of the fifth cranial nerve. -Patients should be taught to avoid triggers when possible, but although eating may be a trigger, it is necessary for the patient to maintain nutrition.
-Social isolation is a possible problem arising from the condition. Time alone does not contribute significantly to improvement of the condition. Although treatment rarely provides total relief, trigeminal neuralgia can be controlled with carbamazepine (Tegretol) and surgical release of vessels, nerve roots, or scar tissue.
-If other treatments are ineffective, partial destruction of the nerve branches with heat, balloon compression, or glycerol injection may be performed.
-Newer therapies to be considered are botulinum toxin injection and gamma radiation with stereotactic surgery.
A severe type of headache that occurs more frequently in men than women and is described as having unrelenting, unilateral pain located most frequently in the orbit is called what?
a) Tension headache
b) Migraine headache
c) Chronic daily headache
d) Cluster headache
Cluster headache is a type of primary neurovascular headache that typically includes severe, unrelenting, unilateral pain located, in order of decreasing frequency, in the orbital, retro-orbital, temporal, supraorbital, and infraorbital region. The other answers are incorrect
A client is experiencing acute pain. The nurse would anticipate the client to manifest:
The client in acute pain will most likely exhibit signs of tachycardia (an abnormally rapid heart rate) because of increased stimulation to the sympathetic nervous system.
-The increased stimulation would result in tachypnea and hypertension.
-The increased stimulation would not result in hyperthermia.
A client fell from a ladder and broke his ankle and is being seen in the emergency department for severe ankle pain with swelling and limited range of motion. What type of pain does the nurse recognize the client experiencing?
a) Subacute pain
b) Acute pain
c) Visceral pain
d) Chronic pain
Acute pain is pain that is elicited by injury to body tissues and activation of nociceptive stimuli at the site of local tissue damage. It is generally of short duration and tends to resolve when the underlying pathologic process has resolved. Acute pain's purpose is to serve as a warning system. It alerts a person to the existence of actual or impending tissue damage and prompts a search for medical help.
A nurse who is testing a patient's response to passive movement of the fingers with the patient's eyes closed, notes that the patient cannot accurately identify on which side the movement occurred or in what position the finger was placed. Which of the following is an appropriate interpretation of this result?
a) Abnormal discrimination pathway function
b) That the sense of proprioception is intact
c) Normal reflex function
d) Intact thermal sensations
Abnormal discrimination pathway function
The discriminative dorsal column-medial lemniscus pathway is able to sense fine touch and discriminate between two points as close as 5 mm. This pathway also mediates sense of position. Loss of this pathway means only that the anterolateral pathway is functioning and is unable to make fine distinctions in touch proprioception and points. The test does not test reflexes or temperature.
A client asks if pain threshold and pain tolerance are the same. The best response by the health care provider would be:
a) "Pain tolerance is not affected by psychological, familial, cultural, and environmental factors."
b) "Pain tolerance is the minimum intensity of pain a client will endure."
c) "Pain threshold is the point at which a stimulus is perceived as painful."
d) "Pain threshold is not varied for person to person."
"Pain threshold is the point at which a stimulus is perceived as painful."
Pain threshold is closely associated with the point at which a nociceptive stimulus is perceived as painful.
-Pain tolerance relates more to the total pain experience; it is defined as the maximum intensity or duration of pain that a person is willing to endure before the he or she wants something done about the pain.
-Psychological, familial, cultural, and environmental factors significantly influence the amount of pain a person is willing to tolerate.
-The threshold for pain is fairly uniform from one person to another, whereas pain tolerance is extremely variable.
When conducting a health assessment that focuses on the pain experienced by an older client diagnosed with early dementia, the nurse will pay particular attention to which of the following?
a) Behavioral signs of pain demonstrated by the client
b) The client's verbal perception of pain
c) The client's comfort level regarding the discussion of pain
d) Cultural beliefs held by the client regarding the cause of pain
Behavioral signs of pain demonstrated by the client
The assessment of pain in older adults can range from relatively simple in a well-informed, alert, cognitively intact person with pain from a single source and no comorbidities (the simultaneous presence of two chronic diseases or conditions) to extraordinarily difficult in a confused person. When possible, a person's report of pain is the gold standard, but behavioral signs of pain should also be considered. This is especially true when the client's cognitive function is impaired. While the other options should be considered, the client's non verbal behaviors should be of particular interest to the nurse.
A 7 year old child had an emergency appendectomy during the night. When trying to assess their pain, the nurse should:
a) Consider their pulse and BP readings to be the most specific indicators of the amount of pain they are experiencing.
b) Show them a scale with faces of actual children and have them point to the picture that best describes how they are feeling.
c) Ask them to rate their pain on a scale of 0-10, with 0 =no pain, and 10=worse pain ever.
d) Try to distract them by blowing bubbles to minimize the use of opioids so that they don't become addicted to the narcotic.
Show them a scale with faces of actual children and have them point to the picture that best
describes how they are feeling.
Children do feel pain and have been shown to reliably and accurately report pain...With children 3-8 years of age, scales with faces of actual children or cartoon faces can be used to obtain a report of pain. Physiologic measures, such as heart rate, are convenient to measure but they are nonspecific. They may be a sign of anxiety and not pain. Distraction methods are good but medications should be used on an individual basis to match the analgesic agent with the level of pain.
When testing nociceptive stimuli to elicit a withdrawal reflex in the body, what stimuli are commonly used?
a) Water heated to 5°C above skin temperature
b) Skin temperature damp cotton ball
c) Pressure from a sharp object
d) Weak electrical current
Pressure from a sharp object
Stimuli used include pressure from a sharp object, strong electric current to the skin, or application of heat or cold of approximately 10°C above or below normal skin temperature. The other answers are incorrect.
Which of the following explains how nonsteroidal anti-inflammatory drugs (NSAIDs) control pain?
a) NSAIDs inhibit nociceptor sites from receiving signals.
b) NSAIDs allow thermal conduction of noxious stimuli.
c) NSAIDs block the enzyme that synthesizes prostaglandins.
d) NSAIDs Srelay mechanical signal transmission to receptors.
NSAIDs block the enzyme that synthesizes prostaglandins.
Nociceptors respond to three different types of stimuli: chemical, thermal, and mechanical. The chemical mediators such as bradykinin, histamine, serotonin, and potassium activate or sensitize nociceptors and continue the inflammatory response by releasing prostaglandins. Aspirin, ibuprofen, and other NSAIDs block inflammation by blocking the enzyme needed to synthesize prostaglandins.
A nurse assessing an older adult 3 hours postoperative notes guarding, grimacing, and stiff body movement when changing positions. The patient denies feeling pain. Which of the following responses will help the nurse best manage this patient's pain?
a) "I can come back in an hour to see if you are having any pain then."
b) "You seem to be uncomfortable. Pain is common with surgery. I can bring you pain medication."
c) "Are you afraid of becoming addicted if I give you any pain medication?"
d) "You just had surgery. Are you sure you are not having any pain?"
"You seem to be uncomfortable. Pain is common with surgery. I can bring you pain medication."
Older adults are often reluctant to report pain if it might be a bother to others, or they assume they should experience pain as a result of increased age and health issues. The nurse needs to be specific in asking questions about the pain an older adult is experiencing while using therapeutic communication skills. A closed-ended question will not provide as much data as more open-ended responses will.
Which of the following would be an example of a child born with congenital insensitivity to pain? A child that:
a) Cries every time the wind blows because it hurts their face and ears.
b) Develops pins-and-needles sensation after jumping out of a tree.
c) Skinned knee from a bike accident but only told parents when it started burning.
d) Fell off a skate board and fractured ankle but did not feel any pain, just noted swelling in foot.
Fell off a skate board and fractured ankle but did not feel any pain, just noted swelling in foot.
Analgesia is the absences of pain on noxious stimulation or the relief of pain without loss of consciousness.
-Congenital insensitivity is when the peripheral nerve defect apparently exists such that the transmission of painful nerve impulses does not result in perception of pain.
-Pens-and-needles sensation is called paresthesia.
-Burning sensations are usually associated with temperature (hyperthermia).
-Pain associated with wind (or any non-noxious stimuli) is called allodynia.
The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to non-medication centered therapy?
Tension-type headaches often are more responsive to nonpharmacologic techniques, such as biofeedback, massage, acupuncture, relaxation, imagery, and physical therapy, than other types of headache. For people with poor posture, a combination of range-of-motion exercises, relaxation, and posture improvement may be helpful. The other options are usually best treated with medications that focus on the cause of the pain
What can the nurse assume about a child's behavior when faced with the need to repeat a painful procedure?
a) Children act to avoid pain based on their memory of past painful events.
b) Pain causes similar responses in people regardless of their age.
c) A child will benefit from a matter-of-fact approach on the part of the nurse.
d) A child will resist any intervention that involves contact with their body.
Children act to avoid pain based on their memory of past painful events.
Children do feel pain and have been shown to reliably and accurately report pain. They also remember pain. This is evidenced in studies of children with cancer, whose distress during painful procedures increases over time without intervention, and in neonates in intensive care units, who demonstrate protective withdrawal responses to a heel stick after repeated episodes. The other options may not necessarily be true of most children.
With which of the following activities would a patient experiencing astereognosis need help?
a) Chewing and swallowing food
b) Identifying an object by touch
c) Maintaining bladder continence
d) Recognizing faces
Identifying an object by touch
Astereognosis is the inability to identify objects by touch. The patient would be able to describe the object's characteristics but not recognize it without visual cues.
The nurse is caring for a client who has returned from surgery after having a colon resection. What is the best method for the nurse to use when administering an opioid for pain in order to optimize pain control?
a) If the client is asleep, wait until she awakens to administer an opioid, because sleeping clients are not in pain.
b) Administer the opioid preemptively and before pain becomes extreme.
c) Administer the opioid if the client is becoming restless.
d) Administer the opioid each time the client asks for it.
Administer the opioid preemptively and before pain becomes extreme.
When giving opioids for relief of severe pain, such as that occurring after surgery, there is much evidence that opioids given routinely before the pain starts (preemptive analgesia) or becomes extreme are far more effective than those administered in a sporadic manner. People who are treated in this manner seem to require fewer doses and are able to resume regular activities sooner.
A 58-year-old woman comes to the clinic for evaluation of a sharp, intermittent, severe, stabbing facial pain that she describes as, "like an electric shock." The pain occurs only on one side of her face; it seems to be triggered when she chews, brushes her teeth, or sometimes when she merely touches her face. There is no numbness associated with the pain. What is most likely causing her pain?
a) Post-herpetic neuralgia
b) Trigeminal neuralgia
c) Complex regional pain syndrome
d) Migraine headache
Her symptoms are characteristic of trigeminal neuralgia, caused by damage to the fifth cranial nerve, which carries impulses of touch, pain, pressure, and temperature to the brain from the face and jaw.
Select the most appropriate pain assessment tool for a health care provider to use when caring for children between the ages of 3 to 7 years old.
a) Behavioral distress scale
b) Numeric pain scale
c) Faces pain scale
d) Word graph scale
Faces pain scale
Children ages 3 to 7 are more articulate in describing the intensity, location, and severity of their pain. There are self-report measures for children this age that include scales of faces of actual children or cartoon faces. Children 8 years of age or older can use numeric scales and word graphic scales.
An elderly client is experiencing pain and is concerned about how the pain will be managed. The nurse is aware that the first line of therapy for managing pain in the elderly would be:
Nonopioids are generally the first line of therapy for mild to moderate pain, and acetaminophen is usually the first choice because it is relatively safe for older adults. -Opioids are used for more severe pain and for palliative care.
-The other medications may be used for respiratory, gout and cardiac conditions
The nurse knows that chronic pain lacks which of the characteristic pain-related reactions?
a) Loss of appetite
b) Increased heart rate
c) Disturbed sleep patterns
Increased heart rate
Characteristics of chronic pain do not include autonomic responses like increased heart and respiratory rate.
-Loss of appetite, disturbed sleep patterns and depression are common among people dealing with chronic pain
A patient reports feeling a tingling sensation in the last two fingers of one hand after hitting the inner surface of the elbow on a desk. Which of the following is the cause of this symptom?
a) Hypersensitivity reaction to nerve injury
b) Paresthesia from temporary nerve compression
c) Hyperpathia from localized ischemia
d) Hypoesthesia from an inherited response
Paresthesia from temporary nerve compression
Temporary mild compression of a peripheral nerve can lead to paresthesia. -Hypersensitivity is an increased response to mild stimuli. -Hyperpathia is a syndrome in which pain is explosive after the raised sensory threshold is reached.
-Hypoesthesia is reduced or lost sensation of touch or temperature and may be an inherited trait.
Which of the following conditions or events commonly trigger neuropathic pain? Select all that apply.
a) Diabetes mellitus
e) Myocardial infarction
• Diabetes mellitus
Neuropathic pain arises from direct injury or dysfunction of the sensory axons of peripheral or central nerves.
-Nociceptive pain is the result of free nerve ending activation from a source outside of the nervous system that signals actual or impending tissue injury. -Diabetes mellitus and the herpes zoster virus that causes shingles both impair the nerves.
Which of the following factors are characteristic of acute pain? Select all that apply.
a) Loss of appetite
c) Mental depression
d) Pulse rate 120 beats/min
e) Shallow breathing, 26 breaths/min
• Pulse rate 120 beats/min
• Shallow breathing, 26 breaths/min
Acute pain generally is classified as being of short duration and arises from a specific pathological process that resolves. Acute pain may lead to tachycardia (abnormally rapid heart rate), increased sympathetic activity such as sweating, decreased mobility, and shallow breathing.
-Chronic pain lasts longer than expected and may have fluctuations. Signs of chronic pain include insomnia, depression, and loss of appetite.
A nurse is assessing the pain level of an adult with the use of a visual analog scale. Select the response that best indicates the client's rating using this tool.
a) "My pain level is moderate."
b) "My pain level is at 6 out of 10."
c) "My pain level falls above the 5-cm mark."
d) "My pain level looks like the smiley face."
"My pain level falls above the 5-cm mark."
A visual analog scale is a straight 10-cm-long line with a word description associated with the length. The pain can be quantified by measuring the line in centimeters to correspond with the pain. The other options do not refer to the visual analog scale.
A nurse is caring for a 60-year-old patient who experiences headaches several times a month. Which of the following additional characteristics would support a diagnosis of tension headaches? Select all that apply.
a) The pain occurs with the menstrual cycle.
b) The pain is described as dull and aching.
c) The headache occurs 15 or more days per month.
d) The headache is preceded by an aura.
e) The pain responds to NSAIDs.
• The pain is described as dull and aching.
• The pain responds to NSAIDs.
Tension headaches are commonly described as dull, diffuse aching that occurs in a hatband pattern around the head. There are no neurologic symptoms such as aura, nausea and vomiting, or visual changes. Tension headaches respond to treatment with over-the-counter agents such as aspirin and NSAIDs. Cluster headaches tend to affect people their twenties and thirties. The classic onset is sudden, with an intense increase of symptoms for the first 10-15 minutes. Attacks last from 15 minutes-e hours. The pain behind the eye radiates to the temple cheek and gum on the same side. The eyelid may droop or be edematous and the eye may tear or be reddened. Nasal congestion, rhinorrhea, and forehead or facial sweating may occur. There is no direct correlation with the menstrual cycle, nausea and vomiting, or an aura as may be the case with migraine.
Which of the following tactile receptors will signal continuous touch on the skin?
a) Meissner corpuscles
b) Ruffini's end organs
c) Merkel discs
d) Hair-follicle receptors
Merkel discs transmit an initial strong signal but decrease in strength, indicating continuous pressure on the skin. -Meissner corpuscles respond to light touch and low-frequency vibration.
-Ruffini's end organs are found in skin and deeper structures like joint capsules.
-Hair-follicle receptors are near the skin surface and respond to light touch.
An older adult tells the nurse, "My friend just developed shingles and has a lot of pain. Is there a way for me to protect myself from it?" Which of the following is an appropriate response from the nurse?
a) "Use antiviral drugs as soon as you are exposed."
b) "Avoid children and people with shingles."
c) "Apply a topical anesthetic agent."
d) "Get a Zostavax vaccination."
"Get a Zostavax vaccination."
-Herpes zoster is the viral infection caused by the varicella zoster virus. The first infection is called chicken pox. When there is a recurrence it is called shingles. The virus is believed to remain dormant in the nerve root until the patient has a decline in cellular immunity when the virus will replicate. The pain is often described as throbbing, burning, or stabbing. The best prevention is a vaccine for adults age 60 and older.
-Antivirals will lessen the severity at the time but will not prevent infection.
A client with a history of migraine headaches tells the physician that he or she usually experiences an aura before the onset of the headache. The client is most likely experiencing:
d) Visual disturbances
Migraine aura is associated with visual symptoms, including flickering lights, spots, or loss of vision; sensory symptoms, including feeling of pins or needles, or numbness; and speech disturbances or other neurologic symptoms.
A client is experiencing chest pain that radiates to the left arm and neck. The nurse would interpret this pain as:
Referred pain is pain that is perceived at a site different from its point of origin but innervated by the same spinal segment.
-Visceral pain originates in the visceral organs and is one of the most common pains produced by disease,
-cutaneous pain arises from superficial structures, and
- somatic pain originates in deep body structures
Nonopioids, such as acetaminophen (Tylenol), are the first line of therapy for managing mild to moderate pain in the elderly because they are safe.
Opiods are used for more severe pain and palliative care
Which tract in the spinal cord conducts the diffuse, dull, aching sensations that are associated with chronic and visceral pain?
a) Neospinothalamic tract
b) Paleospinothalamic tract
c) Anterolateral tract
d) Multisynaptic tract
The paleospinothalamic tract is a slower-conducting, multisynaptic tract concerned with the diffuse, dull, aching, and unpleasant sensations that commonly are associated with chronic and visceral pain. The other answers are incorrect.
A 25-year-old woman who works as an air-traffic controller presents with facial pain and severe headache. She reports that she sometimes feels the pain in her neck or ear and that it is particularly bad during very busy times at the airport. What is the most likely diagnosis?
a) Cluster headache
b) Migraine headache
c) Temporomandibular joint syndrome
d) Sinus headache
Temporomandibular joint syndrome
Temporomandibular joint syndrome causes pain that originates in the temporomandibular joint and is usually referred to the face, neck, or ear. Headache is also common. It is aggravated by jaw function and can be particularly severe in people under stress, especially if they grind their teeth.
A client is admitted to the acute care facility with severe pain in the abdomen related to inflammatory bowel disease. What type of pain will the nurse be administering medication to relieve?
a) Cutaneous pain
b) Visceral pain
c) Referred pain
d) Somatic pain
Visceral pain has its origin in the visceral organs (in the chest or abdomen) and is one of the most common pains produced by disease. -While similar to somatic pain in many ways, both the neurologic mechanisms and the perception of visceral pain differ from somatic pain.
-One of the most important differences between surface pain and visceral pain is the type of damage that causes pain.
-Strong contractions, distention, or ischemia affecting the walls of the viscera can induce severe pain.
A client is experiencing a cluster headache. The client would most likely manifest:
a) Severe pain behind the eye
b) Symptoms aggravated by physical activity
c) Sensitivity to light
d) Nausea with vomiting
Severe pain behind the eye
Symptoms of cluster headache include severe, unrelenting unilateral pain located in the orbital area. The pain radiates behind the eye to the ipsilateral trigeminal nerve. The client may also experience symptoms such as restlessness or agitation, conjunctival redness, lemical mediators directly stimulate noacrimation (the flow of tears), nasal congestion, rhinorrhea (runny nose), forehead and facial sweating, miosis (excessive constriction of the pupil of the eye), ptosis (drooping or falling of the upper eyelid), and eyelid edema. The other options are all associated with migraine headache.
A client who is being treated for chronic low back pain is using a TENS unit for relief of pain. The nurse is aware that the use of this device is considered what type of pain relief?
a) Stimulus-induced analgesia
d) A physical agent
Stimulus-induced analgesia is one of the oldest known methods of pain relief. Electrical stimulation methods of pain relief include TENS, electrical acupuncture, and neurostimulation.
-A physical agent would be the use of heat or cold.
-Distraction is a nonpharmacologic method of reduction of pain by distracting the patient from his pain. -Biofeedback is used to provide feedback to a person concerning the current status of some body function, temperature, temporal artery pulsation, blood pressure, or muscle tension.
A female client with bone metastases secondary to lung cancer is admitted for palliative radiation treatment and pain control. The client is presently experiencing pain that she rates at 9 out of 10. Which of the following non-pharmacological treatments is most likely to be a useful and appropriate supplement to pharmacological analgesia at this point?
a) Relaxation and distraction
b) Heat therapy
c) Teaching the client guided imagery and meditation
d) Initiating neurostimulation
Relaxation and distraction
-Given the client's high pain rating, initiating teaching around imagery and meditation is unlikely to be effective or appropriate. -Neurostimulation requires implantation and/or placement of internal components, -while heat is more likely to address superficial pain or pain caused by muscle tension. -Relaxation and distraction would be plausible treatment options for this client.
Which of the following skin receptors communicate the sensation of heavy and continuous touch and pressure?
a) Hair follicle end organ
b) Merkel disks
c) Meissner corpuscle
d) Ruffini's end organs
Ruffini's end organs
Ruffini's end organs are important for signaling continuous states of deformation, such as heavy and continuous touch and pressure since they are sensitive to skin stretch.
- Hair follicle end organs are rapidly adapting and detect movement on the surface of the body.
-Meissner corpuscles are sesitive to the movement of very light objects over the surface of the skin and low frequency vibration. -Merkel disks are responsible for giving steady-state signals that allow for continuous determination of touch against the skin.
A patient with diabetes mellitus has just undergone a right, below the knee amputation following gangrene infection. A few days post-op, the patient confides in the nurse that he still feels his right foot. Knowing the pathophysiologic principles behind this, the nurse can:
a) Call the physician and ask them for an order for a psychological consult.
b) Educate the patient that this area has an usually abnormal increase in sensitivity to sensation but that it will go away with time.
c) Explain that many amputees have this sensation and that one theory surmises the end of a regenerating nerve becomes trapped in the scar tissue of the amputation site.
d) Administer a psychotropic medication to help the patient cope with the loss of his leg.
Explain that many amputees have this sensation and that one theory surmises the end of a regenerating nerve becomes trapped in the scar tissue of the amputation site.
Multiple theories exist related to the causes of phantom limb pain. One rationale is that the end of the regenerating nerve becomes trapped in the scar tissue that forms a barrier to regenerating outgrowth of the axon. The usual treatment includes: the use of sympathetic blocks; TENS of the large myelinated afferents innervating the area; hypnosis; and, relaxation training.
It is often necessary to assess a client's pain. What factors would the nurse assess when assessing pain? (Select all that apply.)
a) Spinal tract involvement and radiation of pain
b) Severity and spinal reflex involvement of pain
c) Spinal reflex involvement and nature of pain
d) Location and radiation of pain
e) Nature and severity of pain
• Nature and severity of pain
• Location and radiation of pain
Assessment includes such things as the nature, severity, location, and radiation of the pain. Spinal reflex involvement and spinal tract involvement are not assessed when assessing pain.
Migraine headaches affect millions of people worldwide. What are first-line agents for the treatment of migraine headaches?
a) Sumatriptan and tramadol
b) Naproxen sodium and metoclopramide
c) Ondansetron and morphine
d) Caffeine and syrup of ipecac
Naproxen sodium and metoclopramide
Based on clinical trials, first-line agents include acetylsalicylic acid, combinations of acetaminophen, acetylsalicylic acid, and caffeine and nonsteroidal anti-inflammatory drug analgesics (e.g., naproxen sodium, ibuprofen), serotonin (5-HT1) receptor agonists (e.g., sumatriptan, naratriptan, rizatriptan, zolmitriptan), ergotamine derivatives (e.g., dihydroergotamine), and antiemetic medications (e.g., ondansetron, metoclopramide). -Morphine, tramadol, and syrup of ipecac are not first-line drugs in the treatment of migraine.
The health care provider is assessing the functional integrity of all spinal nerves utilizing a pinpoint pressed against the skin. A normal response would be interpreted as:
a) The withdrawal reflex is activated.
b) No response when the pin is pressed.
c) Saying "Ouch" when the pin is pressed.
d) Verifying the intensity of the pin's force of compression.
The withdrawal reflex is activated.
Observation of a normal withdrawal reflex rules out peripheral nerve disease, disorders of the dorsal root and ganglion, disease of the myoneural junction, and severe muscle diseases. Having no response is abnormal and may identify neurological damage. A verbal response is not a reflex response.
A nurse on a post-surgical unit is providing care for a 76 year-old female client who is two days post-hemiarthroplasty (hip replacement) and who states that her pain has been out of control for the last several hours, though she is not exhibiting signs of pain. Which of the following guidelines should the nurse use for short-term and long-term treatment of the client's pain?
a) Knowing that the client's self-report of pain is the most reliable indicator of pain.
b) Realizing that chronic pain is likely to require innovative and complex treatment.
c) Reconciling the client's need for opioid analgesics with the risk of addiction to these drugs.
d) Recognizing the client's pain is not likely self-limiting.
Knowing that the client's self-report of pain is the most reliable indicator of pain.
Clinically, the patient's self-report of pain is the most reliable indicator of pain. The risk of addiction to opioids is extremely low and since the client's pain is acute rather than chronic, it is likely self-limiting.
A nurse is treating a patient who has chronic daily headache (CDH). In addition to possible administration of medication, Which of the following instructions should be included? Select all that apply.
a) Implement a guided imagery program.
b) Consider acupuncture treatment.
c) Avoid exercise during the headache.
d) Reduce or eliminate caffeine .
e) Eat soft foods to reduce jaw activity.
• Reduce or eliminate caffeine .
• Implement a guided imagery program.
• Consider acupuncture treatment.
CDHs may have some symptoms similar to migraine or appear as a tension-type headache. Although the symptoms may vary, CDH can respond to nonpharmacological interventions such as biofeedback, massage, acupuncture, physical therapy, and guided imagery. Patients should regulate medication use because rebound headaches may occur with overuse of caffeine or migraine medications. CDH is not aggravated by exercise but may be relieved through the relaxation and distraction that activity provides. Soft foods may temporarily reduce pain from temporomandibular joint dysfunction but is not considered effective for CDH.
Which of the following factors influence pharmacologic choices for pain management in older adults? Select all that apply.
a) Risk for opioid addiction requires avoidance.
b) Organ function may be less efficient.
c) Polypharmacy may cause drug interactions.
d) Poor nutrition may lead to poor drug distribution.
• Poor nutrition may lead to poor drug distribution.
• Organ function may be less efficient.
• Polypharmacy may cause drug interactions.
Older adults may experience less effective organ function that interferes with medication function. Organ changes may include reduced drug absorption from the gastrointestinal tract, slower renal clearance, impaired liver function, and reduced blood flow. In addition, other illnesses requiring medication may create a situation of polypharmacy where multiple drugs interact to increase side effects. While acetaminophen is considered a first line drug for mild to moderate pain, opioids are generally used for several pain and palliative care and not restricted as a result of potential addiction. Addiction potential is reduced in any client with adequate pain control
Which of the following factors influence pharmacologic choices for pain management in children? Select all that apply.
a) Liver function is less efficient in an infant.
b) Premature infants may have reduced renal function.
c) Body size requires dosage adjustment.
d) Risk for opioid addiction requires avoidance.
e) The goal is to minimize side effects.
• Body size requires dosage adjustment.
• Liver function is less efficient in an infant.
• The goal is to minimize side effects.
• Premature infants may have reduced renal function.
Children experience pain at all ages and need appropriate intervention. Smaller body size and immature organs of excretion (liver and kidney) require careful calculations of dosage to be safe. Addiction potential is reduced in any patient with adequate pain control. Children should have minimal sedation when opioids are used. The goal of pain control is for the child to have minimal side effects from the pain control method.
When a peripheral nerve is irritated enough, it becomes hypersensitive to the noxious stimuli, which results in increased painfulness or hyperalgesia. Health care professionals recognize both primary and secondary forms of hyperalgesia. What is primary hyperalgesia?
a) Pain sensitivity that occurs in the viscera
b) Pain that occurs in the tissue surrounding an injury
c) Pain sensitivity that lasts longer than 1 week
d) Pain sensitivity that occurs directly in damaged tissues
Pain sensitivity that occurs directly in damaged tissues
Primary hyperalgesia describes pain sensitivity that occurs directly in damaged tissues. The other answers are incorrect.
The nurse instructs the certified nursing assistant (CNA) to be sure to turn the client every 2 hours in order to avoid pressure on the skin and avoid a pressure ulcer. What type of stimuli is the nurse encouraging the CNA to avoid?
a) Chemical stimuli
b) Pain stimuli
c) Mechanical stimuli
d) Thermal stimuli
Mechanical stimuli can arise from intense pressure applied to skin or from the violent contraction or extreme stretch of a muscle. -Chemical stimuli arise from a number of sources, including tissue trauma, ischemia, and inflammation.
-Thermal stimuli can result from extremes of heat or cold.
- Pain stimuli is not a stimuli.
The nurse on the pediatric unit is implementing distraction strategies for a child who is experiencing pain. The best strategies for the nurse to implement would be: Select all that apply.
Distraction helps children of any age divert their attention away from pain and onto other activities. Common attention diverters include bubbles, music, television, conversation, and games.
Which of the following hospital patients is most likely to be diagnosed with complex regional pain syndrome II (CRPS II)?
a) A man who has been admitted for treatment of continuing hyperalgesia after sustaining a nerve injury in a motor vehicle accident.
b) A woman who requires analgesia more than 3 months after an episode of shingles.
c) A female who has seemingly unprovoked attacks of pain that are accompanied by facial tics and spasms.
d) A male client with diabetes mellitus who requires analgesia prior to each dressing change on his chronic foot wound.
A man who has been admitted for treatment of continuing hyperalgesia after sustaining a nerve injury in a motor vehicle accident.
CRPS is marked the presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve with evidence at some time of edema, changes in skin blood flow, or abnormal sensorimotor activity in the region of pain. Pain related to shingles is an example of postherpetic neuralgia, while a need for analgesia prior to dressing changes would not indicated CRPS. Sudden attacks of pain accompanied by facial tics and spasms may be indicative of trigeminal neuralgia.
A student is feeling inside her backpack to find her mobile phone. There are a number of other items in the bag other than the phone. The nurse knows that which of the following terms best describes one's ability to sense of shape and size of an object in the absence of visualization?
The sense of shape and size of an object in the absence of visualization is known as stereognosis. -Astereognosis is a deficit whereby a person can correctly describe the object but does not recognize that it is a screwdriver.
-Modalities is a term used for qualitative, subjective distinctions between sensations such as touch, heat, and pain.
-Somesthesia describes most of the perceptive aspects of body sensation and requires the function of the parietal association cortex.
A nurse is caring for a 30-year-old patient who experiences intense one-sided headaches. Which of the following additional characteristics would support a diagnosis of cluster headaches? Select all that apply.
a) Pain occurring with the menstrual cycle
b) Nausea and vomiting
c) Headache preceded by an aura
d) Rhinorrhea on the same side as the headache
e) Pain behind the eye
• Rhinorrhea on the same side as the headache
• Pain behind the eye
Cluster headaches tend to affect people their twenties and thirties. The classic onset is sudden with an intense increase of symptoms for the first 10-15 minutes. Attacks last from 15 minutes to 3 hours. The pain behind the eye radiates to the temple cheek and gum on the same
A patient experiencing acute pain finds relief for several hours after the light touch of a soft-bristled brush has been applied over the area. Which of the following pain theories is best supported by this event?
The gate control theory proposes that you can block pain by sending a different signal such as cold or pressure that will close a gate in the spinal cord to prevent transmission of the pain signal.
-The specificity theory states that pain is experienced when specific sensors are stimulated.
- The pattern theory is a collection of theories that proposes that pain receptors share pathways with other senses, but that different activity patterns indicate whether there is pain or not.
-The neuromatrix theory joins multiple sources of input to aid in understanding the multiple dimensions of pain experience and behavior in chronic pain and other complex pain phenomena.
When giving pain medicine for acute pain, health care workers are reluctant to provide much needed opioid pain medicine. What is the major concern of health care workers when providing opioid pain relief?
a) Fear of adverse reactions
b) Fear of depressed respirations
c) Fear of oversedation
d) Fear of addiction
Fear of addiction
Part of the reluctance of health care workers to provide adequate relief for acute pain has been fear of addiction. However, addiction to opioid medications is thought to be virtually nonexistent when these drugs are prescribed for acute pain. The other answers are not the major concern
In assessing a patient with a cerebral infarct for sensation, which of the following results would a nurse find that would indicate that third-order neurons are intact?
b) Patellar reflex +2
c) Flaccid hemiparesis
d) Identifying a scent
Identifying a scent
First-order neurons transmit sensory information from the periphery to the central nervous system. -Second-order neurons communicate directly with the thalamus and work with the reflex networks and sensory pathways in the spinal cord.
-Third-order neurons relay information from the thalamus to the cerebral cortex.
-Level of consciousness does not indicate sensation.
A patient reports chronic pain. Assessment indicates it is located at the T6 dermatome. How will this information assist the nurse to develop an effective plan of care?
a) Biologic treatment is more effective than psychosocial.
b) Treatment can be tailored to the specific location.
c) Management can prevent referred pain.
d) Activities of daily living (ADLs) will be compromised.
Treatment can be tailored to the specific location.
A dermatome is the region of the body wall that is supplied by a single pair of dorsal root ganglia. Isolating the location of the pain allows for focused treatment.
-Pain commonly interferes with ADLs. Interventions are designed to minimize disruption of ADLs. -Management may reduce referred pain but may not alleviate them because the visceral and somatic neurons share the same dorsal horn projections.
-Clients with chronic pain benefit most from interventions that include physical, emotional, financial, and spiritual components of care.
-Using biologic treatments alone is less effective than the combination of all modalities.
The nurse is reviewing a food diary for a client who has migraine headaches. Which foods identified by the nurse may be triggers for the onset of a migraine headache? Select all that apply.
a) Tossed salad with cucumbers and tomatoes
b) Beef and broccoli from the Chinese restaurant
c) Hamburgers with bleu cheese crumbles
d) French fries
e) Chocolate candy bar
• Beef and broccoli from the Chinese restaurant
• Hamburgers with bleu cheese crumbles
• Chocolate candy bar
Dietary substances such as monosodium glutamate, aged cheese, and chocolate may precipitate migraine headaches. The actual triggers for migraine are the chemicals in the food, not allergens
Which of the following chemical mediators directly stimulate nociceptors to produce a pain response? Select all that apply.
Bradykinin, histamine, serotonin, and potassium all activate and also sensitize nociceptors.
- Adenosine triphosphate, acetylcholine, and platelets all can sensitize nociceptors through other agents such as prostaglandins but do not directly activate nociceptors.
While explaining the somatosensory cortex to a group of nursing students, the instructor asks, "What is involved in the final processing of somatosensory information?" The correct response includes: Select all that apply.
a) Autonomic nervous system
b) Interpretation of somatosensory stimuli
c) Pacinian corpuscle receptors
d) Discrimination of intensity
e) Full localization
• Full localization
• Discrimination of intensity
• Interpretation of somatosensory stimuli
The full localization, discrimination of the intensity, and interpretation of the meaning of the stimuli require processing by the somatosensory cortex.
-The anterolateral pathway gives off numerous branches that travel to the reticular formation of the brain stem;
-the branches provide the basis for increased wakefulness or awareness after strong somatosensory stimulation and for the generalized startle reaction that occurs with sudden and intense stimuli.
-They also stimulate the autonomic nervous system.
- Ruffini end organs are found in the skin and deeper structures and detect tissue vibration, heavy and continuous touch, and pressure. -Stretch-sensitive receptors in the skin (i.e., Ruffini endings, Pacinian corpuscles, and Merkel cells) also signal postural information.
A client has been seen in the clinic with severe recurring sharp, stabbing pain in the face that begins after brushing teeth or being exposed to cold air. The client states that he feels no numbness. What medication does the nurse anticipate educating this client regarding?
a) Acetaminophen (Tylenol)
b) Lopressor (Atenolol)
c) Carbamazepine (Tegretol)
d) Ibuprofen (Advil)
This client has trigeminal neuralgia or tic douloureux and the first line treatment for this disorder is with carbamazepine (Tegretol).
The client asks the health care provider to explain what the purpose is for the application of cold to a sprained ankle. The best response would be:
a) Cold provides alternating vasoconstriction and dilatation when applied locally.
b) Cold provides pain relief and suppresses the release of products from tissue damage.
c) Cold causes extravasation of blood into the damaged area.
d) Cold dilates the blood vessels and can be left on for as long as needed.
Cold provides pain relief and suppresses the release of products from tissue damage.
Cold prevents the release of products of tissue damage and provides pain relief (produces vasoconstriction at the site).
-Application of heat would cause blood vessels to dilate and more blood to be drawn to the local area.
Stretch-sensitive receptors in the skin (Ruffini end organs, Pacinian corpuscles, and Merkel cells) help signal postural information and are processed through the:
a) Third-order neurons
b) Anterolateral pathway
c) Posterior column of the spinal cord
d) Dorsal column-medial lemniscus pathway
Dorsal column-medial lemniscus pathway
There are two submodalities of proprioception: the stationary or static component (limb position sense) and the dynamic aspects of position sense (kinesthesia). Both of these depend on constant transmission of information to the CNS regarding the degree of angulation of all joints and the rate of change in angulation.
-In addition, stretch-sensitive receptors in the skin (Ruffini end organs, pacinian corpuscles, and Merkel cells) also signal postural information.
-Signals from these receptors are processed through the dorsal column-medial lemniscus pathway. In addition, stretch-sensitive receptors in the skin (Ruffini end organs, pacinian corpuscles, and Merkel cells) also signal postural information.
-Third-order neurons forward information from the thalamus to the somatosensory cortex.
-The anterolateral pathway crosses within the first few segments of entering the spinal cord and consists of bilateral, multisynaptic, slow-conducting tracts that transmit information such as pain, thermal sensations, crude touch, and pressure.
-Lesions affecting the posterior column of the spinal cord impair position sense.
A nurse is assessing the pain level of a client who has just had surgery. The client tells the nurse he does not think he should take any medication until the pain becomes extreme. The best response would be:
a) "The use of pain medication before the pain becomes extreme will help prevent hyperexcitability of the CNS."
b) "If you wait for a longer period of time, the pain will decrease in intensity."
c) "If you wait longer, you will receive stronger medication."
d) "Asking for pain medication with the early onset of pain will cause addiction."
"The use of pain medication before the pain becomes extreme will help prevent hyperexcitability of the CNS."
Usually, less medication is needed when the drug is given before the pain becomes severe and the pain pathways become sensitized.
-Addiction should not occur with short-term use.
-Pain from acute illness, trauma, surgery, or medical procedures should be aggressively managed, and preemptive analgesia provided before the pain becomes severe. Waiting longer periods of time may increase pain intensity and will not result in stronger medication.
A client is being taught how to use a TENS unit .The nurse determines that teaching was effective when the client states:
a) "Anytime that the setting on my TENS unit needs to be changed I will have to return it to the company and wait for them to deliver a new one."
b) "The TENS unit is the easiest and most cost-effective way to manage my pain at home."
c) "I will need to return to the doctor's office to have this TENS unit surgically implanted under my skin for the best pain relief."
d) "I should take my medication and apply the TENS unit to the painful area as soon as I feel the pain."
"I should take my medication and apply the TENS unit to the painful area as soon as I feel the pain."
Early intervention for pain relief is the best practice. The client should understand that he or she should take his or her pain medication and apply the TENS unit. TENS units are noninvasive and should be applied as soon as the client starts to perceive pain. It is often used in conjunction with pain-relieving medication.
The nurse is studying sensory systems. She understands that signal transduction of an impulse to the thalamus for processing is accomplished by which of the following?
a) Fourth-order neurons
b) First-order neurons
c) Second-order neurons
d) Third-order neurons
Second-order neurons communicate with various reflex networks and sensory pathways in the spinal cord and travel directly to the thalamus.
- First-order neurons transmit sensory information from the periphery to the CNS. -Third-order neurons relay information from the thalamus to the cerebral cortex.
While batting, a baseball player is struck in the ribs by a pitch. Place the following components of the player's pain pathway in the chronological order as they contribute to the player's sensation of pain. Use all the options.
a) Cerebral cortex
c) Dorsal root ganglion body
d) Dorsal root ganglion periphery
• Cerebral cortex
• Dorsal root ganglion body
• Dorsal root ganglion periphery
All somatosensory information from the limbs and trunk shares a common class of sensory neurons called dorsal root ganglion neurons. Somatosensory information from the face and cranial structures is transmitted by the trigeminal sensory neurons, which function in the same manner as the dorsal root ganglion neurons. The cell body of the dorsal root ganglion neuron, its peripheral branch (which innervates a small area of periphery), and its central axon (which projects to the CNS) communicate with the thalamus, which in turn communicates with the cerebral cortex using third order neurons.
Children feel pain just as much as adults do. What is the major principle in pain management in the pediatric population?
a) Treat pediatric pain the way the parents want it treate
b) Always use nonpharmacologic pain management before using pharmacologic pain management.
c) Treat on individual basis and match analgesic agent with cause and level of pain.
d) Base treatment of pain on gender and age group.
Treat on individual basis and match analgesic agent with cause and level of pain.
The overriding principle in all pediatric pain management is to treat each child's pain on an individual basis and to match the analgesic agent with the cause and the level of pain. The other answers are incorrect.
A client who has had a spinal injury now has sensory changes on the distal forearm and fourth and fifth fingers. The nurse can predict that this client has experienced an injury to the: Select all that apply.
a) Thoracic (T) 2 dorsal root
b) Cervical (C) 8
c) Cervical (C) 7
d) Thoracic (T) 1 dorsal root
• Cervical (C) 8
• Thoracic (T) 1 dorsal root
Dermatome maps are helpful in interpreting the level and extent of sensory deficits that are the result of segmental nerve and spinal cord damage. For example, on the basis of the dermatomal map, we can predict that sensory changes limited to the distal forearm and fourth and fifth fingers are the result of injury to the cervical (C) 8 and thoracic (T) 1 dorsal roots.
A mother is placing her child into the bathtub. The child immediately jumps out of the tub and begins to cry, stating their feet are 'burning'. The nurse in the emergency department knows that the child's response is based on which of the following pathophysiological principles listed below?
a) The thermal processing center is located on the rapid-conducting anterolateral system on the same side of the brain as the injury.
b) The tactile sensation occurs well in advance of the burning sensation. The local withdrawal reflex reacts first.
c) It takes a long time for thermal signals to be processed before the brain can send a signal through the spinal cord and tell the foot to withdraw.
d) Child react much quicker to contact with hot water than adults.
The tactile sensation occurs well in advance of the burning sensation. The local withdrawal reflex reacts first.
If a person places a foot in a tub of hot water, the tactile sensation occurs well in advance of the burning sensation. The foot has been removed from the hot water by the local withdrawal reflex well before the excessive heat is perceived by the forebrain. All other responses are incorrect.
A patient experiencing phantom limb pain after a traumatic amputation finds that opioids, biofeedback, a transcutaneous electrical nerve stimulation unit, and relaxation therapy are all needed to reduce the pain to a tolerable level. Which of the following pain theories is best supported by this event?
b) Gate control
The neuromatrix theory joins multiple sources of input to aid in understanding the multiple dimensions of pain experience and behavior in chronic pain and other complex pain phenomena such as phantom limb pain.
-The gate control theory proposes that you can block pain by sending a different signal such as cold or pressure that will close a gate in the spinal cord to prevent transmission of the pain signal.
-The specificity theory states that pain is experienced when specific sensors are stimulated.
-The pattern theory is a collection of theories that proposes that not only do pain receptors share pathways with other senses but that different activity patterns indicate whether pain is present or not.
If the patient's dorsal columns are not functioning, the nurse will observe which of the following responses during neuro testing, where the nurse asks the patient to close their eyes and then proceeds to touch corresponding parts of the body on each side simultaneously with two sharp points?
a) No response to two-point discrimination.
b) Heightened proprioception response.
c) Grimacing when body touched with sharp points.
d) Inability to identify which way their finger was moved during the test.
No response to two-point discrimination.
When comparing discriminative dorsal column-medial lemniscus pathway compared with anterolateral tactile pathways with testing (with eyes closed), gently brush the skin with cotton, touch an area with 1-2 sharp points, touch corresponding parts of the body on each side simultaneously or random sequence, and passively bend the person's finger one way and then another. If dorsal columns are not functioning, the tactile threshold 2-point discrimination and proprioception are missing and the person has difficulty discriminating which side of the body received stimulation.
A patient in pain uses analgesic medications and heat for pain control. Which of the following should the nurse teach the patient about the safe application of heat? Select all that apply.
a) Heat can loosen collagen fibers before therapy.
b) Use heat up to 115°F
c) Alternate heat and ice for acute injuries.
d) Avoid heat on areas with vascular impairment.
• Heat can loosen collagen fibers before therapy.
• Avoid heat on areas with vascular impairment.
Heat relieves pain by dilating blood vessels and increasing local blood flow. Heat therapy can be used to loosen collagen in ligaments, tendons, and joints for greater range of motion during physical therapy. -Heat should not be applied to an area with vascular impairment where increased metabolism may cause harm or in areas with loss of sensation because the patient could experience tissue damage without being aware of it.
-Heat greater than 113°F can damage tissue and should be avoided. Acute injuries should be treated with cold therapy, not heat
Which of the following types of pain is characterized by severe, brief, often repetitive pain?
b) Neuropathic pain
c) Tic douloureux
d) Postherpetic neuralgia
Neuralgia is characterized by severe, brief, often repetitive attacks of lightning-like or throbbing pain. Neuropathic pain is widespread and is not otherwise explainable, burning pain and attacks of pain that occur without seeming provocation.
-Tic douloureux is characterized by paroxysmal attacks of stabbing pain that usually are limited to the unilateral sensory distribution of one or more branches of the trigeminal nerve, most often the maxillary or mandibular divisions.
- Postherpetic neuralgia affects sensory ganglia, and the peripheral nerve to the skin of the corresponding dermatomes cause a unilateral localized vesicular eruption and abnormally exaggerated subjective response to pain.
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