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Chapter 07: Drugs for Pain Control
Workman & LaCharity: Understanding Pharmacology: Essentials for Medication
Safety, 2nd Edition
MULTIPLE CHOICE
BASIC CONCEPTS
6. Which schedule of controlled substance has the lowest potential for addiction?
a. Schedule II
b. Schedule III
c. Schedule IV
d. Schedule V
ANS: D
In the United States any drug that contains ingredients known to be addictive is classified by
the federal government as a controlled substance and is regulated by the Federal Controlled
Substances Act of 1970. This act classifies controlled substances into five schedules based on
how likely they are to result in addiction. The drugs most likely to lead to addiction are in
schedule I. Those with the least potential for addiction are in schedule V.
9. What is the most common side effect of an opioid used for 5 days?
a. Addiction
b. Hallucinations
c. Constipation
d. Excessive thirst
ANS: C
The most common side effect of opioids is constipation because these drugs slow intestinal
movement. Most patients who are on opioids for 2 or more days experience constipation. Ask
patients who are prescribed opioids about constipation on a daily basis. Be sure to administer
any prescribed stool softeners or laxatives.
12. A patient who is paralyzed from the waist down as a result of an injury that completely
severed the spinal cord has an open wound on the right heel. Why is this patient unaware of
any pain caused from this wound?
a. The nociceptors in the heel are no longer stimulated when injury occurs.
b. The patient has become completely desensitized to this type of chronic pain.
c. The severed spinal cord prevents the sensation of pain from reaching the brain.
d. The spinal cord injury results in chronic pain that can mask any acute pain
sensation.
ANS: C
Pain is perceived in the brain, not in the area of tissue injury. When the nociceptors are
stimulated by tissue damage, the impulse must be transmitted to the brain before it can be
“felt” as pain. With a completely severed spinal cord, the pain impulses are not transmitted to
the brain.
13. A patient with arthritis of the left knee reports pain extending from the knee half-way down
the lower leg. What type of pain is this patient perceiving?
a. Localized
b. Referred
c. Radiating
d. Phantom
ANS: C
Radiating pain may be felt all around and extending from the damaged area causing the pain.
14. Pain is considered to be the “fifth vital sign.” How does this principle affect patient care?
a. It ensures that pain assessment occurs on a regular basis for all patients.
b. It helps health care workers understand that experiencing pain can change heart
rate and respiratory rate.
c. It helps health care workers to ensure that vital organ function is adequate before
administering drugs to reduce pain.
d. It encourages health care providers to assess two parameters during patient contact
to improve time management.
ANS: A
Pain is common in patients and undertreated pain remains a major yet avoidable health
problem. More frequent and more accurate assessment can improve pain management.
Making pain assessment the “fifth vital sign” assists health care workers to both recognize the
presence of pain and see how the patient responds to drugs and other interventions. These
actions increase the likelihood of appropriate pain management.
DIF: Cognitive Level: Remembering REF: p. 104
16. How do morphine and other opioid pain medications relieve a patient’s pain?
a. They reduce tissue damage and alter the physical problems causing the pain.
b. They bind to opioid receptors in the central nervous system and alter the
perception of pain.
c. They inhibit the generation of impulses along sensory nerve tracts and alter pain
transmission.
d. They redirect substance P release from nociceptors and alter the amount of
neurotransmitters reaching the brain.
ANS: B
Morphine and other opioid agonists do nothing to change the cause or transmission of pain.
They bind to naturally occurring opioid receptor sites and alter a patient’s perception of the
painful experience.
18. A child who is taking gabapentin (Neurontin) for pain control has begun demonstrating all of
the following behaviors. Which behavior represents a common side effect of this drug?
a. Fighting at school
b. Difficulty sleeping
c. Wetting the bed three to four nights per week
d. Crying more frequently for no apparent reason
ANS: A
Gabapentin is an anticonvulsant drug that can reduce certain types of pain. Children taking
gabapentin often demonstrate an increase in aggressive behavior.
19. Which term best describes what occurs when long-term opioid is suddenly stopped?
a. Addiction
b. Tolerance
c. Withdrawal
d. Dependence
ANS: C
Withdrawal is the occurrence of autonomic nervous system symptoms when long-term opioid
therapy is stopped suddenly after physical dependence is present. Symptoms include nausea,
vomiting, abdominal cramping, sweating, delirium, and seizures.
ADVANCED CONCEPTS
20. Which statement by a patient indicates the need for more teaching about pain and pain
control?
a. “If my pain interferes with my usual activities, I will take medication for it.”
b. “There is no reason for me to take drugs for pain; after all, you can’t cure old age.”
c. “I don’t mind taking pain drugs for my sprained ankle because I know it won’t hurt
this way forever.”
d. “I will take enough pain medication to make me comfortable without making me
too sleepy.”
ANS: B
One cause of underreporting pain and undertreating it is that many patients and health care
providers believe that pain is a normal part of aging. Pain may occur more frequently among
older adults, but is never considered “normal.” Patients of any age with pain for any reason
deserve to have their pain reduced to a manageable level.
21. What is the best way for you to determine a patient’s need for pain medication on the second
day after an abdominal laparotomy?
a. Check when the patient last received medication for pain.
b. Assess the patient’s facial expression and vital signs.
c. Consider the patient’s age and ethnicity.
d. Ask the patient to rate his or her pain.
ANS: D
Pain experience and pain tolerance are very personal. True assessment of a patient’s
discomfort cannot be determined by and should not be based on the patient’s behaviors or
changes in vital signs. Nor can it be based on how recently the patient received a drug for
pain. The only way to know is to ask the patient to rate the pain.
22. After surgery, a patient expresses the fear of becoming addicted to the opioid analgesic that
has been prescribed for pain. What is your best response?
a. “Opioid-based drugs are not addictive.”
b. “Have you or anyone in your family ever been addicted to drugs?”
c. “When opioid drugs are taken for acute pain, they are rarely addictive.”
d. “If you take the medication no more frequently than every 4 hours, it is not
possible for you to become addicted.”
ANS: C
The fear of addiction to opioids is one cause of poorly treated pain. Remind the patient that
addiction will not occur if the drugs are taken to relieve pain. Pain after surgery is acute and
temporary pain. The use of opioid drugs, when used for relief of acute pain, even in high
doses, rarely results in addiction.
23. You are assigned to care for a patient with chronic low back pain. What adjustment in pain
management do you expect to make?
a. Encouraging the patient to hold off taking a pain drug as long as possible to reduce
the potential for addiction.
b. Relying on patient report of pain rather than on changes in heart rate, blood
pressure, and pulse rate.
c. Keeping the environment as quiet as possible to avoid distracting or irritating the
patient.
d. Using nondrug measures in place of analgesics to relieve the patient’s pain.
ANS: B
Adaptation to the presence of chronic pain is physiologic, not psychologic. Thus the usual
alterations in physiologic parameters when acute pain is present do not accompany chronic
pain.
24. You check a patient for pain relief 1 hour after administering 15 mg of morphine
intramuscularly. The patient is sleeping and has a respiratory rate of 10 breaths/min. What is
your best first action?
a. Attempt to arouse the patient by calling his or her name and lightly shaking the
arm.
b. Administer oxygen by mask or nasal cannula and notify the prescriber.
c. Check the patient’s oxygen saturation and raise the head of the bed.
d. Document the finding as the only action.
ANS: A
Many patients experience some degree of respiratory depression with opioid analgesics. If the
patient can be aroused with minimally intrusive techniques and the respiratory rate increases
spontaneously, no further intervention is required.
25. You prepare to give a patient the next scheduled dose of an opioid analgesic. The patient
arouses easily but the respiratory rate remains at 10 breaths/min. What is your best first
action?
a. Hold the dose and notify the prescriber.
b. Hold the dose and apply oxygen by mask or nasal cannula.
c. Check the patient’s oxygen saturation and ask about his or her pain level.
d. Call the Rapid Response Team and prepare to administer the prescribed opioid
antagonist.
ANS: C
Many people experience mild respiratory depression with opioid analgesics. If the patient is
easily arousable and the oxygen saturation is at normal levels, it is not necessary to apply
oxygen, call the Rapid Response Team, or prepare to administer an opioid antagonist. If the
patient’s oxygen saturation level is acceptable and he or she is in pain, it is alright to give the
next scheduled opioid dose. Checking the patient’s normal respiratory rate is also a good idea.
Most people have a usual respiratory rate that is at least 12 breaths/min, but some patients
may have a usual rate of only 10 breaths/min. Although this is not a customary response and
you should document it in the patient care notes, check other indicators of breathing adequacy
before notifying the prescriber.
26. A patient taking oxycodone with acetaminophen (Percocet) for pain at home 3 days after
fracturing an ankle reports constipation and continuing moderate to severe pain that is relieved
by the prescribed drug. What is your best advice?
a. “Either increase the time between drug doses or take only half the dose at each
scheduled time.”
b. “Stop taking the Percocet and switch to acetaminophen alone.”
c. “Wrap your foot tightly and walk for at least 30 minutes daily.”
d. “Drink at least 3 L of fluid daily and increase fiber intake.”
ANS: D
This patient still needs the Percocet. Most patients taking opioids for 2 days or longer have
constipation. Urge the patient to drink plenty of fluids. Increasing fiber intake, either with
food containing fiber or with over-the-counter fiber supplements, can help reduce
constipation. Although increasing activity can help reduce constipation, walking for 30
minutes with a fractured ankle is not permitted at this time.
27. An older adult is taking an oral opioid drug at home for pain control. Which precaution to
prevent injury is important for you to teach this patient?
a. “Increase room lighting to reduce the risk for tripping.”
b. “Sleep in a sitting position to reduce respiratory problems.”
c. “Drink at least 3 L of fluids daily to reduce constipation.”
d. “Avoid drinks containing caffeine to prevent inactivating the drug.”
ANS: A
In addition to the usual side effects and adverse effect of opioids, an older adult is at risk for
low vision. The pupil of the older adult does not dilate fully and less light enters the eye,
reducing vision. When the older patient takes an opioid drug, the pupil is even smaller than
usual, reducing vision even more. This problem increases the older patient’s risk for tripping
over objects and falling.
28. What is the most important question to ask before administering the first dose of celecoxib
(Celebrex) to a patient?
a. “Do you floss your teeth daily?”
b. “Are you allergic to sulfa drugs?”
c. “Do you have diabetes mellitus?”
d. “Have you ever had glaucoma?”
ANS: B
Celecoxib is similar to the class of antibiotics known as “sulfa drugs.” An allergic reaction to
celecoxib is more likely if the patient is also allergic to sulfa drugs.
29. A patient taking warfarin (Coumadin) has mild to moderate pain after exercising. Which
over-the-counter pain reliever should you recommend?
a. Aspirin (Bufferin)
b. Ibuprofen (Advil)
c. Naproxen (Aleve)
d. Acetaminophen (Tylenol)
ANS: D
Only acetaminophen does not interfere with blood clotting. The other drugs do interfere with
blood clotting, and so does warfarin. Taking warfarin with any other drug that interferes with
blood clotting places the patient at extreme risk for excessive bleeding and brain hemorrhage.
30. A patient is taking acetaminophen (Tylenol) for mild headache pain. Which precaution is
most important for you to teach the patient?
a. “Avoid alcoholic beverages while taking this drug.”
b. “Avoid coffee and other caffeinated drinks while taking this drug.”
c. “If any decrease in vision occurs, stop the drug and notify your prescriber
immediately.”
d. “Do not drive or operate dangerous machinery until you know how this drug
affects you.”
ANS: A
Acetaminophen can cause severe liver damage and even liver failure when taken at high doses
or too often. This adverse reaction is much more likely to occur in people who drink alcoholic
beverages while on acetaminophen therapy.
DIF: Cognitive Level: Applying or Higher REF: p. 111
31. You note all of the following changes in the last week in a 72-year-old nursing home patient
taking nortriptyline (Pamelor) for chronic pain. For which problem do you immediately notify
the prescriber?
a. Heart rate decreased from 80 to 72 beats/min.
b. Respiratory rate decreased from 20 to 16 breaths/min.
c. Weight increased from 128 to 137 lb.
d. Morning blood glucose increased from 86 to 94 mg/dL.
ANS: C
Nortriptyline is an antidepressant. These drugs can make heat failure worse and can cause
urinary retention. Fluid retention with weight gain is a symptom of worsening heart failure. A
weight gain of 9 lb in a week is significant and an indicator of rapidly worsening heart failure.
32. Eight weeks after surgery, a patient without pain still takes oxycodone and acetaminophen
(Percocet) four to six times a day. What phenomenon do you recognize?
a. Addiction
b. Dependence
c. Withdrawal
d. Tolerance
ANS: B
Dependence is described as physical changes in autonomic nervous system function that can
occur when opioids are used long term and are not needed for pain control.
33. A patient tells you that the usual dose of an opioid drug for cancer pain no longer relieves the
pain. What is your best response?
a. “We have to be careful about increasing opioid drug dosages to prevent drug
addiction.”
b. “You may be developing dependence on the drug and that is why it no longer
relieves your pain.”
c. “Your body may be adjusting to the drug, eliminating it more rapidly, and thus you
will need a higher dose to achieve pain relief.”
d. “The danger of increasing your opioid drug dosage is that you may experience
respiratory failure.”
ANS: C
An issue that can occur with longer-term opioid use is drug tolerance. Tolerance is the
adjustment of the body to long-term opioid use that increases the rate of drug elimination and
reduces the main effect (pain relief) and side effects of the drug. It occurs with anyone who is
taking opioids for a long period of time. More drug is needed to achieve the same degree of
pain relief.
35. A patient is receiving morphine (MS Contin) for severe cancer pain. His wife states that he
has difficulty swallowing and asks if the tablets can be crushed and given with applesauce or
pudding. What is your best response?
a. “That is an excellent solution and will make it much easier for him to swallow his
pain medicine.”
b. “It might be best if we talk with the prescriber about having a feeding tube placed
for medication administration.”
c. “You can dissolve the tablets in water then give the drug to your husband mixed
with juice.”
d. “I will contact the prescriber about this because your husband may need to be
prescribed a different form of morphine for his pain.”
ANS: D
MS Contin is an extended release tablet so crushing or dissolving it can cause a drug overdose
from releasing too much drug at a time. The best action is to contact the prescriber with the
information about the patient’s difficulty swallowing because a different form or morphine or
a different drug may be needed to control the pain. Teach patients and their families to take an
extended release (ER) form of an oral opioid drug by swallowing the capsule or tablet whole
because chewing it or opening the capsule allows too much of the drug to be absorbed all at
once and an overdose can occur.
36. Which key point should you teach a pregnant woman who is prescribed opioids drugs during
pregnancy?
a. Your child may become addicted to opioids and go through withdrawal after birth.
b. These drugs do not cross the placenta so are safe to use during pregnancy.
c. Some opioids have been found to cause birth defects in animal studies.
d. Opioids are not present in breast milk so it is safe to breastfeed.
ANS: A
Opioids may be prescribed to women during pregnancy. These drugs do cross the placenta
and enter the fetus. The fetus can become addicted to opioids and go through withdrawal after
birth. Opioids also cross into breast milk.
37. For which opioid pain drug order should you contact and question the prescriber?
a. Adult male, hydromorphone (Dilaudid) 4 mg orally every 4 hours
b. Older adult, meperidine (Demerol) 50 mg IM every 3 hours
c. Child, codeine 0.5 mg/kg orally every 6 hours
d. Adult women, hydrocodone with acetaminophen (Vicodin) 5 mg orally every 6
hours
ANS: B
Opioids, especially meperidine (Demerol), can make the chest muscles of older adults tighter,
which makes breathing and coughing more difficult. Thus the risk for pneumonia and hypoxia
is greater for them. Check the respiratory rate and depth as well as the oxygen saturation at
least every 2 hours. In addition, meperidine causes the buildup of a toxic metabolite in older
adults that can result in seizures. Avoid the use of meperidine in older adults.
38. After receiving the first dose of an opioid drug, a patient is sleeping and has a respiratory rate
of less than 8 per minute. When called by name the patient does not respond. What is your
next best action?
a. Place an ice cube on his or her forehead.
b. Firmly shake his or her leg or arm.
c. Apply pressure to his or her nail bed.
d. Squeeze his or her trapezius muscle.
ANS: B
When the patient is receiving an opioid for the first time or when the drug dosage has been
increased, if the respiratory rate is 8 or less and the patient is sleeping, try to wake him or her.
First call the patient’s name. If there is no response, gently shake his or her arm or leg. Shake
more firmly if needed. If the patient does not respond to these actions, use a slightly stronger
trigger (without using enough force to cause harm) such as squeezing the trapezius muscle
(located at the angle of the shoulder and neck muscle) or applying pressure to the nail bed.
39. The patient who received a first dose of an opioid drug is not arousable and has an oxygen
saturation of 88% (five percentage points lower than his or her normal saturation) even when
fully awake. What is your best next action?
a. Wait 2 minutes and recheck respiratory rate and oxygen saturation.
b. Shake the patient firmly and keep trying to arouse him or her.
c. Notify respiratory therapy to draw an arterial blood gas.
d. Call for help and apply supplemental oxygen.
ANS: D
If the patient cannot be aroused, immediately call for help. If the patient’s oxygen saturation is
below 95% or is five percentage points lower than his or her normal saturation, arouse the
patient and check the saturation when fully awake. If the saturation does not improve when
fully awake, apply supplemental oxygen and notify the charge nurse or prescriber.
MULTIPLE RESPONSE
BASIC CONCEPTS
1. Which side effects are commonly associated with most nonsteroidal anti-inflammatory drugs
(NSAIDs)? (select all that apply.)
a. Bleeding
b. Constipation
c. Drowsiness
d. Dry mouth
e. Gastrointestinal ulcers
f. Hypertension
g. Memory loss (temporary)
ANS: A, E, F
NSAIDs disrupt platelet action and reduce clotting, which increases the risk for bleeding in
response to minor trauma. NSAIDs also reduce the thick, gel-like coating of the stomach,
allowing normal stomach acids to irritate the stomach lining and form ulcers. Finally, NSAIDs
cause the kidneys to retain more sodium and water. These enter the bloodstream and raise
blood pressure.
COMPLETION
ADVANCED CONCEPTS
ANS:
2.2
1 kg = 2.2 lb. The child’s weight in kilogram is 64/2.2 or 29.09 kg (round down to 29).
29 75 mcg = 2175 mcg or 2.175 mL round up to 2.2 mL.
Sillä paljon tulee uusia ruplia. Kaikenlaisia ruplia tulee. Ynnä muita
ruplia.
(1922.)
ALKAVAT LEIPÄÄNTYÄ
(1922.)
VIRALLISIA TIETOJA KARHUJEN,
SUSIEN JA KETTUJEN
KUVERNEMENTISTA
(1923.)
PÄÄSI PERILLE, VAIKKA VÄHÄN
VIIPYIKIN MATKALLA
(1923.)
IHMEELLINEN, MUTTA TOSI
KERTOMUS KOLMESTA AHKERASTA
KOMMUNISTISTA
Eikä sillä hyvä, että nämä kolme miestä raatavat kuin turkaset
kaikki kahdeksantuntiset työpäivät umpeensa lautatarhassa, niin että
lankut ja laudat läiskivät. Kun he kuulivat, että eräällä toisella yhtiöllä
oli siinä lähistöllä propsien lastausta, niin juoksivat he propsipösöjen
luo ja tarjoutuivat ottamaan ylitöikseen myöskin propsien lastauksen.
(1923.)
OPPIPAS RYSSÄ HIIHTÄMÄÄN!
Mutta tuli neuvostovalta, Lenin tuli ja Trotski tuli, ja juks kaks ryssä
hiihdon oppimaksi.
*****
Ryssä on hauska.
(1923.)
TAKSOITUSLAUTAKUNNAN TÄYSI-
ISTUNNOSSA SAVONMAASSA