Wong’s Nursing Care of Infants and Children 9th Edition by Marilyn J. Hockenberry, David Wilson – Test Bank

Wong’s Nursing Care of Infants and Children 9th Edition by Marilyn J. Hockenberry, David Wilson – Test Bank

Hockenberry: Wong’s Nursing Care of Infants and Children,
9th Edition

Chapter 07: Pain Assessment and Management in Children

Test Bank

MULTIPLE CHOICE

1. Which of the following is the most consistent and commonly used data for assessment of pain in infants?
a. Self-report
b. Behavioral
c. Physiologic
d. Parental report

ANS: B
Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate they are in pain. Infants are not able to self-report. Physiologic measures are not able to distinguish between physical responses to pain and to other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.

DIF: Cognitive Level: Comprehension REF: p. 222
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity: Basic Care and Comfort

2. Children as young as age 3 years can use facial scales for discrimination. Suggested anchor words for the preschool age-group include:
a. “No hurt.”
b. “Red pain.”
c. “Zero hurt.”
d. “Least pain.”

ANS: A
“No hurt” is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age-group. First the child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age-group. “Least pain” is less concrete than “no hurt.”

DIF: Cognitive Level: Application REF: p. 185
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity: Basic Care and Comfort

3. Which of the following 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. Scale can be used with most children as young as 3 years.
c. Scale is not appropriate for use with adolescents.
d. FACES scale is useful in pain assessment but not as accurate as physiologic responses.

ANS: B
The FACES scale is validated for use with children ages 3 years and older. Children point to the face that best describes their level of pain. The scale can be used through adulthood. The child’s estimate of the pain should be used. The physiologic measures may not reflect more long-term pain.

DIF: Cognitive Level: Application REF: p. 182
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity: Basic Care and Comfort

4. Nonpharmacologic strategies for pain management:
a. may reduce pain perception.
b. usually take too long to implement.
c. make pharmacologic strategies unnecessary.
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. The nonpharmacologic strategy should be matched with the child’s pain severity and taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child’s experience with mild pain, but the child will still know the discomfort was present.

DIF: Cognitive Level: Analysis REF: p. 194 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity: Basic Care and Comfort

5. Which of the following nonpharmacologic interventions appears to be effective in decreasing neonatal procedural pain?
a. Tactile stimulation
b. Commercial warm packs
c. Doing procedure during infant sleep
d. Oral sucrose and nonnutritive sucking

ANS: D
Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles.

DIF: Cognitive Level: Analysis REF: p. 194 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity: Basic Care and Comfort

6. A child age 6 years has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. Your explanation to the parents should include:
a. the child will continue to sleep and be pain free.
b. parents cannot administer additional medication with the button.
c. the pump can deliver baseline and bolus dosages.
d. there is a high risk of overdose so monitoring is done every 15 minutes.

ANS: C
The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a child the age of 6, the parents and nurse must assess the child to ensure that adequate medication is being given, since the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

DIF: Cognitive Level: Comprehension REF: p. 204
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

7. Which of the following drugs 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 in parenteral form is is not used in a PCA but is given po or IV for pain in the infant. Meperidine is not used for continuous and extended pain relief.

DIF: Cognitive Level: Analysis REF: p. 199
TOP: Nursing Process: Implementation
MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

8. A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning the care, the nurse recognizes that the indicated action is to:
a. give only an opioid analgesic at this time.
b. increase 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 she or he can have pain medications.

ANS: C
For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive. It focuses the child’s attention on how long he will need to wait for pain relief.

DIF: Cognitive Level: Analysis REF: p. 207 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

9. The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurse’s response should be based on knowledge that preterm infants:
a. may react to painful stimuli but are unable to remember the pain experience.
b. perceive and react to pain in much the same manner as children and adults.
c. do not have the cortical and subcortical centers that are needed for pain perception.
d. lack neurochemical systems associated with pain transmission and modulation.

ANS: B
Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as children and adults. Preterm infants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response.

DIF: Cognitive Level: Analysis REF: p. 188
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

10. A preterm infant has just been admitted to the neonatal intensive care unit. The infant’s parents ask the nurse about anesthesia and analgesia when painful procedures are necessary. The nurse’s explanation should be based on knowledge that:
a. nerve pathways of neonates are not sufficiently myelinated to transmit painful stimuli.
b. the risks accompanying anesthesia and analgesia are too great to justify any possible benefit of pain relief.
c. neonates do not possess sufficiently integrated cortical function to interpret or recall pain experiences.
d. pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates.

ANS: D
Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response. The pathways are sufficiently myelinated to transmit the painful stimuli and produce the pain response. Local and systemic pharmacologic agents are available to permit anesthesia and analgesia for neonates.

DIF: Cognitive Level: Analysis REF: p. 188
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

11. A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is to:
a. administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure.
b. use a combination of fentanyl and midazolam for conscious sedation.
c. apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure.
d. apply transdermal fentanyl (Duragesic) “patch” immediately before the procedure.

ANS: B
A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after application to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For this procedure, systemic analgesia is required. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.

DIF: Cognitive Level: Analysis REF: p. 221
TOP: Nursing Process: Implementation
MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

12. A significant, common side effect that occurs with opioid administration is:
a. euphoria.
b. diuresis.
c. constipation.
d. allergic reactions.

ANS: C
Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus.

DIF: Cognitive Level: Knowledge REF: p. 211 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

13. The nurse is caring for a child receiving continuous IV low dose infusion of 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 first to do which of the following?
a. Administer naloxone (Narcan).
b. Discontinue intravenous 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.

DIF: Cognitive Level: Analysis REF: p. 211
TOP: Nursing Process: Implementation
MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

14. The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which of the following statements by one of the participants would indicate a correct understanding of the teaching?
a. “With minimal sedation the patient’s respiratory efforts are affected and cognitive function is not impaired.”
b. “With general anesthesia the patient’s airway cannot be maintained but cardiovascular function is maintained.”
c. “During deep sedation the patient can be easily aroused by loud verbal commands and tactile stimulation.”
d. “During moderate sedation the patient responds to verbal commands but may not respond to light tactile stimulation.”

ANS: D
When discussing levels of sedation, the participants should understand that during moderate sedation the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation the patient responds to verbal commands and may have impaired cognitive function; the respiratory and cardiovascular systems are unaffected. In deep sedation the patient cannot be easily aroused except by painful stimuli, the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained. With general anesthesia the patient loses consciousness and cannot be aroused with painful stimuli, the airway cannot be maintained, and ventilation is impaired; cardiovascular function may or may not be impaired.

DIF: Cognitive Level: Analysis REF: p. 216
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

MULTIPLE RESPONSE

1. Which of the following are components of the FLACC scale? Select all that apply.
a. Color
b. Capillary refill time
c. Leg position
d. Facial expression
e. Activity

ANS: C, D, E
Facial expression, consolability, cry, activity, and leg position are components of the FLACC scale. Color is a component of the Apgar scoring system. Capillary refill time is a physiologic measure that is not a component of the FLACC.

DIF: Cognitive Level: Comprehension REF: p. 180
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity: Basic Care and Comfort

2. The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which of the following is a component of this tool? Select all that apply.
a. Color
b. Moro reflex
c. Oxygen saturation
d. Posture of arms and legs
e. Sleeplessness
f. Facial expression

ANS: C, E, F
Need for increased oxygen, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale.

DIF: Cognitive Level: Application REF: p. 188
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity: Basic Care and Comfort