Chapter 29: Pain Management in Patients with Cancer Test Bank

MULTIPLE CHOICE 1. A patient who has cancer reports pain as burning and shooting alternating with feelings of

numbness and coldness. The nurse will contact the provider to discuss the use of which medication? a Acetaminophen
. b Ibuprofen . c Imipramine (Tofranil) . d Oxycodone (OxyContin) .

ANS: C

This patient is describing neuropathic pain, which results from injury to peripheral nerves. This type of pain responds poorly to opioid analgesics but does respond to adjuvant analgesics, which include antidepressants such as imipramine. Acetaminophen and ibuprofen are used for mild nociceptive pain, and oxycodone is used for more severe nociceptive pain.
DIF: Cognitive Level: Application REF: Nociceptive Pain Versus Neuropathic Pain TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 2. A patient with bone cancer has recently undergone chemotherapy and radiation therapy to

reduce the size of the tumor. The patient is taking a large dose of an opioid analgesic, along with acetaminophen and an antidepressant. The nursing student caring for this patient is concerned that the patient is showing drug-seeking behaviors, because the individual requested an increased dose of the opioid. The student discusses this concern with the nurse. Which statement by the student indicates a need for further teaching? a It would probably help this patient more to give a larger antidepressant dose.
. b . c . d .

Patients often need more drug to achieve the same effect. Radiation and chemotherapy can damage bone tissue and cause increased pain. The patients description of pain is the most important part of the assessment of pain.

ANS: A

Pain in cancer patients can arise both from the cancer itself and from the treatments. This patient has bone cancer, which causes somatic pain, and the treatments can increase this pain. Although neuropathic pain can occur as well, this patient is more likely to need analgesia for the nociceptive pain, so increasing the antidepressant dose is not indicated. Patients very often require more drug to achieve the same effect as tolerance develops. Radiation and chemotherapy can damage tissue and increase pain. When assessing pain in patients, the patients own description of pain intensity is the most important.
DIF: Cognitive Level: Application REF: Pain in Cancer Patients | Nociceptive Pain Versus Neuropathic Pain | Assessment of Pain Intensity and Character: The Patient Self-Report TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 3. A patient with cancer who has been receiving an opioid analgesic reports having pain at a new

location even though the previous pain is well controlled. The nurse will contact the provider to discuss: a breakthrough pain.
. b drug-seeking behavior. . c infection or metastasis. . d tolerance to drug therapy. .

ANS: C

Caregivers should be alert for new pain; this usually results from a new cause, such as metastasis, infection, or fracture, and should be investigated. Breakthrough pain is pain that occurs even when adequate levels of analgesics are given. Drug-seeking behavior refers to patients who use drugs for euphoric effects instead of for intended effects. Tolerance occurs when more drug is required to receive the same effect.
DIF: REF: TOP: MSC: Cognitive Level: Application Ongoing Evaluation | Tolerance and Physical Dependence | Addiction Nursing Process: Planning NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

4. An 8-year-old child with advanced cancer has an order for oxycodone (OxyContin) PO, PRN

for moderate to severe pain. The nurse notes that the child is constantly playing computer games and repeatedly denies having pain. What will the nurse do? a Administer the oxycodone at regular intervals around the clock.
. b Contact the provider to discuss using patient-controlled analgesia (PCA). . c Reassure the childs parent that the child will ask for pain medication as needed. . d Tell the child to notify the nurse when pain is present. .

ANS: B

For a number of reasons, even children who can verbalize pain correctly often underreport it. The child may fear that reporting pain may lead to painful procedures or may worry caregivers, or the child may be unaware that pain can be alleviated. Children involved in activities such as computer games may actually be using the activity to distract themselves from the pain, so such an activity is not an indication that the child is comfortable. This child has advanced cancer and is likely to have severe pain. A PCA device would give the child control and provide adequate pain relief. The oxycodone order is for PRN dosing, so the nurse cannot administer it around the clock without a prescribers order to do so. Also, because this child is more likely to have severe pain, a PCA would be more effective. Reassuring the parent that the child will report pain and asking the child to report pain do not take into account the fact that children often hide pain for the reasons previously mentioned.
DIF: REF: TOP: MSC: Cognitive Level: Application Pain Management in Special Populations | Young Children | Assessment Nursing Process: Diagnosis NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

5. An older adult patient who has cancer and Alzheimers disease is crying but shakes her head

no when asked about pain. The prescriber has ordered morphine sulfate 2 to 4 mg IV every 2 hours PRN pain. It has been 4 hours since a dose has been given. What will the nurse do? a Administer 4 mg of morphine and monitor this patients verbal and nonverbal . responses. b Give 2 mg of morphine for pain to avoid increasing this patients level of . confusion. c Request an order for a nonopioid analgesic or an antidepressant adjuvant . analgesic. d Withhold any analgesic at this time and reassess the patient in 30 to 60 minutes.
.

ANS: A

Older adult patients often are undertreated for pain, because assessing pain is difficult in patients with cognitive impairment and because practitioners often believe that reduced dosages are necessary to alleviate side effects. This patient does not verbalize pain, but her nonverbal cue (crying) indicates that pain is present. The nurse should give the higher dose, especially because the dosing interval has already been exceeded, and then monitor the patients response to the medication. Giving 2 mg to avoid side effects is not indicated; patients with Alzheimers disease will continue to have confusion unrelated to the opioid. Nonopioid analgesics and antidepressants are not indicated. Withholding pain medication is not appropriate, because this patient shows nonverbal signs of pain.
DIF: REF: TOP: MSC: Cognitive Level: Application Pain Management in Special Populations | The Elderly | Undertreatment of Pain Nursing Process: Assessment NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

6. A nursing student caring for a patient with cancer tells the nurse that the patient seems to be

exaggerating when reporting the degree of pain. Which statement by the nurse is an appropriate response to this concern?

a . b . c . d .

Evaluation of the patients vital signs can help you tell if this patient is exaggerating. It is important to give pain medication as ordered for the degree of pain the patient reports. We may need to evaluate the patient for the development of metastasis or infection. You should monitor this patients behavior and facial expressions for a more accurate assessment.

ANS: B

The patients description of his or her pain is the cornerstone of assessment. Pain is a personal experience, and caregivers must act on what the patient says, even if they suspect the patient is exaggerating or not telling the truth. Evaluation of vital signs can be used to monitor responses to pain medication, as can assessments of behaviors and facial expressions, but they are not determinants of the level of pain in initial assessments. Patients with pain in new locations should be evaluated for metastases or infection or other causes.
DIF: Cognitive Level: Application REF: Assessment of Pain Intensity and Character: The Patient Self-Report | Physical and Neurologic Examinations | Barriers to Assessment TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation 7. A patient with cancer has been receiving codeine and a nonsteroidal anti-inflammatory

medication for pain. The patient reports worsening of pain in both intensity and frequency. The nurse will tell the patient to contact the provider to discuss: a using a fentanyl transdermal patch.
. b adding an adjuvant analgesic drug. . c increasing the dose of the codeine. . d using hydrocodone or oxycodone. .

ANS: D

As patients have increased pain, it is important to increase the level of analgesia. Hydrocodone or oxycodone is useful as pain increases, after nonopioid analgesics have been tried. Fentanyl transdermal patches are used for chronic, severe pain in patients who are already tolerant to opioids. Adjuvant analgesics can be used at any stage of pain progression but are used for neuropathic pain. Codeine is not recommended for cancer pain, because it has dose-limiting side effects; increasing the dose of codeine is never recommended.
DIF: REF: TOP: MSC: Cognitive Level: Application Table 29-2: Drugs That Are Not Recommended for Treating Cancer Pain Nursing Process: Planning NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

8. A patient who is taking a fixed-dose combination drug with an opioid and acetaminophen for

cancer pain reports increased muscular pain. The patient asks the nurse if the pain medication dose can be increased. What will the nurse tell this patient? a An adjuvant analgesic medication will probably be used to help with this pain.
. b An additional dose of acetaminophen can be used to enhance pain relief. . c Increasing the dose is possible, because there is no ceiling to opioid pain relief. . d The provider will prescribe separate dosing of the opioid and acetaminophen. .

ANS: D

Fixed-dose combination products are not useful as pain increases, because the side effects of the nonopioid drug become intolerable as the dosage increases. As pain becomes more severe, the components of the combined regimen should be given separately. Adjuvant analgesics are used for neuropathic pain and not nociceptive pain (which this patient has described). Acetaminophen doses should not be increased. Increasing the dose of a fixed-dose combination drug is not recommended.
DIF: Cognitive Level: Application REF: Drug Therapy TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 9. A patient with cancer is admitted to the hospital. The nurse obtains an admission history and

learns that the patient has been taking oxycodone and a nonsteroidal anti-inflammatory drug (NSAID) for a year. The patient reports a recent increase in the intensity of pain, along with a new pain described as burning and shooting. The nurse anticipates that the prescriber will order: a a combination opioid/NSAID and an adjunctive analgesic.
. b a fentanyl transdermal patch, acetaminophen, and an adjunctive analgesic. . c an increase in the oxycodone and NSAID doses. . d intramuscular morphine sulfate and acetaminophen. .

ANS: B

As pain increases in severity, more powerful opioids should be used. This patient has been taking oxycodone, which is a moderate-strength opioid; fentanyl is stronger. Because the pain is chronic and is now severe and because the patient has opioid tolerance, a transdermal patch may be used. Long-term use of NSAIDs is not recommended because of the risk of thrombotic events. The patient also is describing neuropathic pain, which can be treated with an adjuvant analgesic. Fixed-dose combination drugs are not recommended for increasing pain. NSAIDs are not recommended long term. Intramuscular medications are not recommended because of the pain associated with administration.
DIF: Cognitive Level: Application

REF: Drug Therapy | Nonopioid Analgesics | Nonsteroidal Anti-inflammatory Drugs TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 10. A patient is taking hydrocodone and ibuprofen for cancer pain and is admitted to the hospital

for chemotherapy. The nurse anticipates that the prescriber will _____ ibuprofen. a reduce the dose of
. b discontinue the . c increase the dose of . d order aspirin (ASA) instead of .

ANS: B

NSAIDs are contraindicated in patients undergoing chemotherapy because of decreased platelet production caused by bone marrow suppression. Any NSAID further increases the risk of bruising and bleeding. ASA is especially dangerous, because it causes irreversible inhibition of platelet aggregation. Ibuprofen should be discontinued, not reduced or increased.
DIF: Cognitive Level: Application REF: Nonsteroidal Anti-inflammatory Drugs TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential 11. A nurse is teaching a group of nursing students about the differences between pure opioid

agonists and agonist-antagonist opioids. Which statement by a student indicates understanding of the teaching? a Agonist-antagonists opioids act as agonists at mu receptors only.
. b Agonist-antagonists opioids are effective for treating cancer pain. . c Agonist-antagonists opioids enhance the effects of pure agonists. . d Pure agonists act as agonists at both mu receptors and kappa receptors. .

ANS: D

Pure agonists are agonists at mu and kappa receptors. Agonist-antagonist opioids are agonists at kappa, not mu, receptors. At mu receptors, agonist-antagonists act as antagonists. Agonistantagonists are not recommended for treating cancer pain; because of their antagonist effect, they block access of the pure agonists to mu receptors and thus block their actions.
DIF: REF: TOP: MSC: Cognitive Level: Application Opioid Analgesics | Mechanism of Action and Classification Nursing Process: Assessment NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

12. A patient newly diagnosed with cancer is admitted to the hospital, and the provider orders

oxycodone (OxyContin) every 4 to 6 hours PRN pain. The patient requests pain medication whenever he reports pain as a 7 or 8 on a scale of 1 to 10 (10 being the worst pain), but he tells the nurse the medication is not working well. The nurse will contact the provider to discuss: a a fixed dosing schedule for the oxycodone.
. b intramuscular meperidine (Demerol). . c intravenous morphine sulfate. . d transdermal fentanyl. .

ANS: A

Dosing should be done on a fixed schedule to prevent opioid levels from becoming subtherapeutic once patients begin to have more severe pain. IM and IV dosing are more invasive and should not be used unless other methods have failed. Transdermal fentanyl is used for chronic, severe pain in patients tolerant to opioids.
DIF: REF: TOP: MSC: Cognitive Level: Application Opioid Analgesics | Dosage | Routes of Administration Nursing Process: Implementation NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

13. A patient who has had cancer for 1 year uses a fentanyl transdermal patch for pain relief. The

patient reports having three or four episodes of pain (which she rates as 8 or 9 on a scale of 1 to 10) each day, and each episode lasts 15 to 30 minutes. The nurse will contact the provider to: a discuss the use of an adjuvant analgesic.
. b request an order for an NSAID. . c request a strong, short-acting opioid PRN. . d suggest increasing the dose of fentanyl. .

ANS: C

Breakthrough pain can occur in patients who otherwise have well-controlled pain, and it should be managed with extra doses of short-acting, strong opioids. This pain is moderate to severe and is not neuropathic, so adjuvant analgesics or NSAIDs are not useful. Increasing the dose of the long-acting opioid would not alleviate breakthrough pain.
DIF: Cognitive Level: Application REF: Managing Breakthrough Pain TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies MULTIPLE RESPONSE

1. Over time, patients taking opioid analgesics develop tolerance to which side effects? (Select

all that apply.) a Constipation

. b . c . d . e .

Euphoria Physical dependence Respiratory depression Sedation

ANS: B, D, E

With continuous use, tolerance develops to most side effects of opioids, except to constipation and physical dependence.
DIF: Cognitive Level: Comprehension REF: Opioid Analgesics TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 2. Which nonpharmacologic therapies are effective in reducing cancer pain? (Select all that

apply.) a Acupuncture
. b . c . d . e .

Cold Exercise Heat Transcutaneous electrical nerve stimulation (TENS)

ANS: B, C, D

Cold, heat, and exercise have been shown to reduce pain. Acupuncture and TENS have not been demonstrated to be effective, although in theory they should work.
DIF: Cognitive Level: Comprehension REF: Physical Interventions TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation