Pain Management for Children

MULTIPLE CHOICE

1. The nurse is aware when assessing a child for pain that:

a.
neonates do not feel pain.
b.
pain is an individualized experience.
c.
children do not remember pain.
d.
a child must cry to express pain.

ANS: B

The manner and intensity of how a child expresses pain are dependent on the individual child’s experiences. It is a myth that neonates do not feel pain. Neonates do express a total-body response to pain with a cry that is intense, high pitched, and harsh sounding. It is a myth that children do not remember pain. Children of all ages have been reported to have sleeping and eating disruptions after painful experiences. Not all children will cry to express pain.

DIF: Cognitive Level: Comprehension REF: p. 319

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

2. When pain is assessed in an infant, it would be inappropriate to assess for:

a.
facial expressions of pain.
b.
localization of pain.
c.
crying.
d.
thrashing of extremities.

ANS: B

Infants cannot localize pain to any great extent. Frowning, grimacing, and facial flinching in an infant may indicate pain. Infants often exhibit high-pitched, tense, harsh crying to express pain. Infants may exhibit thrashing extremities in response to a painful stimulus.

DIF: Cognitive Level: Comprehension REF: p. 320

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

3. The nurse is aware that physiological changes associated with pain in the infant include which finding(s)?

a.
Increased blood pressure and decreased arterial saturation
b.
Decreased blood pressure and increased arterial saturation
c.
Increased urine output and increased heart rate
d.
Decreased urine output and increased blood pressure

ANS: A

Increased blood pressure and heart rate and decreased arterial saturation are physiological responses to pain in the neonate. An increase in blood pressure and a decrease in arterial saturation are documented when the neonate is feeling pain. Although an increase in heart rate is associated with pain and an increase in blood pressure occurs with pain, urine output changes have not been associated with pain.

DIF: Cognitive Level: Comprehension REF: p. 321

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

4. Which statement best reflects a myth that may interfere with the treatment of pain in infants and children?

a.
Infants may have sleep difficulties after a painful event.
b.
Children and infants are more susceptible to respiratory depression from narcotics.
c.
Pain in children is multidimensional and subjective.
d.
A child’s cognitive level does not influence the pain experience.

ANS: B

No data are available to support the belief that infants and children are at higher risk of respiratory depression when given narcotic analgesics. This is a myth. It is true that infants may have sleep difficulties after a painful event. This is not a myth. It is true that pain in children is multidimensional and subjective. This is not a myth. The child’s cognitive level, along with emotional factors and past experiences, does influence the perception of pain in children. This is not a myth.

DIF: Cognitive Level: Comprehension REF: p. 319

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

5. The nurse caring for the child in pain knows that distraction:

a.
can give total pain relief to the child.
b.
is effective when the child is in severe pain.
c.
is the best method for pain relief.
d.
must be developmentally appropriate to refocus attention.

ANS: D

Distraction can be very effective in helping to control pain, but it must be appropriate to the child’s developmental level. It is rarely able to provide total pain relief and is not the best method for pain relief. Children in severe pain are not distractible.

DIF: Cognitive Level: Comprehension REF: p. 324

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

6. Which medication is the most effective choice for treating pain associated with inflammation?

a.
Opioids
b.
Acetaminophen
c.
Ibuprofen
d.
Midazolam

ANS: C

Ibuprofen is a type of nonsteroidal antiinflammatory drug (NSAID) that is used primarily for pain associated with inflammation. Opioids are the preferred drugs for the management of acute, severe pain, including postoperative pain, posttraumatic pain, pain from vaso-occlusive crisis, and chronic cancer pain. Acetaminophen lacks the antiinflammatory effects of NSAIDs and provides only minimal antiinflammatory relief. Midazolam (Versed) is a short-acting drug used for conscious sedation and preoperative sedation, and as an induction agent for general anesthesia.

DIF: Cognitive Level: Comprehension REF: p. 329

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

7. When using the Poker Chip Tool, it is important for the nurse to know which fact?

a.
Any number of chips can be used.
b.
Only a specified number of chips can be used.
c.
The assessment tool is used with adolescents.
d.
The assessment tool is most effectively used with 2-year-old children.

ANS: B

In the Poker Chip Tool, four chips are used to represent a hurt. One chip represents a little hurt, and four chips represent the most hurt the child could have. Pain tools are valid only if used as directed; this tool uses four chips. Adolescents are able to think abstractly. They can describe, quantify, and identify intensity and feelings about pain. The Poker Chip Tool is recommended for children ages 4 to 12. Self-report tools are effective in children older than 3 years of age, not 2 years of age.

DIF: Cognitive Level: Application REF: p. 323

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

8. An appropriate tool to assess pain in a 3-year-old child would be the:

a.
Visual Analogue Scale (VAS).
b.
Adolescent and Pediatric Pain Tool.
c.
Oucher Tool.
d.
Poker Chip Tool.

ANS: C

The Oucher Tool can be used to assess pain for children 3 to 12 years of age. The VAS is indicated for use with older school-age children and adolescents. It can be used with younger school-age children, although less-abstract tools are more appropriate. The Adolescent and Pediatric Pain Tool is indicated for use with children 8 to 17 years of age. The Poker Chip Tool can be used to assess pain in children 4 to 12 years of age.

DIF: Cognitive Level: Knowledge REF: p. 323

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

9. At which developmental stage is the child first able to localize pain and describe both the amount and the intensity of the pain felt?

a.
Toddler stage
b.
Preschool stage
c.
School-age stage
d.
Adolescent stage

ANS: B

The preschool stage is the period when the child is first able to describe the location and intensity of pain, stating, for example, “ear hurts bad,” when feeling pain. The toddler expresses pain by guarding or touching the painful area, verbalizes words that indicate discomfort, such as “ouch” and “hurt,” and demonstrates generalized restlessness when feeling pain. The school-age child describes both the location of the pain and its intensity. The adolescent also describes the location and intensity of pain.

DIF: Cognitive Level: Knowledge REF: p. 321

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

10. Which statement indicates a nurse’s lack of understanding about the use of patient-controlled analgesia (PCA) therapy?

a.
Children as young as 3 years old can effectively and successfully use a PCA pump.
b.
Two registered nurses (RNs) are required to double check the dosage and programmed administration of opioids.
c.
The child should be carefully monitored for signs and symptoms of overmedication with opioids.
d.
Naloxone (Narcan) should be readily available.

ANS: A

Children as young as 5 years old have effectively used PCA therapy. Further data are needed to evaluate the use of PCA therapy in children younger than 5 years of age. Two RNs are needed to check the amount of opioid being administered. Once the opioid infusion is hung and programmed, a second RN must double check the process. Children receiving PCA therapy should be monitored closely to ensure effective pain control and for signs or symptoms of overmedication. Initially, vital signs should be monitored every 15 to 30 minutes and then every 2 to 4 hours. Respiratory rate should be assessed every hour. Narcan should be readily available to reverse opioid overmedication exhibited by respiratory distress.

DIF: Cognitive Level: Analysis REF: p. 328

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

11. Which assessment indicates to a nurse that a 2-year-old child is in need of pain medication?

a.
The child is restless and guarding the painful site.
b.
The child’s current vital signs are consistent with vital signs over the past 4 hours.
c.
The child is quieted when held and cuddled.
d.
The child has just returned from the recovery room and is crying.

ANS: A

Behaviors such as generalized restlessness, guarding the site, and touching the painful area are signs of pain in the toddler. Current vital signs that are consistent with earlier vital signs do not suggest that the child is feeling pain. Response to comforting behaviors does not suggest the child is feeling pain. Crying in a child who is returning from the recovery room may not be indicative of pain. The child may just be fearful or having anxiety because of the strange surroundings and having just completed surgery.

DIF: Cognitive Level: Application REF: p. 321

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

12. When assessing pain in any child, the nurse should consider which information?

a.
Any pain assessment tool can be used to assess pain in children.
b.
Children as young as age 1 year use words to express pain.
c.
The child’s behavioral, physiological, and verbal responses are valuable when assessing pain.
d.
Pain assessment tools are minimally effective for communicating about pain.

ANS: C

Children’s behavioral, physiological, and verbal responses are indicative when assessing pain. The use of pain measurement tools greatly assists in communicating about pain. The child’s age is important in determining the appropriate pain assessment tool to use. Developmentally appropriate assessment tools need to be used to effectively identify and determine the level of pain felt by a child. Toddlers may use words such as “ouch” or “hurt” to identify pain, but infants and young children may not have the language or cognitive abilities to express pain. Pain assessment tools when used appropriately are successful and efficient in identifying and quantifying pain with children. Behavioral and physiological signs and symptoms in combination with pain assessment tools are most effective in diagnosing pain levels in children.

DIF: Cognitive Level: Application REF: p. 319

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

MULTIPLE RESPONSE

1. A nurse is administering an opioid medication to a child. Which side effects should the nurse watch for with this classification of medication? Select all that apply.

a.
Respiratory depression
b.
Hepatic damage
c.
Constipation
d.
Pruritus
e.
Gastrointestinal bleeding

ANS: A, C, D

The nurse should remember opioids can produce sedation and respiratory depression, in addition to analgesia. Other adverse effects can include constipation, pruritus, nausea, vomiting, cough suppression, and urinary retention. Acetaminophen (Tylenol) is associated with hepatic damage and nonsteroidal antiinflammatory drugs (NSAIDs) are associated with gastrointestinal bleeding.

DIF: Cognitive Level: Application REF: p. 320

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

2. A nurse is assessing pain on a 12-year-old child. Which pain assessment tools are developmentally appropriate for the nurse to use? Select all that apply.

a.
CRIES pain scale
b.
Numeric Rating Scale
c.
Visual Analog Scale
d.
FLACC
e.
Adolescent and Pediatric Pain Tool

ANS: B, C, E

Developmentally appropriate pain assessment tools for a 12-year-old child include the Numeric Rating Scale, the Visual Analog Scale, and the Adolescent and Pediatric Pain Tool. The CRIES pain scale is recommended for neonates to 6 months and the FLACC is recommended for children who are preverbal.

DIF: Cognitive Level: Application REF: p. 323

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity