Pain Management and Special Populations: Analgesia, Older Adults, Children, and Sports Injuries Practice Questions

25 multiple-choice questions on Pain management and special populations: analgesia, older adults, children, and sports injuries for paramedic and EMT students, from Chapter 38 (Orthopaedic Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. The first and simplest measures for reducing pain from an isolated fracture are:

   1. A. Splinting, cold, and elevation
   2. B. Heat, massage, and early walking
   3. C. Range-of-motion exercises
   4. D. Tight elastic wraps alone
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   Answer: A. Splinting, cold, and elevation

   Immobilization prevents bone ends from moving, and cold and elevation reduce swelling; these work before and alongside medications. Heat and movement increase bleeding, swelling, and pain.

2. Some EMS systems give IV acetaminophen for fracture pain. Compared with opioids, an advantage of IV acetaminophen is that it:

   1. A. Works faster than IV fentanyl
   2. B. Is safe in severe liver disease
   3. C. Gives stronger relief than morphine
   4. D. Does not depress breathing
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   Answer: D. Does not depress breathing

   IV acetaminophen provides moderate analgesia without respiratory depression, sedation, or hypotension and reduces opioid needs. It acts more slowly and less strongly than IV opioids for severe pain, and liver disease limits its use because of liver toxicity.

3. Fentanyl is often preferred over morphine for prehospital fracture pain because fentanyl:

   1. A. Has a much longer duration
   2. B. Causes less histamine release
   3. C. Cannot depress respirations
   4. D. Is not an opioid receptor agonist
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   Answer: B. Causes less histamine release

   Fentanyl's rapid onset and minimal histamine release make hypotension less likely than with morphine. It is still a potent opioid that can cause respiratory depression.

4. To rate pain in a 10-month-old with a leg fracture, the most appropriate tool scores:

   1. A. Face, legs, activity, cry, consolability
   2. B. A number from 0 to 10 the infant chooses
   3. C. Pictures of faces the infant points to
   4. D. The parent's guess of the infant's pain
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   Answer: A. Face, legs, activity, cry, consolability

   Preverbal children cannot use numeric or picture scales, so behavioral tools such as FLACC (face, legs, activity, cry, consolability) are used. Numeric scales need older children, and faces scales need a child who can point, usually about 3 years or older. Parent input helps but is not a validated score alone.

5. During a 90-minute rural transport, your patient with a femur fracture got good relief from IV fentanyl 40 minutes ago, but his pain is returning. This is because fentanyl:

   1. A. Is cleared fast by the kidneys
   2. B. Builds tolerance after the first dose
   3. C. Has a short duration of action
   4. D. Stops working once a splint is on
   Show answer

   Answer: C. Has a short duration of action

   IV fentanyl acts within minutes but lasts only about 30 to 60 minutes after a single dose because it redistributes out of the brain, so pain often returns on long transports. Reassess pain and vital signs regularly and give repeat doses per protocol. Its short action is not due to kidney clearance or tolerance after one dose, and splinting does not block its effect.

6. A trauma patient with a femur fracture and possible internal bleeding asks for ketorolac. It is usually avoided here mainly because it:

   1. A. Causes severe sedation
   2. B. Raises the heart rate
   3. C. Impairs platelets
   4. D. Is a controlled drug
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   Answer: C. Impairs platelets

   Ketorolac is an NSAID that inhibits platelet function and can worsen bleeding; it also carries kidney risk in hypovolemia. Many protocols restrict it to patients without bleeding risk, kidney disease, or advanced age. It is not sedating or controlled.

7. Some EMS systems perform a fascia iliaca nerve block for patients with hip fractures. The main benefit of this block is that it:

   1. A. Lets the patient bear weight again
   2. B. Relieves pain with fewer opioids
   3. C. Removes the need for splinting
   4. D. Numbs the whole leg to the toes
   Show answer

   Answer: B. Relieves pain with fewer opioids

   A fascia iliaca block numbs the femoral and lateral femoral cutaneous nerves, giving good hip and thigh pain relief and reducing opioid use, which is valuable in older adults at risk of sedation, respiratory depression, and delirium. It does not let the patient bear weight on a broken hip or replace careful packaging, and it does not reach the sciatic nerve, so much of the lower leg and the foot keep their sensation.

8. A patient with an obvious ankle deformity calmly rates his pain 9/10, and his vital signs are normal. You should:

   1. A. Accept his report and treat the pain
   2. B. Doubt it because he looks calm
   3. C. Wait for his heart rate to rise
   4. D. Give pain medication only at the hospital
   Show answer

   Answer: A. Accept his report and treat the pain

   The patient's self-report is the standard for pain assessment. People express pain differently, and normal vital signs do not exclude severe pain. Offer splinting, cold, and analgesia per protocol, and reassess. Undertreatment of pain is common and is not justified by a calm appearance.

9. Treating pain well in an 84-year-old with a hip fracture matters partly because uncontrolled pain in older adults increases the risk of:

   1. A. Bradycardia
   2. B. Hypotension
   3. C. Seizures
   4. D. Delirium
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   Answer: D. Delirium

   Severe untreated pain is a major trigger of delirium in older adults with hip fractures, and delirium worsens recovery and survival. Careful, titrated analgesia with monitoring reduces this risk. Pain tends to raise rather than lower the heart rate and blood pressure, and it does not cause seizures.

10. An 81-year-old woman fell 2 days ago. She has been walking with a limp and now has right groin pain. Her leg is not shortened or rotated. You should:

    1. A. Rule out a fracture since she can walk
    2. B. Suspect a hip fracture and transport
    3. C. Advise ice and a clinic visit next week
    4. D. Have her walk to the ambulance
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    Answer: B. Suspect a hip fracture and transport

    Impacted and nondisplaced femoral neck fractures are stable enough to bear weight and do not shorten or rotate the leg, so groin pain after a fall in an older adult is a hip fracture until imaging proves otherwise. Move her by stretcher, give analgesia, and ask why she fell. Walking does not rule out a fracture, which is how these injuries are missed. Advising a delayed clinic visit, or letting her walk to the ambulance, risks turning a stable impacted fracture into a displaced one, which raises the risk of avascular necrosis and major surgery.

11. A 74-year-old woman with osteoporosis felt sudden mid-back pain while lifting a bag of groceries. She has point tenderness over one thoracic vertebra and normal strength and sensation. The most likely injury is a:

    1. A. Vertebral compression fracture
    2. B. Simple back muscle strain
    3. C. Herniated thoracic disk
    4. D. Hip fracture with referred pain
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    Answer: A. Vertebral compression fracture

    Osteoporotic vertebrae can collapse under everyday loads such as lifting, bending, or coughing, and sudden pain with point tenderness over one vertebra is the typical picture. Most are stable, but they are painful and some cause neurologic deficits, so assess strength and sensation, provide analgesia, and pad and position her for comfort. A muscle strain causes diffuse paraspinal soreness rather than point bony tenderness, and in a patient with osteoporosis it is a diagnosis of exclusion. A herniated thoracic disk is rare and causes band-like nerve pain around the chest. A hip fracture causes groin or thigh pain, not mid-back pain.

12. A 70-year-old had a hip replacement 6 weeks ago. She bent forward to tie her shoe, felt a clunk, and now has a shortened leg that is flexed and turned inward. You suspect:

    1. A. A new fracture of the femoral shaft
    2. B. Anterior hip dislocation
    3. C. Dislocation of the hip prosthesis
    4. D. Lumbar disk herniation
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    Answer: C. Dislocation of the hip prosthesis

    A hip replacement can dislocate with little force, most often posteriorly and in the first months after surgery, when deep flexion with adduction and inward rotation (bending to tie a shoe or rising from a low seat) levers the ball out of the socket. The leg rests short, flexed, and internally rotated. Splint it as found with pillows, check sciatic nerve function and distal pulses, give analgesia, and transport. A femoral shaft fracture needs a fall or a blow and causes mid-thigh deformity. An anterior dislocation holds the leg abducted and turned outward. A disk herniation causes back and leg pain but no fixed deformity of the hip.

13. When giving opioids to a frail 85-year-old with a hip fracture, you should:

    1. A. Double the usual adult dose
    2. B. Withhold all pain medication
    3. C. Give the full dose as a bolus
    4. D. Start low and titrate slowly
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    Answer: D. Start low and titrate slowly

    Older adults are more sensitive to opioids because of reduced renal and hepatic function, so start low and titrate slowly. Withholding analgesia leaves them in pain, which itself can contribute to delirium.

14. When splinting the fractured wrist of an 88-year-old with thin, fragile skin, which step is most important?

    1. A. Strap the splint tightly to stop motion
    2. B. Use tape directly on the skin to secure it
    3. C. Pad the splint well over all bony areas
    4. D. Skip padding to keep the splint snug
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    Answer: C. Pad the splint well over all bony areas

    Aging thins the skin and the fat beneath it, so pressure injuries and skin tears develop quickly under a splint. Generous padding over bony points spreads the pressure, and the splint is secured with roller gauze or straps over padding. Strapping tightly causes pressure injury and can cut off circulation in a swelling limb. Adhesive tape on fragile skin tears it when removed. A splint without padding presses directly on bone and leaves gaps that let the limb shift.

15. Ligaments in children are relatively stronger than their growth plates. As a result, a child with a joint injury is more likely than an adult to have a:

    1. A. Ligament sprain
    2. B. Joint dislocation
    3. C. Complete tendon rupture
    4. D. Growth plate fracture
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    Answer: D. Growth plate fracture

    The open physis is the weakest point in a child's skeleton, so force that would sprain an adult ligament often fractures the growth plate instead. Assuming a child has only a sprain can miss an injury that affects growth.

16. A 2-year-old cries and will not use her arm after her father pulled her up by the hand. She holds the arm slightly flexed at the elbow with the palm facing down. The most likely injury is:

    1. A. Radial head subluxation
    2. B. Supracondylar fracture
    3. C. Midshaft clavicle fracture
    4. D. Shoulder dislocation
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    Answer: A. Radial head subluxation

    Nursemaid elbow occurs when a sudden pull on the forearm slips the radial head out from under the annular ligament, usually in children aged 1 to 4. A supracondylar fracture follows a fall and causes swelling and deformity.

17. A 4-year-old has a bump in the distal forearm after a fall, with the bone bulging on one side but not broken through. This is most likely a:

    1. A. Comminuted fracture
    2. B. Buckle (torus) fracture
    3. C. Pathologic fracture
    4. D. Spiral shaft fracture
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    Answer: B. Buckle (torus) fracture

    In a buckle fracture, the soft bone of a young child compresses and bulges without a complete break. Comminuted fractures need high energy and are uncommon in young children.

18. On an X-ray report, which fracture type in an infant is considered highly specific for physical abuse?

    1. A. Clavicle fracture at birth
    2. B. Metaphyseal corner fracture
    3. C. Single linear skull fracture
    4. D. Buckle fracture of the wrist
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    Answer: B. Metaphyseal corner fracture

    Classic metaphyseal lesions (corner or bucket-handle fractures) result from violent shaking or twisting of a limb and are highly specific for abuse in infants. A clavicle fracture can occur during birth, and buckle fractures and isolated linear skull fractures more often follow accidental falls, although history must always be considered.

19. Which pattern of fractures in an infant is most suggestive of nonaccidental trauma?

    1. A. A single clavicle fracture from birth
    2. B. A buckle fracture after a fall
    3. C. A forearm fracture in a skier
    4. D. Posterior rib fractures of varied ages
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    Answer: D. Posterior rib fractures of varied ages

    Posterior rib fractures from squeezing and multiple fractures at different stages of healing strongly suggest abuse. A clavicle fracture during birth is a common accidental injury.

20. If you suspect a child's fracture resulted from abuse, you should:

    1. A. Report your concern as required
    2. B. Confront the parents about it
    3. C. Record it as an accident
    4. D. Ask the child to name a suspect
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    Answer: A. Report your concern as required

    Paramedics are mandated reporters and must document objective findings and report suspicions to the appropriate authorities. Confronting the caregivers can escalate the scene and endanger the child.

21. A 19-year-old football player has a recurrent anterior shoulder dislocation and asks you to pop it back in on the sideline. Your protocol does not authorize reduction. You should:

    1. A. Reduce it if he has done it before
    2. B. Let the athletic trainer decide
    3. C. Splint it as found and transport
    4. D. Tape it in place so he can play
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    Answer: C. Splint it as found and transport

    Without protocol authorization or medical direction, splint the shoulder in a position of comfort and transport for x-ray and reduction. A prior dislocation does not authorize a field reduction outside your scope.

22. The acronym RICE for a minor sports sprain stands for rest, ice, compression, and:

    1. A. Exercise
    2. B. Ibuprofen
    3. C. Evaluation
    4. D. Elevation
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    Answer: D. Elevation

    Elevation reduces swelling by aiding venous and lymphatic drainage. Exercise early on can worsen the injury.

23. A cold pack on an acute ankle sprain should generally be applied:

    1. A. For about 20 minutes at a time
    2. B. Continuously for many hours
    3. C. Directly against bare skin
    4. D. Starting after the first full day
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    Answer: A. For about 20 minutes at a time

    Intermittent cold limits swelling and pain without causing cold injury to the skin. Leaving it on for hours or against bare skin risks frostbite-like damage.

24. A 16-year-old cross-country runner has gradually worsening shin pain with pinpoint tenderness on the tibia, no trauma, and pain that worsens with each run. You should advise:

    1. A. Running through the pain
    2. B. Evaluation for stress fracture
    3. C. Applying heat before each run
    4. D. Stretching more before runs
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    Answer: B. Evaluation for stress fracture

    Focal bony tenderness with activity-related pain in a runner suggests a tibial stress fracture that needs imaging and rest. Running through the pain can convert a stress fracture into a complete fracture.

25. A 28-year-old at 34 weeks of pregnancy has a deformed wrist after a fall and rates her pain 8/10. Her vital signs are normal. Which analgesic plan is most appropriate?

    1. A. IV ketorolac, to avoid any opioid exposure
    2. B. Withhold all analgesia until delivery
    3. C. IV fentanyl given in small, titrated doses
    4. D. IV midazolam alone to ease her distress
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    Answer: C. IV fentanyl given in small, titrated doses

    Untreated severe pain is harmful to both mother and fetus, and a short course of a titrated opioid such as fentanyl is acceptable in pregnancy; monitor her breathing, position her on her left side or with the uterus displaced rather than supine, and tell the hospital what was given, since opioids given near delivery can depress the newborn's breathing. Ketorolac and other NSAIDs should be avoided at 20 weeks or later because they can reduce fetal kidney function and amniotic fluid, and after about 30 weeks they can close the ductus arteriosus early. Withholding analgesia until delivery is outdated and leaves her in pain. Midazolam sedates but does not relieve pain and adds respiratory depression. Follow local protocol for doses.