NP Pain Management Case Mastery Test
Bank.150 Questions, Answers And
Rationale. (2025/2026)
1. A 55-year-old male presents with chronic low back pain for 6
months. He reports pain rated 7/10, worsened by movement. He
has a history of hypertension and takes lisinopril. Which is the
safest initial pharmacologic option?
Acetaminophen
Rationale: Acetaminophen is first-line for chronic low back pain
due to its efficacy and safety profile, especially in patients with
comorbidities like hypertension. NSAIDs may increase blood
pressure and risk renal impairment.
2. A 62-year-old female with osteoarthritis reports persistent knee
pain despite acetaminophen. She has mild chronic kidney disease
(eGFR 45 mL/min). Which is the most appropriate next step?
Topical NSAID (e.g., diclofenac gel)
Rationale: Topical NSAIDs provide local analgesia with minimal
systemic absorption, reducing the risk of kidney injury associated
with oral NSAIDs in patients with CKD.
3. A patient with metastatic cancer pain is taking morphine 30 mg
orally every 4 hours but reports inadequate pain control. What is
the best next step?
Consider opioid rotation or titration under supervision
Rationale: In cancer pain, opioid rotation or careful titration can
improve analgesia and reduce side effects. Consultation with a
pain or palliative care specialist may also be warranted.
,4. A 45-year-old male with neuropathic pain following a diabetic foot
ulcer reports burning and tingling. Which medication is first-line?
Gabapentin
Rationale: Gabapentin and pregabalin are first-line agents for
diabetic neuropathic pain. They modulate calcium channels and
reduce abnormal neuronal firing.
5. A patient on chronic opioid therapy reports constipation. Which is
the most appropriate management strategy?
Prescribe a stool softener and/or laxative
Rationale: Opioid-induced constipation is common and should be
proactively managed with stool softeners (e.g., docusate) and/or
laxatives (e.g., senna) rather than reducing the opioid dose
prematurely.
6. A 70-year-old male with chronic low back pain has mild cognitive
impairment and is taking oxycodone. Which side effect is most
concerning?
Delirium
Rationale: Opioids can exacerbate cognitive impairment in older
adults, increasing the risk of delirium, sedation, and falls.
Monitoring and dose adjustment are essential.
7. A patient with fibromyalgia reports widespread pain and sleep
disturbance. Which nonpharmacologic intervention has the most
evidence for symptom improvement?
Aerobic exercise program
Rationale: Regular low-impact aerobic exercise has been shown
to reduce pain and improve function and sleep quality in
fibromyalgia patients.
8. A patient with postherpetic neuralgia reports burning pain. Which
topical therapy is FDA-approved and effective?
, Lidocaine 5% patch
Rationale: Lidocaine patches provide localized pain relief with
minimal systemic effects, making them effective and safe for
postherpetic neuralgia.
9. A patient with chronic low back pain reports a 3/10 pain at rest
but severe pain during activity. Which class of medication is
preferred for breakthrough pain?
Short-acting opioid
Rationale: Short-acting opioids can be used for breakthrough
pain in chronic pain patients who are already on a stable
baseline analgesic regimen.
10. A patient presents with opioid-induced hyperalgesia. What
is the recommended intervention?
Opioid rotation or dose reduction
Rationale: Opioid-induced hyperalgesia is a paradoxical increase
in pain sensitivity with chronic opioid use. Opioid rotation or
gradual dose reduction often improves symptoms.
11. A 68-year-old female with chronic osteoarthritis reports
persistent hip pain. She has a history of peptic ulcer disease.
Which analgesic is safest?
Acetaminophen
Rationale: Acetaminophen is safe for patients with
gastrointestinal disease, unlike NSAIDs which increase risk of
ulcer complications.
12. A 50-year-old male with severe cancer pain is on fentanyl
patch 100 mcg/hr but reports breakthrough pain. What is the best
approach?
Short-acting opioid for breakthrough pain
Rationale: Fentanyl patches provide continuous baseline
Bank.150 Questions, Answers And
Rationale. (2025/2026)
1. A 55-year-old male presents with chronic low back pain for 6
months. He reports pain rated 7/10, worsened by movement. He
has a history of hypertension and takes lisinopril. Which is the
safest initial pharmacologic option?
Acetaminophen
Rationale: Acetaminophen is first-line for chronic low back pain
due to its efficacy and safety profile, especially in patients with
comorbidities like hypertension. NSAIDs may increase blood
pressure and risk renal impairment.
2. A 62-year-old female with osteoarthritis reports persistent knee
pain despite acetaminophen. She has mild chronic kidney disease
(eGFR 45 mL/min). Which is the most appropriate next step?
Topical NSAID (e.g., diclofenac gel)
Rationale: Topical NSAIDs provide local analgesia with minimal
systemic absorption, reducing the risk of kidney injury associated
with oral NSAIDs in patients with CKD.
3. A patient with metastatic cancer pain is taking morphine 30 mg
orally every 4 hours but reports inadequate pain control. What is
the best next step?
Consider opioid rotation or titration under supervision
Rationale: In cancer pain, opioid rotation or careful titration can
improve analgesia and reduce side effects. Consultation with a
pain or palliative care specialist may also be warranted.
,4. A 45-year-old male with neuropathic pain following a diabetic foot
ulcer reports burning and tingling. Which medication is first-line?
Gabapentin
Rationale: Gabapentin and pregabalin are first-line agents for
diabetic neuropathic pain. They modulate calcium channels and
reduce abnormal neuronal firing.
5. A patient on chronic opioid therapy reports constipation. Which is
the most appropriate management strategy?
Prescribe a stool softener and/or laxative
Rationale: Opioid-induced constipation is common and should be
proactively managed with stool softeners (e.g., docusate) and/or
laxatives (e.g., senna) rather than reducing the opioid dose
prematurely.
6. A 70-year-old male with chronic low back pain has mild cognitive
impairment and is taking oxycodone. Which side effect is most
concerning?
Delirium
Rationale: Opioids can exacerbate cognitive impairment in older
adults, increasing the risk of delirium, sedation, and falls.
Monitoring and dose adjustment are essential.
7. A patient with fibromyalgia reports widespread pain and sleep
disturbance. Which nonpharmacologic intervention has the most
evidence for symptom improvement?
Aerobic exercise program
Rationale: Regular low-impact aerobic exercise has been shown
to reduce pain and improve function and sleep quality in
fibromyalgia patients.
8. A patient with postherpetic neuralgia reports burning pain. Which
topical therapy is FDA-approved and effective?
, Lidocaine 5% patch
Rationale: Lidocaine patches provide localized pain relief with
minimal systemic effects, making them effective and safe for
postherpetic neuralgia.
9. A patient with chronic low back pain reports a 3/10 pain at rest
but severe pain during activity. Which class of medication is
preferred for breakthrough pain?
Short-acting opioid
Rationale: Short-acting opioids can be used for breakthrough
pain in chronic pain patients who are already on a stable
baseline analgesic regimen.
10. A patient presents with opioid-induced hyperalgesia. What
is the recommended intervention?
Opioid rotation or dose reduction
Rationale: Opioid-induced hyperalgesia is a paradoxical increase
in pain sensitivity with chronic opioid use. Opioid rotation or
gradual dose reduction often improves symptoms.
11. A 68-year-old female with chronic osteoarthritis reports
persistent hip pain. She has a history of peptic ulcer disease.
Which analgesic is safest?
Acetaminophen
Rationale: Acetaminophen is safe for patients with
gastrointestinal disease, unlike NSAIDs which increase risk of
ulcer complications.
12. A 50-year-old male with severe cancer pain is on fentanyl
patch 100 mcg/hr but reports breakthrough pain. What is the best
approach?
Short-acting opioid for breakthrough pain
Rationale: Fentanyl patches provide continuous baseline
