Chapter 14 (MS-C Final)

The nurse is caring for an older adult patient with terminal cancer who is receiving medication via patient-controlled analgesic (PCA) pump. The nurse shows an understanding of primary end-of-life concerns when asking the patient: a. "Do you have any concerns about receiving your medication intravenously?" b. "Are you satisfied with the way your pain is being managed?" c. "Are you worried about becoming addicted to the narcotic analgesics?" d. "Do you have any questions concerning how to use the PCA properly?"

b. "Are you satisfied with the way your pain is being managed?" Terminally ill patients generally identify their main concern as pain control. The other questions do not address this issue.

The nurse is performing a pain assessment when the older adult patient reports pain in his left shoulder that radiates down into the forearm. The nurse immediately: a. recognizes that the patient is experiencing cardiac distress. b. alerts the rapid response team to provide emergency care. c. asks whether he has ever experienced this pain before. d. questions the patient about additional related symptoms.

c. asks whether he has ever experienced this pain before. Assessment is essential in differentiating acute life-threatening pain from longstanding chronic pain. Otherwise, disease progression and acute injury may go unrecognized and be attributed to preexisting disease or illness. The patient may or may not be experiencing cardiac ischemia, the rapid response team does not need to be called, and the nurse can assess for other symptoms after determining if this pain is new or not.

The nurse is caring for a 78-year-old with a history of chronic depression. The patient currently reports persistent left shoulder pain since having a fall a year ago. To best address the patient's pain, the nurse initially determines: a. if the patient is still at risk for falls. b. the severity of the shoulder injury. c. how effectively depression is being managed. d. the patient's ability to effectively cope with pain.

c. how effectively depression is being managed. Persistent depression affects a person's ability to cope with the pain, so it must be treated. The nurse should also assess fall risk but that is secondary to determining why the pain has lasted so long and if the patient is able to cope.

The nurse is discussing pain control with an older patient who has been prescribed an opiate. When the patient expresses concerns about the diminishing effect that the medication has had on the pain, the nurse responds: a. "It appears that the dosage you take needs to be adjusted upward." b. "We need to be concerned about you developing a drug tolerance." c. "This drug category is well known for its low ceiling effect." d. "Opiate addiction is a concern when tolerance occurs."

a. "It appears that the dosage you take needs to be adjusted upward." Tolerance is defined as the diminished effect of a drug while maintaining the same dosage over time. It is a characteristic of opiates when given over time. With opiates, some individuals might need higher and higher doses of a drug to maintain effectiveness. This should not be confused with addiction.

A director of nursing in a long-term care facility was concerned after reading that as many as 80% of residents have untreated pain. What action by the director is best? a. Establish protocols for routine assessment. b. Make a "pain plan" for every resident. c. Involve family members in treating pain. d. Educate the staff on how to assess pain.

a. Establish protocols for routine assessment. Nursing begins with assessment. The director should implement a protocol for routine assessments of pain in both cognitively impaired and intact residents. A "pain plan" cannot be created without this assessment data. Family members should be encouraged to provide input. The staff may or may not need to have education on assessment.

When planning nursing care for an older adult who is experiencing chronic pain, the nurse includes which of the following interventions? (Select all that apply.) a. Maintain mobility. b. Promote autonomy. c. Manage any chronically painful condition. d. Provide economical sensitive pain relief. e. Support the patient's right to be pain-free.

a. Maintain mobility. b. Promote autonomy. c. Manage any chronically painful condition. Goals for pain management in older adults include control of chronic disease conditions that cause pain, maintenance of mobility and functional status, promotion of maximum independence, and improvement of quality of life.

The nurse is caring for four frail patients with pain. Which patient's pain medication prescription does the nurse question? a. The patient taking pentazocine (Talwin) b. The patient taking acetaminophen (Tylenol) c. The patient taking ibuprofen (Motrin) d. The patient taking hydromorphone (Dilaudid)

a. The patient taking pentazocine (Talwin) Talwin should not be used in frail older people because it leads to central nervous system excitement, confusion, and agitation. The other drugs are appropriate choices.

An older patient is observed grimacing whenever walking and getting in and out of bed. When assessed, the patient regularly denies having any pain. To best provide the patient with effective pain control, the nurse initially: a. discusses the effects of untreated pain on the patient's general wellness. b. offers the patient a prescribed prn analgesic. c. asks the patient why he is denying the presence of pain. d. documents the symptoms that the patient is exhibiting.

a. discusses the effects of untreated pain on the patient's general wellness. Older adult patients actually underreport pain and are therefore at risk for undertreatment of pain, which may cause unnecessary suffering, exacerbation of the underlying disease, and reduction in activities of daily living (ADLs) and quality of life. Without this information the patient is unlikely to take the prn medication. "Why" questions are not therapeutic, as they place people on the defensive. The symptoms should be documented, but this should not be the only action.

A patient has just had surgery. What pain control strategy is best? a. Administer prn medications when requested. b. Give pain medications around the clock at first. c. Start with nonopioids then progress to opioids. d. Ask the patient his or her preference for medication.

b. Give pain medications around the clock at first. After surgery the patient is expected to have pain. The best way to control acute pain is through round-the-clock dosing (at least at first) to keep the patient's pain from getting out of control. The nurse should assess the patient's preferences, but should assess preferences for pain levels, because the patient may not be experienced in receiving pain medications. Opioids are expected for acute pain from surgery.

The nurse caring for an older cognitively impaired patient with osteoarthritis in both hands assesses the patient for hand pain by: a. observing for facial grimacing when the patient uses a fork to eat. b. being alert for signs of agitation when washing the patient's hands. c. listening to detect moaning when patient makes a fist. d. watching for signs that the patient is reluctant to shake hands.

b. being alert for signs of agitation when washing the patient's hands. Cognitively impaired patients in pain may not portray any visible signs of pain or distress or may be unable to communicate their pain. Pain may result in agitation, as well as increased pulse, respiration, blood pressure, and confusion. The other options are not as indicative of pain in the cognitively impaired older adult.

An older adult patient has been prescribed an opioid to manage chronic pain resulting from a shoulder injury. To eliminate a common barrier to opioid drug compliance, the nurse: a. encourages the patient to use the opioid only as prescribed. b. educates the patient about the appropriate management of constipation. c. assures the patient that dizziness will decrease as therapeutic levels are reached. d. suggests the patient take the medication with meals or a snack.

b. educates the patient about the appropriate management of constipation. Older adults have a high rate of discontinuation of opiates because of the resulting constipation. The treatment for constipation, especially that which is opioid induced, is readily available and should be provided as a preventive measure before starting narcotic pain medication. The other actions do not address this issue.

An older adult patient is prescribed an analgesic to manage the joint pain resulting from stiffness in his right shoulder. When the patient asks about alternative therapy techniques that might be helpful, the nurse suggests: a. applying ice packs to the area three to four times a day. b. placing a moderately warm heating pad to the shoulder. c. arranging for a professional massage on a weekly basis. d. discussing electrical nerve stimulation with the physician.

b. placing a moderately warm heating pad to the shoulder. Heat is useful in decreasing pain and discomfort resulting from joint stiffness by increasing the elasticity of muscles. Ice is better for acute exacerbations. Massage may or may not help but would be more expensive. Electrical nerve stimulation is not warranted.

An older adult who injured her knee several years ago tells the nurse that she has been managing the resulting intermittent pain with a prescription for propoxyphene (Darvon). The nurse is concerned with this treatment plan, primarily because: a. less expensive alternative analgesics are available. b. this long-term need for a narcotic warrants investigation. c. aspirin would likely be as effective in managing the pain. d. the knee should not still be causing pain for the patient.

b. this long-term need for a narcotic warrants investigation. The nurse needs to complete a full assessment to determine what type of pain the patient is experiencing and if a narcotic is the best alternative for the patient. Other medications may be more beneficial.

An older patient is being treated for arthritic pain with a nonsteroidal anti-inflammatory drug (NSAID). Which question best assesses for side effects of this medication class? a. "Have you noticed your heart skipping beats since you began taking this drug?" b. "Did you know you should not to stand up too quickly?" c. "Are you aware that you should take your pain medication with food?" d. "Have you had any episodes of shortness of breath since starting this medicine?"

c. "Are you aware that you should take your pain medication with food?" The most common complaint associated with NSAIDs is indigestion. Indigestion may be reduced with antacid use or food consumption timed to coincide with analgesic intake.

An older patient who lives alone is brought to the clinic by an adult child who reports the patient has become "depressed" and no longer wants to go out of the home. What action by the nurse is best? a. Assess the patient for depression. b. Ask the patient why activities are avoided. c. Assess the patient for pain. d. Assess the patient for elder abuse.

c. Assess the patient for pain. Many older adults have pain that goes untreated. Consequences of untreated pain are numerous and include depression and withdrawal. The nurse should first assess for pain. Assessing for depression or elder abuse may be warranted as well. Asking "why" questions is not therapeutic, as patients tend to become defensive.

An older adult lives alone at home and is being treated for chronic pain. The home health care nurse notes the adult is disheveled and has dirty dishes piled up in the sink. What action by the nurse is best? a. Notify adult protective services. b. Arrange for hospitalization. c. Assess the patient's pain. d. Assess the patient's cognitive status.

c. Assess the patient's pain. Although all actions might be appropriate depending on circumstances, because the patient is being treated for pain and has a functional decline, the nurse should assess first for unrelieved pain.

A confused patient is admitted to the hospital after suffering a fall. When asked about pain, the patient does not respond. What action by the nurse is best? a. Ask the patient again using different words. b. Pantomime what you are asking the patient. c. Observe the patient's nonverbal behaviors. d. Ask the family members if they think the patient has pain.

c. Observe the patient's nonverbal behaviors. In some situations, the nurse cannot rely on the patient's report of pain, so as a second method of assessment, the nurse looks to the patient's nonverbal behaviors. The nurse should be aware, however, that the lack of specific "pain behaviors" does not indicate a lack of pain. The other options may be helpful for individual patients.

The nurse caring for an older adult patient experiencing carpal tunnel syndrome anticipates the patient will best achieve pain control when prescribed a(n): a. narcotic (e.g., fentanyl). b. opioid (e.g., oxycodone). c. tricyclic antidepressant (e.g., amitriptyline [Elavil]). d. nonpharmacologic strategy (e.g., wrist bracing).

c. tricyclic antidepressant (e.g., amitriptyline [Elavil]). Neuropathic pain results from a pathophysiologic process involving the peripheral or central nervous system. These types of pain respond to unconventional analgesic drugs, such as tricyclic antidepressants. Carpal tunnel syndrome is caused by nerve injury.

Acetaminophen (Tylenol) is prescribed for a 70-year-old with chronic pain. When the patient reports to the nurse that the maximum daily dose of medication does not control the pain, the nurse responds: a. "Breakthrough pain can be managed with the addition of another analgesic." b. "Transcutaneous electrical nerve stimulation (TENS) is often helpful." c. "It sounds as though you have developed a tolerance for acetaminophen." d. "We will need to get your physician to prescribe another analgesic for you."

d. "We will need to get your physician to prescribe another analgesic for you." The patient needs a comprehensive review of pain strategies, which will probably include changing pain medication. Using the maximum dose of acetaminophen long term can cause liver damage, which is another reason the patient should switch medications if it is not working.

A patient has constipation as a side effect of opioid analgesics. What menu choice indicates the patient understands nutritional therapy for this problem? a. Scrambled eggs b. White bread c. Canned fruit d. Oatmeal

d. Oatmeal Constipation can be managed with high fiber and increased water. Oatmeal has the highest fiber content of the four foods listed.

An older patient is hospitalized for the first time. After giving a dose of hydromorphone (Dilaudid), what assessment takes priority? a. Pain level b. Nausea c. Urinary retention d. Respiratory rate

d. Respiratory rate Respiratory depression is common with opioid analgesics. All assessments are appropriate; however, respiratory assessment takes priority.

When planning care for the older adult experiencing pain, the nurse bases interventions on the realization that: a. generally pain control is less effective than it is for younger adults. b. this cohort is less pain sensitive than younger adults. c. older adults are more likely to verbally express pain than younger adults. d. pain is undertreated in this cohort compared to younger adults.

d. pain is undertreated in this cohort compared to younger adults. Pain is underrecognized, highly prevalent, and undertreated among older adults.

When planning care for the older adult patient with a history of persistent pain, the nurse acknowledges the effects of the mind-body connection by including: a. regular pain assessments. b. prompt response to reports of pain. c. pain consults. d. relaxation techniques.

d. relaxation techniques. Some mind-body therapies include meditation, relaxation, guided imagery, and cognitive behavioral counseling. The other actions are appropriate but not related to mind-body therapies.