Ebersole and Hess' Chapter 18: Pain and Comfort

5. Each of the following is a pharmacologic intervention for pain except which one? a.Acupuncture treatments b.Adjuvant therapy c.Lidocaine patch d.Capsaicin

ANS: A Acupuncture is a nonpharmacologic treatment that helps reduce the perception of pain. An adjuvant is a medication that has been developed for a different purpose but serves to alter the perception of pain, possibly in combination with a pain medication. Lidocaine patches are a pharmacologic treatment for pain relief. Capsaicin is a pharmacologic means of providing comfort and alleviating pain and distress.

2. Which of the following statements are true about pain in older adults? (Select all that apply.) a.Pain is not a normal aging process. b.Pain sensitivity decreases with age. c.If patients do not complain, they do not have pain. d.Opioid analgesics are often the best treatment for persistent pain.

ANS: A, D Pain is not a normal aging process. Something pathological is usually causing the pain. Pain sensitivity does not decrease with age. Some patients have a variety of reactions to pain; many are stoic and refuse to give in to their pain. Opioid analgesics are beneficial for moderate to severe persistent pain.

10. The nurse uses comfort measures to enhance an older adult's pharmacologic pain management. Which of the following would be most helpful for the nurse to use to identify the relationships between the comfort measures, activity, and pharmacotherapy, and the older adult's pain level? a.Older adult's self-report b.Older adult's pain diary c.Faces Pain Scale-revised (FPS-R) d.Pain medication frequency

ANS: B The nurse instructs the older adult to maintain a pain diary to help the individual achieve some control over the pain experience. The diary is then used to identify trends or the timing of pain and the relationships between the patient's pain level and the comfort measures, activity, and pain medications. Many older adults report feeling useful and having some control over the pain, or at least the pain management program, through maintaining a pain diary. Self-reporting is one parameter used to evaluate pain, but drawing a relationship between the pain level and other factors is still necessary. The FPS-R is a reliable pain assessment tool, but the task remains to link the pain rating to other factors. The frequency of medication administration provides a clue about the patient's pain level.

6. An older adult admitted for back surgery asks for opioid pain medication. The nurse knows the patient asks for pain medication 15 minutes before it is due. Which recommendation should the nurse implement? a.Validate the pain with other assessment data. b.Administer the pain medication as requested by the patient. c.Tell the patient that it is too soon for pain medication. d.Teach the patient alternative comfort measures.

ANS: B The nurse should administer the opioid pain medication as requested because the patient is asking for the pain medication within the prescription's time limit. Most institutions allow the nurse to administer opioid medications 15 to 30 minutes before the designated time on the prescription; therefore, the patient is not asking for the medication too early. In addition, the nurse has an obligation to the patient to administer the pain medication; not doing so violates the patient's rights. The nurse can rely on the patient's report to determine the need for pain medication. As long as the timing is suitable and the patient is stable, the nurse should administer the medication. The nurse should use assessment data to support withholding pain medication in the presence of oversedation or another assessment that would be potentially aggravated by administering the pain medication. The nurse violates the patient's rights by stating that it is too soon for the medication and ignores the possibility that the patient's pain is real. Although the nurse may believe the patient is not having pain and is exhibiting drug-seeking behavior, the nurse must administer the medication. The nurse must administer the pain medication as requested. When patients are experiencing pain, most often, it is not the optimal time to teach patients. However, when the patient's pain is under control, the nurse should teach alternative comfort measures. Comfort measures can be used to enhance the therapeutic effect of the medication and breakthrough pain.

5. A nurse is caring for an older adult with cognitive impairment who recently had hip surgery. The nurse assesses the client for pain. The nurse would suspect that the client is in pain when the client demonstrates which of the following? (Select all that apply.) a.The client ate all of her meals. b.The client pushes caregivers away when they attempt to change the dressing on her hip. c.The client rocks back and forth repetitively when sitting in a chair. d.The client sleeps soundly throughout the night. e.The client cries out repeatedly when anyone approaches her.

ANS: B, C, E Pain cues in people with communication difficulties involve changes in behavior including restlessness, resistance to care, repetitive movements, and vocalizations. Other cues including sleeplessness and a decreased appetite.

12. An older client who was recently admitted to the subacute setting after having a knee replacement, is very anxious and refuses to get out of bed, stating that it is too painful. Which intervention will the nurse implement? a.Share with the patient that it's important to get out of bed and that there is pain medication available if it does hurt. b.Use the Hoyer lift to get her out of bed so that the knee will not experience much movement and so there will be little pain. c.Offer pain medication, administer the medication, and wait 20 minutes before getting her out of bed. d.Allow the patient to remain in bed but share that getting up will be required at least twice a day starting the next morning.

ANS: C The administration of an as-needed analgesic 20 to 30 minutes before an activity may eliminate discomfort and fear of discomfort. It may also enhance the individual's capacity for the activity. It is not true that performing an activity quickly will lessen the pain or that the patient will get used to the pain. A Hoyer lift is only indicated when an individual is completely immobile. Activity is an important part of rehabilitation.

11. When educating a client on the use of an adjuvant medication, which statement best demonstrates the nurse's understanding of this therapy? a."These medications are used instead of opioids to decrease the likelihood of addiction." b."Adjuvant medications are prescribed because they seldom cause any significant side effects." c."These types of medications are used to eliminate the side effects of opioid medications." d."These drugs are used in combination with analgesics to increase the effect of the analgesics."

ANS: D Adjuvant medications are not analgesics but are thought to alter the perception of pain and are used with analgesics to potentiate the effect of the analgesics. Adjuvant medications are used with opioids and may have long half-lives in older adults. The nurse must monitor the patient for adverse effects. Adjuvant medications do not eliminate the side effects of opioids.

9. An older Hispanic man states that he is not having pain, but he had knee replacement surgery 2 days ago. Which is the best pain assessment tool as recommended by the Hartford Institute for Geriatric Nursing (HIGN) from "Try This" for the nurse to apply for this man? a.Numeric Rating Scale b.Verbal Descriptor Scale c.Iowa Pain Thermometer d.Faces Pain Scale-revised (FPS-R)

ANS: D Hispanic men are less likely to report pain because their culture tells them to deny and withstand pain without complaining. The nurse uses the FPS-R to validate the patient's report because the postoperative period in knee replacement surgery is very painful; this fact makes the nurse think that the patient is likely to have pain. The HIGN has data that support the claim that Hispanic and African American older adults prefer using the FPS-R for evaluating pain. The Numeric Rating Scale, the Verbal Descriptor Scale, and the Iowa Pain Thermometer are valid and reliable assessment tools, but older Hispanic adults prefer using the FPS-R.

7. The nurse administers an opioid analgesic to an older male postoperative patient in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the patient's room? a.Place all side rails up. b.Position the patient comfortably. c.Offer toileting and a sip of water. d.Instruct him to ask for help before getting up.

ANS: D The most important intervention for fall and injury prevention is for the nurse to instruct the older adult to ask for help before getting up after receiving an opioid medication. This intervention is important because the medication can cause sedation and dizziness; therefore, the nurse instructs him to ask for help to prevent a fall or injury. Putting all side rails up is considered a restraint and may place the patient at risk for injury. Comfortable positioning is also a good supplemental intervention after administering pain medication. Offering toileting and hydration is a reasonable intervention to implement after administering pain medication, but it does not offer the same degree of safety as instructing the patient to call for help.

3. An older woman had hip replacement surgery 1 day ago, and the nurse thinks that the woman also has dementia. Which patient assessment does the nurse use to determine whether this woman is experiencing pain? a.Holds her abdomen tightly b.Has stable vital signs c.Is not verbalizing d.Moves during sleep

ANS: A Because this older adult has a potential cognitive impairment and is likely to self-report pain unreliably, the nurse uses additional clinical indicators to detect pain. Muscle rigidity and guarding are clinical indicators of pain for a postoperative older adult, regardless of a cognitive impairment. An individual experiencing pain is unlikely to have stable vital signs. Not verbalizing can indicate a sensory impairment and warrants further investigation by the nurse. Nonetheless, this older adult's verbalizations are potentially unreliable indicators of pain. Older adults move normally during sleep to adjust their position in bed; moving during sleep is not an indicator of pain unless the movements are agitated or restless in nature.

4. An older aphasic client has severe osteoarthritis, bilateral contractures of the lower extremities, and a stage IV pressure ulcer. The nurse practitioner prescribes analgesic medications to be administered around the clock, with as-needed doses to be administered as appropriate. What observation by the nurse would indicate that the pain regimen is effective? (Select all that apply.) a.The client slept throughout the night. b.The client winces only when turned and repositioned. c.The client slept during dressing change. d.The client cooperative during morning care. e.The client ate 80% of breakfast, 70% of lunch, and 100% of dinner.

ANS: A, C, D, E Pain cues presented by this client is the wincing when being turned, indicating that this intervention is pain producing. The remaining observations are concurrent with effective pain management.

4. Which of the following statements is true about analgesic medications for older adults? a.Opioids are less effective in older patients than in younger patients. b.Stool softeners and laxatives should be used with opioids. c.Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) are generally harmless. d.The dose limit for acetaminophen is difficult to reach for older adults.

ANS: B Opioids often cause constipation and necessitate bowel stimulation to prevent constipation. A bowel regimen should be instituted at the same time as opioid treatment. Because of changes in metabolism with aging, opioids have a greater and longer lasting analgesic effect in older patients. NSAIDs can cause gastrointestinal bleeding, kidney and liver damage, and drug interactions with potentially fatal results. The maximum daily dose of acetaminophen is 4000 mg, and the limit is lower for patients with kidney or liver failure and patients who use alcohol. A typical dose is two 500-mg ("extra-strength") tablets.

1. Which conditions are likely to cause an older adult chronic pain? (Select all that apply.) a.Hip replacement b.Bone metastasis c.Hypoproteinemia d.Migraine headache e.Compression fracture f.Postherpetic neuralgia

ANS: B, E, F Bone metastasis is likely to cause an older adult chronic pain because it is extremely difficult to eradicate cancer metastasis from bone. In addition, the invasion of cancer into bone can be very painful as a result of tumor growth pressing on nerves. Compression fractures are likely to cause chronic pain because the compressed vertebra is likely to press on spinal nerves, causing muscle spasms. Postherpetic neuralgia is a result of nerve damage from shingles and is likely to cause chronic pain; it is very difficult to treat effectively. A hip replacement is performed to relieve chronic pain or to repair a fracture and is more likely to cause acute pain. Hypoproteinemia is unlikely to cause chronic pain but is more likely to cause fatigue. A migraine headache is likely to cause acute, intense pain. Although headaches can be recurrent, they are usually time limited.

8. The older adult is at a higher risk for acute psychological pain than a younger adult because older adults a.have many illnesses. b.possess fewer assets. c.experience more loss. d.live with impairments.

ANS: C Older adults are at higher risk for acute psychological pain than younger adults because they experience more loss such as the pain occurring in early bereavement or in a major depressive episode. Older adults tend to have more illnesses than younger adults, and illness can trigger depression. The lack of assets of younger and older adults is unlikely to be related to acute psychological distress unless a sudden loss of a large asset is experienced. Older adults do not necessarily live with impairments. Furthermore, if impairment causes psychological distress, then the acute phase is likely to occur at the onset rather than in day-to-day activities.

3. Which of the following pain sensations are associated with neuropathic pain? (Select all that apply.) a.Infection b.Obstruction c.Inflammation d.Postamputation

ANS: D Neuropathic involves a pathophysiological process of peripheral or central nervous system. Infection, obstruction, and inflammation are considered nociceptive pain sensations that are associated with injury to skin, mucosa, muscle, or bone.

1. Compared with acute pain, which of the following statements is true of persistent pain? a.Leads to significantly altered vital signs b.Is usually described as a burning pain c.Is generally gone within 4 months d.Can bring about long-term changes in lifestyle

ANS: D Persistent pain affects the patient's experience on a continuing basis. Both acute pain and persistent pain can affect the vital signs. Persistent pain may be described in many possible ways. Persistent pain is unrelenting.

2. The nurse admits an older man who had abdominal surgery. Admission vital signs are heart rate (pulse) (P), 73 beats/min; respiration rate (R), 20 breaths/min; and blood pressure (BP), 136/84 mm Hg. He is receiving intravenous (IV) fluids but has not requested pain medication since surgery. Seven hours later, his vital signs are P, 98 beats/min; R, 26 breaths/min; and BP, 164/90 mm Hg, and he denies pain. Which intervention should the nurse implement? a.Administer an opioid medication by IV route. b.Check the surgical dressing for bleeding. c.Report the vital signs to the health care provider. d.Ask if he has about discomfort at the surgical site or any other location.

ANS: D The patient's P, R, and BP increased significantly since his admitting vital signs and indicate the potential for pain or discomfort from the surgical incision. This patient may also be experiencing pain unrelated to the surgery because of arthritic changes, neuropathies, and so on. The patient can be misunderstanding the nurse's question or be barred from saying "yes" by cultural patterns. Such miscommunication is common; therefore, the nurse rewords the question using another term for pain such as discomfort, burning, or pressure. Administering an opioid medication by IV route is unethical without the patient's request. When checking the surgical dressing for bleeding, the patient may show signs of pain rather than blood loss. Reporting the vital signs to the health care provider would be premature; the patient's pain assessment is not complete.