Practice Questions Chapter 9

The nurse is evaluating an elderly patient's level of pain. Which statement would indicate that the pain is not being adequately managed? Choose all that apply. 1. "I'm doing O.K. It only hurts when I try to move around too much." 2. "I'm doing better. I've been sleeping and just woke up. But I don't want to get hooked on the drugs." 3. "I wouldn't really call it pain. It's more of a dull ache, but not so bad that I can't take it." 4. "The shooting, burning pain is almost gone and now it's just this tingling, pulling feeling." 5. "I really feel OK and I think I am ready to get started with my day."

1. "I'm doing O.K. It only hurts when I try to move around too much." 3. "I wouldn't really call it pain. It's more of a dull ache, but not so bad that I can't take it." 4. "The shooting, burning pain is almost gone and now it's just this tingling, pulling feeling." Rationale: Discomfort is often described with words other than pain, such as "dull," "stinging," "aching," "burning," "tingling," or "pulling." Older persons should be made aware that immobility is more likely to be a cause of harm than is addiction. The chance of a person developing an addiction when a narcotic is being used to treat pain is extremely low

Nurses working in the rehabilitation unit of a long-term-care facility were required to attend a seminar regarding pain in the elderly. Which of the following statements by a participant indicates the need for further education? 1. "Pain tolerance tends to decrease with aging." 2. "There are few changes in the perception of pain associated with aging." 3. "Overtreating pain may result in increased sensitivity to painful stimuli." 4. "Undertreated pain may be an underlying cause of depression."

1. "Pain tolerance tends to decrease with aging." Rationale: Undertreatment of pain may result in hypersensitivity of pain receptors. The remaining statements are correct.

Non-pharmacological interventions for pain that the nurse might employ for an elderly client with osteoporosis would include: 1. Evening back rubs. 2. Support groups. 3. Daily walks. 4. Increased dairy products in the diet.

1. Evening back rubs. Rationale: Many non-pharmacological interventions, such as a back rub, can be effective in reducing pain. This is the only response listed that includes an intervention that focuses on pain relief. A support group would offer education and emotional support. Items 3 and 4 offer suggestions that could be used as part of the treatment designed to interrupt the disease process.

When administering IV analgesics to the elderly, the nurse should: 1. Expect to "start low and go slow." 2. Expect the response to the medication will be more rapid than in younger clients. 3. Expect that PCA administration will be the most effective method. 4. Wait for a more thorough assessment to be completed before administering the medication.

1. Expect to "start low and go slow." Rationale: As people age their response to many medications is altered. For this reason the elderly have higher peak levels and longer duration of action from IV analgesics so dosing is initiated at lower levels and titrated upwards slowly. Item 2 and 3 are incorrect statements. Item 4 is not a correct response because a "more thorough" assessment would be important after the medication is administered.

Which opioids are to be avoided in older adults? Choose all that apply. 1. Meperidine 2. Morphine 3. Fentanyl 4. Oxycodone 5. Methadone

1. Meperidine 5. Methadone Rationale: Meperidine is known to form toxic metabolites, which accumulate in the elderly and cause delirium. Fentanyl is used widely for the management of persistent pain in the elderly. Oxycodone can be used safely to treat both acute and persistent pain. Methadone should be avoided if possible, as it causes toxicity in those with liver and renal impairments.

The nurse is caring for a patient hospitalized after experiencing a fall down the stairs. The patient has a history of dementia. Which of the following principles should the nurse remember when performing a pain assessment? Choose all that apply. 1. Be aware that episodes of incontinence increase in the presence of pain. 2. Look for signs of increased agitation or restlessness. 3. Screening tools can be used accurately with moderate levels of dementia. 4. Know that only family members could reliably point out pain in their loved one. 5. Aggressiveness can increase in the presence of pain.

2. Look for signs of increased agitation or restlessness. 3. Screening tools can be used accurately with moderate levels of dementia. 5. Aggressiveness can increase in the presence of pain. Rationale: Elderly persons with dementia can express their pain up until the time that they have become nonverbal. Therefore, the usual screening tools can still be dependably used. If the dementia is in the latter stages, the nurse may need to rely on nonverbal behaviors such as agitation, moaning, and resisting care as indicators of pain. Unrelieved pain can cause acute confusion and incontinence, but incontinence will not always occur in the presence of pain.

An elderly client had abdominal surgery 8 hours earlier. When the nurse asks the client about pain, the client responds that there is none. The best intervention on the part of the nurse is to: 1. Administer a PRN dose of IV pain medication as ordered. 2. Assist the client into a sitting position in preparation for ambulation. 3. Question the client further about discomfort to assess the meaning of pain. 4. Assess the abdominal dressing and consult the surgeon about findings.

3. Question the client further about discomfort to assess the meaning of pain. Rationale: Item 3 is correct because a denial of pain does not mean the client is not experiencing any pain. The client may have a different meaning for the term "pain" so the nurse should explore the situation using a variety of terms like discomfort or aching. Without a careful assessment the first response is inappropriate and a post operative client who had abdominal surgery 6 hrs previously will require medication in preparation for ambulation. While assessing the abdominal dressing is important, unless there are indications of complications the surgeon would not need to be notified.

An elderly client is being treated with a fentanyl transdermal patch for moderate pain. The nurse advised this client to: 1. Change the patch site every 4 hours for the first 24 hours and then every 8 hours for the next 24 hours. 2. Expect pain relief within 90 minutes of application. 3. Take another oral pain medication for 24 hours. 4. Refrain from showering for 24 hours.

3. Take another oral pain medication for 24 hours. Rationale: Fentanyl patches are replaced every 3 days so item 1 is incorrect. Item 2 is not a good choice because the peak effect from fentanyl patches is about 24 hours after the first application so the pain needs to be "covered" by other medications until the fentanyl reaches its peak. At this point other pain medications should be discontinued. Persons using a transdermal patch can shower but they should not use soap over the area of the patch.

Which statements are true? Choose all that apply: 1. Around-the-clock opioids should be used only rarely and with extreme caution in older adults with dementia. 2. Acute post-surgical pain is best treated with prn dosing. 3. There is no reason to believe that an elderly person with a cognitive impairment is less sensitive or feels pain less. 4. The nausea and vomiting that occurs when opioids are first begun usually subsides within a few days. 5. The elderly tend to overreport pain rather than denying that pain is being experienced.

3. There is no reason to believe that an elderly person with a cognitive impairment is less sensitive or feels pain less. 4. The nausea and vomiting that occurs when opioids are first begun usually subsides within a few days. Rationale: There are no known neurological changes that result in decreased pain sensitivity in the elderly to any significant degree. Any pain that is known or can be anticipated is best managed with around-the-clock treatment for maximal pain relief with the least amount of adverse effects. Opioids are considered safe and effective for anything other than mild pain, including persistent pain in elderly persons with dementia. Any nausea or vomiting that occurs commonly when persons first start taking morphine usually subsides within a few days.

An elderly client has been hospitalized to manage the complications associated with her metastatic breast cancer. The client reports experiencing "breakthrough pain." What pharmacological action can the nurse reasonably expect will be included in the treatment plan? 1. Initiation of a placebo after every third dose of narcotic. 2. More aggressive use of chemotherapy. 3. Giving narcotics every hour. 4. Increasing the dose of the narcotic.

4. Increasing the dose of the narcotic. Rationale: When a client experiences breakthrough pain it is appropriate to increase the dose of the narcotic, following the principle of "starting low and going slow." Because item 3 suggests hourly doses this is an incorrect response. While chemotherapy might be used to eliminate a source of the pain it would not be used as the primary intervention. Item 1 is not an ethical intervention.

The safest narcotic choice for an elderly client with acute pain is: 1. Meperidine (Demerol). 2. Oxycodone. 3. Fentanyl transdermal patch. 4. Morphine sulfate.

4. Morphine sulfate. Rationale: Morphine is the "gold standard" of narcotics for acute pain. The other choices are incorrect.

Pain is often undertreated in the elderly. What is given the most often by healthcare providers for that undertreatment? 1. Pain is merely the absence of the feeling good. 2. Pain is an abstract concept. 3. The elderly frequently complain of pain so it is hard to believe them consistently. 4. Pain is subjective and, therefore, it is hard to communicate its quality.

4. Pain is subjective and, therefore, it is hard to communicate its quality. Rationale: For any individual, pain is what the client says it is. Items 1 and 2 are incorrect because the intensity, quality, and duration are hard to communicate effectively for anyone. The last response is correct because the nurse should accept the client's description of their pain and respond appropriately.