Chapter 27: Pain and Comfort

Touhy: Ebersole & Hess' Toward Healthy Aging, 9th Edition

Multiple Choice

1. When performing a pain assessment on a client who is aphasic, the nurse should consider: a. reports from the family or staff at the nursing home about changes in functional status. b. that the patient is lying quietly in bed so she is not likely to be experiencing pain. c. that the patient’s previous stroke interrupted pain pathways so she does not feel pain. d. that older adults do not tolerate opioid analgesics well and may exhibit side effects.

ANS: A

When an individual is not able to verbally communicate complaints of pain, reports from family or caregivers are important. In addition, in older adults, pain is often manifested as changes in functional status. To assume that the patient is not in pain because she is lying quietly in bed is incorrect. One should not assume that she feels no pain due to her stroke. Older adults tolerate opioid analgesics.

DIF: Cognitive Level: Understanding REF: pp. 344–345

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

2. An older adult is admitted to the hospital after a serious fall. When noting that the client has been prescribed meperidine (Demerol) for muscle pain, the nurse: a. administers the medication so as to prevent the client from developing the fear of pain. b. questions the client and family concerning any allergies to analgesic medications. c. calls the physician to question the appropriateness of this medication order. d. conducts a pain assessment and determines the client’s need for an analgesic medication.

ANS: C

Some medications used in younger adults, for example, meperidine (Demerol), are always contraindicated in the older adult. The metabolites of Demerol can cause confusion, psychotic behavior, and seizure activity. The remaining options would not be inappropriate, except for the fact that they relate to the administration of an inappropriate medication.

DIF: Cognitive Level: Understanding REF: p. 348

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Pharmacological and Parenteral Therapies

3. Compared with acute pain, persistent pain requires the nurse to: a. monitor vital signs more frequently. b. document the character of the pain as burning. c. administer analgesics at least every 4 hours. d. educate the client to the benefit of specific lifestyle changes.

ANS: D

Persistent pain can manifest itself as depression, eating and sleeping disturbances, and impaired function, all of which can lead to lifestyle changes. Persistent pain usually does not lead to markedly altered vital signs. Acute or persistent pain can manifest itself as a burning pain. Persistent pain has no time frame; it is continually persistent at varying levels of intensity.

DIF: Cognitive Level: Applying REF: p. 340, Box 27-4

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

4. The initial step to effect the safe management of mild to moderate acute pain that has not been controlled with over-the-counter medications is to: a. begin acetaminophen (Tylenol) every 4 hours for 24 hours. b. supplement with nonpharmacological interventions. c. administer a single low dose of short-acting opioid and monitor for relief. d. titrate dosage of a short-acting opioid upward over 24 hours to achieve relief.

ANS: C

If pain continues, consider a single low-dose, short-acting opioid and observe the effect. Acetaminophen is an over-the-counter analgesic and so its effect is already determined to be ineffective. Nonpharmacological interventions are only appropriate once pain management has been successfully implemented. Titrating an opioid dose upward is appropriate only after the effects of the initial dose have been determined.

DIF: Cognitive Level: Understanding REF: p. 245, Box 27-10

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. Check for incompatibilities before taking any new medications. b. Arrange to take a dose of analgesic prior to physical activity. c. Take the analgesic around-the-clock as prescribed. d. Be alert for the signs of overdose toxicity.

5. An older adult is being treated for severe pain resulting from a history of osteoarthritis. In her discharge teaching, which information is most important to relay for the successful management of the pain?

ANS: C

For someone with severe persistent pain it is important to achieve the highest level of pain control; it is helpful to ease the “memory of pain,” especially for those whose persistent pain is intense, like that of many chronic illnesses. This means to prevent the pain, not simply relieve it. The most effective way to do this is to provide around-the-clock (ATC) dosing, at the appropriate dosage. The other options are appropriate medication-related instructions but are not as directed toward successful management of chronic pain as is the correct option.

DIF: Cognitive Level: Applying REF: p. 347

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. “I find that when I drink herbal tea and then take my Tylenol at bedtime, I sleep through the whole night.” b. “I heard that meditation may help me deal with the pain without taking all that Tylenol.” c. “Two extra strength Tylenol tablets (500 mg/tablet) every 4 hours around-the-clock and my pain is gone.” d. “I make sure that I take my Tylenol with breakfast when I first get up.”

6. An older client with a history of hypertension and osteoarthritis who has recently fallen and fractured two ribs is prescribed extra strength Tylenol for the pain. What statement by the client requires further evaluation by the nurse?

ANS: C

The maximum dose for Tylenol is 3 g per 24-hour period; two extra strength Tylenol tablets every 4 hours would mean that the client is taking 6 g and would need further evaluation. Herbal tea may have a relaxing effect and help her sleep. Meditation is one of the alternative modalities that help some patients deal with pain. The practice of taking Tylenol with breakfast upon waking is acceptable.

DIF: Cognitive Level: Understanding REF: pp. 347–348

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Pharmacological and Parenteral Therapies a. The development of a plan to prevent constipation b. Benefits of grief counseling c. Increasing calories in the diet d. Preventing pressure ulcers

7. An older adult with gastric cancer with bone metastases is being discharged from the hospital after beginning a regimen of opioid analgesics to control the metastatic pain. What should be included in the discharge teaching plan?

ANS: A

Side effects of opioids are significant to older adults and include constipation. Because constipation is almost universal when opioids are used, the nurse should ensure that an appropriate bowel regimen is taken at the same time as the opioids. The remaining options are not specifically related to the management of the client’s pain or the effects of opioid treatment.

DIF: Cognitive Level: Understanding REF: p. 349

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. The medications should be taken together to ensure the effectiveness of both medications b. Take ibuprofen 30 minutes after the aspirin so as to not interfere with its effectiveness c. The aspirin will negatively affect the analgesic effect of the ibuprofen d. The medications should be taken at least 4 hours apart to minimize risk of gastric irritation

8. An older adult is currently prescribed both aspirin (81 mg) and ibuprofen daily. What instructions are most important for the nurse to provide to assure the expected outcomes for this client?

ANS: B

In 2006, the Food and Drug Administration in the United States issued a warning regarding the concomitant use of aspirin (81 mg) and ibuprofen. When taken together the aspirin is less cardio-protective; that is, there is less antiplatelet effect increasing the person’s risk for a cardiac event. Persons who take immediate release aspirin and take a single dose of ibuprofen 400 mg should take the ibuprofen at least 30 minutes after or 8 hours before the aspirin.

DIF: Cognitive Level: Understanding REF: p. 348

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Pharmacological and Parenteral Therapies 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.”

9. When educating a client on the use of an adjuvant medication, which statement best demonstrates the nurse’s understanding of this therapy?

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.

DIF: Cognitive Level: Understanding REF: pp. 348–349

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation 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.

10. 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?

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.

DIF: Cognitive Level: Understanding REF: p. 347

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

Multiple Response

1. 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. “Client slept throughout the night.” b. “Client winces only when turned and repositioned.” c. “Client slept during dressing change.” d. “Client cooperative during morning care.” e. “Client ate 80% of breakfast, 70% of lunch, and 100% of dinner.”

ANS: A, C, D, E

A pain cue presented by this client is the wincing when being turned, indicating that this intervention is producing pain. The remaining observations are concurrent with effective pain management.

DIF: Cognitive Level: Understanding REF: p. 345

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. gastrointestinal bleeding. b. renal impairment. c. medication interactions. d. confusion. e. increased anxiety.

2. An older adult is seen in the emergency department after falling and sustaining substantial soft tissue bruising. The assessment interview notes a history of arthritic pain in several joints. The client is prescribed 650 mg of acetaminophen (Tylenol) four times per day and 800 mg of ibuprofen (Motrin) four times per day for control of the persistent arthritic pain. When providing discharge teaching, the nurse includes information regarding the signs and symptoms of: (Select all that apply.)

ANS: A, B, C

There is no indication that the patient is at risk for mental status changes such as confusion or increased anxiety. The remaining options are directly related to the possible outcomes of long-term pain management with these medications.

DIF: Cognitive Level: Understanding REF: pp. 347–348

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Pharmacological and Parenteral Therapies a. titrate the prescribed analgesic medication to provide effective pain management. b. assess the client for cultural beliefs that affect individual expression of pain. c. reassure the client that pain medication is available whenever he or she expresses a need for it. d. anticipate the client’s need for pain medications. e. implement nonpharmacological pain management interventions whenever possible.

3. When individualizing pain management for a client hospitalized after major surgery, the nurse will: (Select all that apply.)

ANS: A, B, D, E

The client will require knowledge about the frequency of the administration of the medication; if the requests are consistently made before the medication can be readministered, the treatment plan should be reevaluated and altered. The other options reflect appropriate interventions for effective pain management.

DIF: Cognitive Level: Understanding REF: pp. 347–349

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation 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.

4. 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.)

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 include sleeplessness and decreased appetite.

DIF: Cognitive Level: Applying REF: p. 341, Box 27-6

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation