The nurse uses comfort measures to enhance an older adult’s pharmacological 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?

Older adult’s self-report

FPS-R

Pain medication frequency

Older adult's pain diary

None of the above

Answer and Explanation

The Correct Answer is D

Choice A reason: Older adult’s self-report is not the most helpful tool, as it may not be reliable or consistent in older adults, especially if they have cognitive impairment, communication difficulties, or cultural barriers. Older adults may also underreport or overreport their pain due to fear, stoicism, or expectations.

Choice B reason: FPS-R (Faces Pain Scale-Revised) is not the most helpful tool, as it may not be suitable or valid for older adults, especially if they have visual impairment, facial paralysis, or dementia. FPS-R is a pictorial scale that uses six facial expressions to represent different levels of pain intensity, from 0 (no pain) to 10 (very much pain).

Choice C reason: Pain medication frequency is not the most helpful tool, as it may not reflect the actual pain level or the effectiveness of the pharmacotherapy. Pain medication frequency may vary depending on the type, dose, route, and duration of the medication, as well as the individual response and tolerance of the older adult.

Choice D reason: Older adult's pain diary is the most helpful tool, as it can provide a comprehensive and longitudinal record of the pain experience, including the location, intensity, quality, frequency, duration, triggers, relievers, and impact of the pain. A pain diary can also help track the use and response of the comfort measures, activity, and pharmacotherapy, and identify the patterns and trends of the pain.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most helpful tool for the nurse to use.

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Correct Answer is ["A","B","C"]

Explanation

Choice A reason: This is a correct answer because heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. This can cause fluid retention and congestion in the lungs, kidneys, and other organs. Heart failure can also affect the thirst mechanism and the secretion of antidiuretic hormone, which can lead to reduced fluid intake and increased fluid loss. Therefore, heart failure can increase the risk of dehydration in older clients.

Choice B reason: This is a correct answer because nonfunctional impairments are limitations in the ability to perform activities of daily living, such as bathing, dressing, or toileting. Nonfunctional impairments can be caused by various factors, such as cognitive decline, mobility problems, or sensory loss. Nonfunctional impairments can affect the access to fluids, the awareness of thirst, or the ability to swallow. Therefore, nonfunctional impairments can increase the risk of dehydration in older clients.

Choice C reason: This is a correct answer because longitudinal furrows on the tongue are signs of dehydration in older clients. The tongue is a mucous membrane that can reflect the hydration status of the body. Dehydration can cause the tongue to lose its moisture and elasticity, and develop cracks or fissures along its length. Therefore, longitudinal furrows on the tongue can indicate dehydration in older clients.

Choice D reason: This is an incorrect answer because hypertension is not an issue that might put your client at risk for dehydration, but rather a complication of dehydration. Hypertension is the elevation of the blood pressure above the normal range, which can damage the blood vessels and increase the risk of cardiovascular disease. Hypertension can be caused by various factors, such as aging, obesity, smoking, stress, or kidney disease. Dehydration can also cause hypertension, as the loss of fluid can reduce the blood volume and increase the blood viscosity and concentration of sodium. Therefore, hypertension is not a risk factor for dehydration, but a consequence of dehydration.

A. Cognitive disorders B. Antibiotics C. Orthostatic hypotension D. Vision E. Balance

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Cognitive disorders are conditions that affect the mental functions, such as memory, reasoning, judgment, or orientation. Cognitive disorders can increase the risk of falls by impairing the awareness, attention, or decision-making of the client.

Choice B reason: Antibiotics are not a factor that requires particular attention when assessing a client who has a history of falls. Antibiotics are medications that treat bacterial infections, and they do not directly affect the risk of falls. However, some antibiotics may have side effects, such as dizziness, nausea, or diarrhea, that can indirectly increase the risk of falls.

Choice C reason: Orthostatic hypotension is a condition where the blood pressure drops significantly when changing position, such as standing up from sitting or lying down. Orthostatic hypotension can cause symptoms, such as lightheadedness, fainting, or blurred vision, that can increase the risk of falls.

Choice D reason: Vision is the sense of sight that allows the perception of the environment and the detection of potential hazards. Vision can decline with age or due to various eye diseases or injuries. Poor vision can increase the risk of falls by affecting the depth perception, contrast sensitivity, or visual field of the client.

Choice E reason: Balance is the ability to maintain the body's center of gravity over its base of support. Balance can be affected by various factors, such as inner ear problems, muscle weakness, joint stiffness, or medication use. Poor balance can increase the risk of falls by impairing the stability and coordination of the client.

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The nurse uses comfort measures to enhance an older adult’s pharmacological 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?

Nursing Test Bank

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When assessing an older male client, what are some issues that might put your client at risk for dehydration? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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