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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This action is correct because the client is showing signs of a possible stroke, such as a severe headache and numbness in one side of the body. The nurse should call 9-11 immediately to get the client to the nearest hospital for urgent evaluation and treatment. The nurse should also monitor the client's vital signs, neurological status, and airway until help arrives.
Choice B reason: This action is incorrect because the client's headache and numbness are not likely to be caused by a migraine, but by a stroke. The nurse should not waste time asking about the client's history of headaches, but rather act quickly to get the client to the hospital. The nurse should also not assume that the client's symptoms are benign or familiar, but rather treat them as an emergency.
Choice C reason: This action is incorrect because the client's headache and numbness are not likely to be relieved by acetaminophen, but by a stroke. The nurse should not give the client any medication without a doctor's order, especially if the client has a history of TIA or stroke. The nurse should also not delay calling 9-11 by administering medication, as every minute counts in saving the client's brain cells.
Choice D reason: This action is incorrect because the client's headache and numbness are not likely to resolve within 24 hours, but by a stroke. The nurse should not reassure the client that the symptoms are temporary or harmless, but rather alert the client that they are signs of a serious condition. The nurse should also not delay calling 9-11 by providing false comfort, as the client's condition may worsen rapidly.
Correct Answer is C
Explanation
Choice A reason: Encouraging the client to use a cane when ambulating is not a cause of concern for the home health nurse, as it is a way of providing support and stability for the client, and preventing falls or injuries.
Choice B reason: Keeping several low wattage night lights on in the evening is not a cause of concern for the home health nurse, as it is a way of improving the visibility and orientation for the client, and reducing the risk of tripping or stumbling in the dark.
Choice C reason: Keeping the side rails up on the client’s bed at night is a cause of concern for the home health nurse, as it is a way of restricting the client’s mobility and increasing the likelihood of entrapment, injury, or death. Side rails can also create a false sense of security and encourage the client to climb over them, which can result in falls or fractures.
Choice D reason: Installing wooden railings on the stairway to the bathroom is not a cause of concern for the home health nurse, as it is a way of enhancing the safety and accessibility for the client, and preventing falls or slips on the stairs.
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