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?

Choice A reason: Over-the-counter NSAIDs are generally harmless is not a true statement, as NSAIDs can cause serious adverse effects in older adults, such as gastrointestinal bleeding, renal impairment, hypertension, and heart failure. NSAIDs should be used with caution and under medical supervision in older adults.

Choice B reason: Stool softeners and laxatives should be used with opioids is a true statement, as opioids can cause constipation in older adults, which can lead to discomfort, abdominal pain, fecal impaction, and bowel obstruction. Stool softeners and laxatives can help prevent and treat constipation and promote regular bowel movements.

Choice C reason: Opioids are less effective in older clients than in younger clients is not a true statement, as opioids can have the same or even greater analgesic effect in older adults, depending on the dose, route, and duration of administration. However, opioids can also cause more side effects in older adults, such as sedation, confusion, respiratory depression, and falls. Opioids should be used with caution and under medical supervision in older adults.

Choice D reason: The dose limit for acetaminophen is difficult to reach for older adults is not a true statement, as older adults may be more susceptible to acetaminophen toxicity, especially if they have liver disease, malnutrition, or chronic alcohol use. The dose limit for acetaminophen is 4 grams per day for adults, but it may be lower for older adults or those with risk factors. Acetaminophen should be used with caution and under medical supervision in older adults.

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.