A home care nurse notes in the assessment that an older adult ...

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A home care nurse notes in the assessment that an older adult expresses anxiety and fatigue. The client sleeps 3 hours at a time at maximum and has had a 10 lb weight loss. Which of the following interventions is priority?
 
  A) Assess the client's level and intensity of pain.
  B) Interview the family.
  C) Perform an assessment of vital signs.
  D) Weigh the client.

Question 2

A nurse administers IV pain medication to an older adult in the hospital. Which of the following actions by the nurse is the priority?
 
  A) Encourage the family to leave.
  B) Identify the client's expectations for relief.
  C) Reassess the pain level.
  D) Reposition the client.

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Answer to Question 1

Ans: A
The symptoms represented reflect functional consequences commonly experienced by older adults. The other assessments are not the priority reflected by these symptoms.

Answer to Question 2

Ans: D
In acute care settings, effectiveness of analgesics should be assessed 30 to 60 minutes after administration. Pain assessment should include open-ended questions to identify the person's expectations for relief before administering medication. Family is not encouraged to leave. Nonpharmacologic interventions are an integral part of pain management: Physical strategies include massage, reflexology, heat and cold, mild exercise, and physical therapy (this would include repositioning the client).

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TYSM

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