The nurse administers a narcotic for pain to a terminal patient with end-stage pulmonary disease and dementia. After one hour, the patient exhibits facial grimacing and restlessness. How should the nurse interpret these assessment findings?
1. The patient has continuing pain.
2. The patient is experiencing a sleep disorder.
3. The patient requires comfort measures.
4. The patient assessment is is within normal limits.
1. The patient has continuing pain.
Explanation: 1. When an older adult is unable to speak or self-report the level of pain, the nurse should carefully observe the patient for behavioral symptoms of pain that may include restlessness and grimacing.
2. Restlessness may indicate a sleep difficulty but grimacing occurs with pain, not insomnia.
3. Comfort measures can augment medication for pain; however, this patient is demonstrating signs of acute pain.
4. The patient is restless and grimacing, which are behavioral symptoms of pain that is not normal and needs to be addressed.
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