An older female adult had hip replacement surgery 1 day ago, and the nurse thinks that the woman also has dementia. Which patient assessment does the nurse use to determine that this woman is experiencing pain?
a. Holds abdomen tightly
b. Has stable vital signs
c. Is not verbalizing
d. Moves during sleep
A
Feedback
A Correct. Because this older adult has a potential cognitive impairment and thus is likely to self-report pain unreliably, the nurse uses additional clinical indicators to detect pain in her. Muscle rigidity and guarding are clinical indicators of pain for a postoperative older adult regardless of a cognitive impairment.
B Incorrect. An individual experiencing pain is unlikely to have stable vital signs.
C Incorrect. Not verbalizing can indicate a sensory impairment and warrants fur-ther investigation by the nurse. Nonetheless, this older adult's verbalizations are potentially unreliable indicators of pain.
D Incorrect. Older adults move normally during sleep to adjust their position in bed, and it is not an indicator of pain unless the movements are agitated or rest-less in nature.
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