During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply
a. Ask the patient, "Do you have pain?"
b. Assess the patient's breathing independent of vocalization.
c. Note whether the patient is calling out, groaning, or crying.
d. Have the patient rate pain on a 1-to-10 scale.
e. Observe the patient's body language for pacing and agitation.
ANS: B, C, E
Patients with dementia may say "no" when, in reality, they are very uncomfortable because words have lost their meaning. Patients with dementia become less able to identify and describe pain over time, although pain is still present. People with dementia communicate pain through their behaviors. Agitation, pacing, and repetitive yelling may indicate pain and not a worsening of the dementia. (See Figure 10-10 for the Pain Assessment in Advanced Dementia [PAINAD] scale, which may also be used to assess pain in persons with dementia.)
You might also like to view...
A nurse is considering pursuing additional education in nursing and hopes to be promoted to a management position. What action should the nurse take to best achieve this?
a. Wait until "the time is right" and inquire about program and promotion opportuni-ties. b. Be the best nurse possible and hope a scholarship or promotion will be awarded. c. Set long-range, mid-range, and short-range goals with specific related activities and time frames to meet these goals. d. Read three books on time management.
A client who is taking chemotherapeutic drugs for treatment of a malignant cancer has
repeated bouts of vomiting. Electrolytes are administered in order to maintain the serum electrolyte balance. However, the client may not be able to absorb electrolytes taken orally. Which is the preferred route of electrolyte administration in such a case? A) Intramuscular B) Intravenous C) Subcutaneous D) Intradermal
Which signs and symptoms are consistent with general anxiety disorder (GAD)? (Select all that apply.)
a. Heart rate of over 100 beats/min b. Restlessness c. Urinary retention d. Fatigue e. Muscular tension
A nurse auscultates low-pitched, coarse snoring sounds in a client's lungs during inhalation. The most appropriate action for the nurse to take next is to:
a. Palpate the posterior thorax for vocal fremitus. b. Ask the client to cough and repeat auscultation. c. Auscultate the posterior thorax for vocal sounds. d. Percuss the posterior thorax for tone.