The nurse is using the Pain Assessment in Advanced Dementia Scale (PAINAD) to assess an older adult patient with dementia. Which finding would score a 1 for this patient?
1) Loud moaning and groaning
2) Facial grimacing
3) Occasional labored breathing
4) Rigid, clenched fists
ANS: 3
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The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time?
a. Cool fluids to drink b. A backrub in the sacral area c. Assisting to lie in a supine position d. Decreasing illumination in the room
The breathing in of volatile substances has become popular with adolescents and young adults because such inhalants are: (Select all that apply.)
a. Legal b. Illegal c. Harmless d. Expensive e. Inexpensive f. Easily obtained g. Undetectable in the body
A patient with a history of osteoarthritis reports discomfort unrelieved by the prescribed medications. Which nonpharmacological interventions might assist the patient in managing the discomfort?
Select all that apply. 1. Suggest the use of ice to the painful joints. 2. Encourage rest of the painful joints. 3. Discuss the use of relaxation techniques. 4. Encourage distraction techniques. 5. Advise the patient to avoid water-based exercises.
A psychiatric nurse working within a competence paradigm would emphasize which of the following when working with a patient with an anxiety disorder?
a. Use of natural family support networks b. Prevention of negative patient outcomes c. The view of anxiety disorder as a disease d. Treatment of dysfunctional characteristics