A new nurse asks, "My elderly patient has Lewy body disease. What should I do about assessing for pain?" Select the best response from the nurse manager
a. "Ask the patient's family if they think the patient is experiencing pain."
b. "Use a visual analog scale to help the patient determine the presence and severity of pain."
c. "There are special scales for assessing patients with dementia. Let's review how to use them."
d. "The perception of pain is diminished by this type of dementia. Focus your assessment on the patient's mental status."
ANS: C
Lewy body disease is a form of dementia. There are special scales to assess the presence and severity of pain in patients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A patient with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths.
You might also like to view...
A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble sleeping at night." How should the nurse respond?
a. "I will consult the provider to prescribe a sleep study to determine the problem." b. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." c. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." d. "Use pillows to elevate your head and chest while you are sleeping."
The nurse manager is reviewing the previous month's budget and notes a favorable efficiency variance of the full-time equivalents (FTEs)
Which options may be reasons for this favorable variance? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Greater client acuity 2. Extravagant use of resources 3. Understaffing the unit 4. Low client acuity 5. Use of agency nurses to supplement staff
A patient with diarrhea has been prescribed methylcellulose (Citrucel). The patient asks the nurse, "I thought this was for constipation. Why am I getting it?" Select the most appropriate response from the nurse
a. "Methylcellulose adds bulk to the stool to firm it up." b. "Methylcellulose acts by reducing the volume of diarrhea." c. "Methylcellulose reduces intestinal motility, slowing intestinal transit." d. "Methylcellulose stimulates the bowel to eliminate the diarrhea, leaving only formed stools."
A nurse says to the mother of a 6-month-old infant, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction?
1. Health promotion 2. Health maintenance 3. Disease surveillance 4. Developmental surveillance