A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

Numerical pain scale

Verbal description

FACES pain scale

Behavioural indicators

Answer and Explanation

The Correct Answer is D

A. Numerical pain scale. Clients with dementia often have difficulty understanding and using numerical pain scales.

B. Verbal description. Many clients with dementia have impaired verbal communication, making it difficult to describe pain effectively.

C. FACES pain scale. While this scale is useful for some nonverbal populations, it still requires the client to actively choose a face, which may be difficult for those with advanced dementia.

D. Behavioral indicators. Observing facial expressions, body movements, vocalizations, and changes in vital signs can help assess pain in clients who cannot self-report. The PAINAD (Pain Assessment in Advanced Dementia) scale is commonly used.

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Correct Answer is B

Explanation

A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.

B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.

C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.

D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.

A. Ensure the cane has a rubber cap. B. Hold the cane on the weaker side. C. Flex the elbow slightly when using the cane. D. Move the cane and stronger leg forward simultaneously. E. Use a quad cane for increased support.

Correct Answer is ["A","C","E"]

Explanation

A. Ensure the cane has a rubber cap. A rubber cap provides stability and prevents slipping, reducing fall risk.

B. Hold the cane on the weaker side. The cane should be held on the stronger side to provide support while stepping forward with the weaker leg.

C. Flex the elbow slightly when using the cane. The elbow should be slightly flexed (15-30 degrees) when holding the cane for optimal support and comfort.

D. Move the cane and stronger leg forward simultaneously. The cane and weaker leg should move forward together to maintain balance, followed by the stronger leg stepping forward.

E. Use a quad cane for increased support. A quad cane provides a broader base of support and is recommended for clients who need extra stability.

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A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is ["A","C","E"]

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